MRONJ Flashcards
What is the initial management of patients at risk of MRONJ (7)
> Risk assessment - high or low
> Informed consent including risk of MRONJ
> OHI, diet, smoking cessation reinforced
> Low risk carry out XLa’s required ideally 2wks before tx begins
> Atraumatic, consider suture + plan in morning
> Adjust ill fitting dentures/sharp trauma regions
> Follow up 8wks refer if not healing, explain signs + symptoms of MRONJ so pt aware
What risk category is a patient who has taken bisphosphonates in the past?
High
What risk category is a patient who has taken Denosumab in the past 9mths
High
What are some alternatives for high risk patients requiring XLa?
RR in absence of infection
What is MRONJ?
> Medication related osteonecrosis of the jaw
> Death of jaw bone tissue
> Rare side effect of anti-resorptive + anti-angiogenic drugs
What features would lead you to a diagnosis of MRONJ in a patient?
> Pt with hx of antiresorptive/anti-angiogenic drugs
> No hx of radiation to jaw/metastatic disease of jaws
> Signs + symptoms of MRONJ
List the signs + symptoms of MRONJ (7)
> Pain
> Infection
> Swelling
> Delayed healing
following XLa
> Exposed bone can be probed I/O or E/O
> Altered sensation/numbness
> Paraesthesia
What are the medical factors that influence the risk for MRONJ? (4)
> Drug type
> Duration of drug use
> Medical condition being treated
> Concurrent tx with systemic glucocorticoids
What are the dental risk factors that influence the risk for MRONJ? (2)
> XLa’s
> Dental trauma - including mucosal trauma from ill fitting dentures
Action of anti-resorptive drugs (2)
> Osteoclast inhibitors
> Inhibit bone resorption and remodelling
> Jaw has an increased remodelling rate so most affected
Name examples of anti-resorptive drugs (2)
> Bisphosphonates
> Denosumab
List indications for Bisphosphonate use
> Cancer tx
- Prostate
- Breast cancer
- Multiple myeloma
> Osteoporosis
> Pagets disease
> Osteogenesis Imperfecta
> Fibrous dysplasia
Action of Denosumab (2)
> Fully human monoclonal antibody
> Osteoclast + RANKL inhibitor
Action of anti-angiogenic drugs
> Restrict tumour vascularisation
> Targets the processes by which new BV’s are formed
Examples of bisphosphonate drugs and the medical condition they target (2)
> Alendronic acid (osteoporosis)
> Zoledronic acid (osteoclast/pagets/cancer)
Examples of anti-angiogenic drugs (2)
> Sunitinib
Bevacizumab
Give a patient friendly description about bisphosphonates and why they are used (9)
> Group of medications that put XLa’s at a higher risk of a rare side effect - MRONJ
> These drugs are called antiresorptive/anti-angiogenic drugs
> They work by inhibiting bone cell function, inhibiting bone formation and remodelling
> This process is required for healing - 1st stage of healing
> So these drugs can affect the healing post XLas and increase risk of a condition called MRONJ
> MRONJ is a rare side effect of these drugs and can cause death of bone tissue
> Rare but still needs consented
> If on both drugs = greater risk
> Risk does depend on what drug, how long for, what medical condition being tx and whether a systemic glucocorticoid is taken alongside
High risk patients for MRONJ
> Oral/IV bisphosphonates for more than 5yrs
> Cancer pt
> Being tx with either antiresorptive drug (bisphosphonate or denosumab) for any length of time + systemic glucocorticoid
> Previous MRONJ
When should tx ideally be carried out for high risk patients?
Prior to commencement of bisphosphonate tx
