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Oral Medicine and Diagnosis > MRONJ > Flashcards

MRONJ Flashcards

1
Q

what is chemotherapy used for

A
  • head and neck squamous cell cancer for organ preservation in advanced disease
  • may be used for palliative treatment as well as in combination with radiotherapy for postoperative high risk cases
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2
Q

what are the 3 possible strategies for chemotherapy for HNSCC

A
  • neoadjuvant therapy or induction chemotherapy
  • adjuvant therapy
  • concurrent chemoradiation for cure or organ preservation
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3
Q

describe neoadjuvant therapy or induction chemotherapy

A
  • chemotherapy is administered before locoregional surgery or radiotherapy
  • sequential therapy generally refers to chemotherapy followed by radiation with concurrent chemotherapy
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4
Q

describe adjuvant therapy

A
  • chemotherapy and radiotherapy are simultaneously administered after surgery in high risk patients, reducing metastatic burden
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5
Q

describe concurrent chemoradiation for cure or organ preservation

A
  • simultaneous chemotherapy and radiotherapy are a definitive and curative treatment for instances in layrngeal tumors
  • radiation is used with cisplatin and 5-fluorouracil for the additive (or supra additive) radiosensitizing effect of chemotherapy to enhance the effectiveness of the radiation treatment
  • considered a standard of care for tumors of the oropharynx
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6
Q

what are the types of chemotherapy agents

A
  • alkylating agents: cisplatin
  • antibiotics- derivatives of antimicrobial compounds from streptomyces - doxorubicin, bleomycin, mitomycin
  • antimetabolites: methotrexate and 5-fluorouracil
  • alkaloids: vincristine or vinblastine
  • taxanes: paclitaxel or docetaxel
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7
Q

what are the types of chemotherapy agents

A
  • bisphosphonates
  • oral agents
  • systemic agents
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8
Q

what are bisphosphonates used for

A

management of malignancies in addition to systemic management of osteoporosis

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9
Q

what are the antiresorptive medications

A
  • bisphosphonates
  • RANK ligand inhibitors
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10
Q

what are bisphosphonates used to treat

A

osteoporosis
- paget’s disease
- osteogenesis imperfecta
- adjunctive cancer treatment

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11
Q

what do bisphosphonates do

A

decrease osteoclastic activity

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12
Q

describe non nitrogen bisphosphonates

A
  • oral only: etidronate- didronel and clodronate- bonefos, clasteon, and loron
  • primarily used for the treatment of Paget’s disease
  • low potency
  • prevents osteoclast proliferation by inhibiting ATP dependent enzymes
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13
Q

describe nitrogen containing bisphosphonates and mechanism of action

A
  • Oral or IV
  • MOA: prevents binding of essential proteins to the cell membrane leading to apoptosis
  • prevents adhesion of the osteoclasts to the hydroxyapatite crystals by altering the cell cytoskeleton
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14
Q

oral nitrogen containing bisphosphonates are approved to treat:

A

paget’s disease and osteoporosis

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15
Q

what are the oral nitrogen containing bisphosphonates

A
  • alendronate (Fosamax)
  • risedronate (Actonel)
  • Ibandronate (Bonvia)
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16
Q

what are IV nitrogen containing bisphosphonates are used for and what drugs for each

A
  • osteoporosis: zolendronate (Reclast) - 5mg/year
  • bone metastases: zolendronate (Zometa)- 4mg/3 weeks and pamidronate (Aredia) - 90mg/3 weeks
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17
Q

what are the antiresorptive agents

A
  • denosumab (monoclonal antibody)
  • osteoporosis - prolia - 60mg/6 months
  • bone metastases - Xgeva - 120mg/4 weeks
18
Q

what is the MOA of antiresorptive agents

A
  • tumor cell promote the release of RANK ligand from the osteoblast with in turn promote the production of osteoclasts
  • denosumab binds to the RANK ligand and prevents osteoclast proliferation
19
Q

what are the antiangiogenic medications

A
  • tyrosine kinase inhibitor: sunitinib (Sutent) and Sorafenib (nexavar)
  • humanized monoclonal antibody (bevacizumab (Avastin)
20
Q

what is the MOA of antiangiogenic medications

A
  • recognizes and blocks vascular endothelial growth factor (VEGF) , a protein necessary for angiogenesis
21
Q

