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Oral surgery > MRONJ > Flashcards

MRONJ Flashcards

1
Q

What are the different classes of anti-angiogenic drugs?

A

VEGF Inhibitor
Tyrosine kinase inhibitor
Fusion protein

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2
Q

What is stage 0 MRONJ?

What is the treatment?

A

No clinical evidence of necrotic bone but radiological changes observed

Analgesics and Antibiotics

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3
Q

According to SDCEP what is a low risk MRONJ patient? (2)

A

Any of the following

  • Treated for osteoporosis with oral or IV bisphosphonates for less than 5 years who are not taking systemic glucocorticoids
    taking systemic glucocorticoids
  • Treated for osteoporosis with denosumab who are not taking systemic glucocorticoids

Essentially systemic glucocorticoids is peak

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4
Q

How do bisphosphonates work?

A

Inhibit bone resorption (via osteoclast apoptosis) with particularly high affinity to areas of bone turnover

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5
Q

What is stage 3 MRONJ?

What is the treatment?

A

Symptomatic exposed bone and infection.
Pathological fracture, presence of a fistula or signs of osteolysis.

Analgesics and antibiotics
Antiseptic mouthwash
Surgical debridement or resection for long term care

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6
Q

What does VEGF stand for?

A

Vascular endothelial growth factor

Bevacizumab is a VEGF inhibitor (anti-angiogenic for metastatic cancer)

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7
Q

What are some clinical presentations of MRONJ if the patient is symptomatic?

What are the 3 worst case presenations

A

Pain
Swelling
Halitosis
Delayed healing after XLA
Exposed bone & Infection

Numbness of ID nerve
Extra or Intra-oral fistula
Fracture

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8
Q

How do RANKL Inhibitors work?

Denosumab

A

Prevent osteoclast maturation
(Inhibit bone resorption)

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9
Q

What is the more common site of MRONJ, Maxilla or Mandible?

A

Mandible

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10
Q

What types of bisphophonates have an increased likelihood to cause MRONJ?

A

Nitrogen-containing bisphosphonates

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11
Q

What duration of oral and IV bisphosphonates puts a patient into a higher risk of MRONJ?

A

Oral - 5+ years
IV - 5+ years

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12
Q

What types of cancers may metastasise to bone?

A

Breast
Prostate
Lung
Kidney
Thyroid
Bowel

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13
Q

What is stage 1 MRONJ?

What is the treatment?

A

Asymptomatic exposed bone

Analgesics and antibiotics
Antiseptic mouthwash

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14
Q

Which teeth are more affected by MRONJ, Anterior or Posterior

A

Posterior

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15
Q

Which route increases the risk of MRONJ, Oral or IV?

A

IV

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16
Q

What conditions require bisphosphonates? (5)

A
  • Osteoporosis
  • Osteogenesis imperfecta
  • Paget’s disease
  • Multiple myeloma
  • Metastatic bone disease
17
Q

According to SDCEP what is a high risk MRONJ patient? (4)

A

Any of the following:

  • Treated for osteoporosis with oral or IV bisphosphonates for more than 5 years
  • Treated for osteoporosis or other non-malignant disease with denosumab or bisphosphonates who are taking systemic glucocorticoids
  • Cancer patients being treated with anti-resoptive or anti-angiogenic drugs
  • Patients with a previous diagnosis of MRONJ
18
Q

How would you manage a MRONJ patient in the dental practice?

A
  • Regular dental check-ups & maintain good OH
  • Non-OS Tx can be done in primary care (e.g. restorations, endo to avoid XLA, pros & non-surgical periodontal tx)
  • Undertake precautions for OS
19
Q

What are the 4 criteria for diagnosing MRONJ?

A
  1. Current or previous treatment with anti-resorptive or anti-angiogenic medication
  2. Exposed bone or bone that can be probed through an intra-oral or extra-oral fistula in the maxillofacial region that has persisted for more than 8 weeks
  3. No history of radiotherapy to the jaws
  4. No obvious metastatic disease to the jaws
20
Q

What does RANKL stand for?

A

Receptor activator of nuclear factor kappa-B ligand

Denosumab is a RANKL inhibitor

21
Q

How do anti-angiogenic drugs work?

A

Interfere with new formation of blood vessels (angiogenesis) involving multiple kinases

22
Q

How do you manage a patient who is high risk for MRONJ who needs extractions?

A
  • One sextant at a time & review healing
  • Antiseptic mouthwash prescription (CHX)
  • Flapless surgery
  • Antibiotics (no evidence)
23
Q

What is stage 2 MRONJ?

What is the treatment?

A

Symptomatic exposed bone

Analgesics and antibiotics
Antiseptic mouthwash (CHX)
Superficial debridement

24
Q

What should we do to a patient prior to them starting anti-resorptive or anti-angiogenic drugs?

A
  • Extraction of poor prognosis/unrestorable teeth
  • Allow for mucosal healing (ideally 10 days)
  • Encourage good OH
  • Smoking cessation
25
Q

What is the proposed mechanisms of action of bisphosphonates causing MRONJ?

A

Inhibition of osteoclast differentiation & function leading to apoptosis
Which leads to decreased bone resorption & remodelling

26
Q

What are the different classes of anti-resorptive drugs?

A

Bisphosphonates
RANKL Inhibitor monoclonal antibody

27
Q

How often are Denosumab intravenous injections given to a patient?

Oral surgery (8 decks)

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