MRONJ

Question 1

What is MRONJ?

Answer 1

Medication related osteonecrosis of the jaw

Question 2

Which 3 drug types are associated with MRONJ?

Answer 2

Anti-resorptive/ anti-angiogenic drugs:

Bisphosphonates
RANKL Inhibitor
Anti-angiogenic

Question 3

How should patients starting these drugs be initially managed

Answer 3

Get patient dentally fit before taking medication

Explain risk of developing MRONJ is small - so aren’t discouraged from taking medication/ receiving dental treatment

Advice to optimise oral health

Question 4

What time period could MRONJ be suspected after extraction?

Answer 4

8 weeks with no healing

Question 5

What are bisphosphonates?

Answer 5

Anti resorptive drugs which inhibit osteoclast activity and so inhibit bone resorption and therefore, bone renewal.
These drugs may remain in the body for years

Question 6

What are RANKL inhibitors and an example?

Answer 6

Denosumab
Monoclonal antibody which inhibits production of osteoclasts

Question 7

What are antiangiogenic drugs?

Answer 7

Divided into monoclonal antibodies and small molecule drugs.
Monoclonal antibodies stop receptor/ growth factor.
Small molecules bind to tyrosine kinase receptor to block binding.

Question 8

What can cause MRONJ?

Answer 8

Extractions
Following denture trauma
Spontaneous

Question 9

What are the risk factors for MRONJ?

Answer 9

Dental treatment - extractions, trauma from dentures, infection, perio
Duration of bisphosphonate drug therapy
Dental implants - insufficient evidence to say
Other medication - +steroids, +anti resorptive, +anti angiogenic
Prev drug history

Question 10

How long does denusomabs effect on bone turnover last?

Answer 10

9 months

Question 11

Who are low risk patients?

Answer 11

Patients being treated for osteoporosis (or other non malignant diseases of bone) with oral/ IV/ infusions of bisphosphonates for <5 years (and not on systemic glucocorticoids)
Or being treated with denosumab (and not steroids)

Question 12

Who are high risk patients?

Answer 12

Patients being treated for osteoporosis or other non malignant bone diseases with bisphosphonates for >5 years
Treated with denosumab or bisphosphonates for any length of time ++ systemic glucocorticoids
Pt being treated with anti resorptive/ anti angiogenic drugs for cancer management
Previous MRONJ

Question 13

What is the management of MRONJ?

Answer 13

Manage symptoms by removing sharp edges of bone/ Chlorohexidine mouthwash
Prevent invasive treatment