what are antiangiogenic medications used to treat

A

GI tumors, renal cell carcinomas, and neuroendocrine tumors

22
Q

what are the drug related risks for MRONJ

A
  • oral non nitrogen containing bisphosphonates
  • oral nitrogen containing bisphosphonates (0.4%-4%)
  • IV bisphosphonates (4%-12%)- aredia and Zometa
  • XGEVA
  • IV bisphosphonates plus an antiangiogenic medication
23
Q

what is the duration of drug use that puts you at risk for MRONJ

A

increased risk after 18 months

24
Q

what are the local risk factors for MRONJ

A
  • surgery/trauma: dental extractions, osseous surgery (periodontal, apicoectomy), implant placement
  • anatomy: mandible vs maxilla (2:1 ratio), tori, exostoses, mylohyoid ridge
25
Q

what are the demographic risk factors for MRONJ

A
  • age: 9% increased risk of MRONJ with each passing decade
  • race: caucasian
26
Q

what are the systemic factors that are risk factors for MRONJ

A
  • primary cancer diagnosis: multiple myeloma- highest risk
  • breast cancer-2nd highest risk
  • concurrent osteopenia or osteoporosis diagnosis
27
Q

prior to starting antiresorptive medications:

A
  • extract non restorable and questionable teeth along with alveoplasty, tori removal
  • complete necessary periodontal therapy
  • complete any endodontic and restorative work
28
Q

what is the protocol for patients wearing removable appliances

A
  • limit amount of use
  • place silicone liners if necessary (GC reline)
  • educate the patient
  • 3 month recall intervals
29
Q

while on antiresorptive/antiangiogenic agent therapy what should be done prior to therapy

A

any surgery or invasive procedure requires 3 month drug holiday prior to therapy and use of antiresorptive/antiangiogenic agents should not be started again until after osseous healing has occurred

30
Q

how does Denosumab affect the body

A
  • osteoclasts deceased by 85% in 3 days
  • 1/2 life of denosumab is 25 days
  • 80% degraded in 2 months
  • denosumab only affects the RANK ligand
  • not incorporated in the bone
31
Q

describe the denosumab vacation

A
  • 2 month presurgical holiday: 80% degradation
  • average 4 month post surgical holiday (ideally 8 months)
  • no needed alteration in denosumab therapy if planned correctly
32
Q

how do you predict complications

A

CTX testing

33
Q

what is CTX testing and what does it show

A
  • measures serum levels of C-terminal telopeptide
  • metabolite of bone matrix degradation
  • marker for osteoclastic activity
  • normal is greater than 300 (average 400-550)
  • 150 or less is at risk for MRONJ
34
Q

how do you avoid complications of MRONJ

A
  • when there is significant risk of MRONJ or previous/current MRONJ present, avoid all surgical procedures if possible
  • even if teeth are not restorable by traditional methods, roots can be retained by completing RTC and covering with composite or amalgam to avoid extraction
35
Q

what 3 things are needed to dx MRONJ

A
  • current or previous antiresorptive medication therapy
  • exposed necrotic bone for longer than 8 weeks
  • no history of radiation to the jaws
36
Q

what is stage 0 and what is the treatmetn

A
  • no exposed bone but pt is symptomatic
  • radiographic changes may be present
  • tx: systemic monitoring, systemic management (antibiotics and pain meds)
37
Q

what is stage 1 and what is the tx

A
  • bone is exposed, asymptomatic, no infection present
  • tx: monitor closely for the first 8 weeks, if no change monitor every 3 months. meticulous home care. antimicrobial oral rinses such as peridex
38
Q

what is stage 2 and what is the treatment

A
  • exposed bone with associated pain and erythema
  • purulent exudate may be present
  • tx: same treatment as stage 1
  • addition of systemic antibiotics (penicillin, clindamycin, doxycycline)
  • pain management
  • superficial debridement to relieve soft tissue irritation
39
Q

what is stage 3 and what is the treatment

A
  • exposed bone with pain and one of the following: pathologic fracture, extra oral fistula, necrotic lesion extends to the inferior border
  • treatment:
  • surgical debridement or resection
  • antibiotic therapy
  • possible hyperbaric oxygen
40
Q

describe Forteo and who it is contraindicated in

A
  • resolve MRONJ in osteoporotic patients
  • may be used to treat osteoporosis
  • contraindicated in pts with bone metastases or previous radiation (risk of osteogenic sarcoma)
41
Q
A

Oral Medicine and Diagnosis (12 decks)

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