MRONJ

Question 1

What is the initial management of patients at risk of MRONJ (7)

Answer 1

> 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

Question 2

What risk category is a patient who has taken bisphosphonates in the past?

Answer 2

High

Question 3

What risk category is a patient who has taken Denosumab in the past 9mths

Answer 3

High

Question 4

What are some alternatives for high risk patients requiring XLa?

Answer 4

RR in absence of infection

Question 5

What is MRONJ?

Answer 5

> Medication related osteonecrosis of the jaw

> Death of jaw bone tissue

> Rare side effect of anti-resorptive + anti-angiogenic drugs

Question 6

What features would lead you to a diagnosis of MRONJ in a patient?

Answer 6

> Pt with hx of antiresorptive/anti-angiogenic drugs

> No hx of radiation to jaw/metastatic disease of jaws

> Signs + symptoms of MRONJ

Question 7

List the signs + symptoms of MRONJ (7)

Answer 7

> Pain

> Infection

> Swelling

> Delayed healing
following XLa

> Exposed bone can be probed I/O or E/O

> Altered sensation/numbness

> Paraesthesia

Question 8

What are the medical factors that influence the risk for MRONJ? (4)

Answer 8

> Drug type

> Duration of drug use

> Medical condition being treated

> Concurrent tx with systemic glucocorticoids

Question 9

What are the dental risk factors that influence the risk for MRONJ? (2)

Answer 9

> XLa’s

> Dental trauma - including mucosal trauma from ill fitting dentures

Question 10

Action of anti-resorptive drugs (2)

Answer 10

> Osteoclast inhibitors

> Inhibit bone resorption and remodelling

> Jaw has an increased remodelling rate so most affected

Question 11

Name examples of anti-resorptive drugs (2)

Answer 11

> Bisphosphonates

> Denosumab

Question 12

List indications for Bisphosphonate use

Answer 12

> Cancer tx
- Prostate
- Breast cancer
- Multiple myeloma

> Osteoporosis

> Pagets disease

> Osteogenesis Imperfecta

> Fibrous dysplasia

Question 13

Action of Denosumab (2)

Answer 13

> Fully human monoclonal antibody

> Osteoclast + RANKL inhibitor

Question 14

Action of anti-angiogenic drugs

Answer 14

> Restrict tumour vascularisation

> Targets the processes by which new BV’s are formed

Question 15

Examples of bisphosphonate drugs and the medical condition they target (2)

Answer 15

> Alendronic acid (osteoporosis)

> Zoledronic acid (osteoclast/pagets/cancer)

Question 16

Examples of anti-angiogenic drugs (2)

Answer 16

> Sunitinib
Bevacizumab

Question 17

Give a patient friendly description about bisphosphonates and why they are used (9)

Answer 17

> 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

Question 18

High risk patients for MRONJ

Answer 18

> 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

Question 19

When should tx ideally be carried out for high risk patients?

Answer 19

Prior to commencement of bisphosphonate tx