mronj Flashcards
what are the risk factors for MRONJ
- treatment indication
cancer > osteoporosis - duration of tx
- first 3 years lower risk for oral BP in OP pt
- >2 years in cancer pt higher risk - concurrent medications
- long term glucocorticoid + chemotherapy»_space; - type of antiresorptive
- denosumab/ IV BP»_space; oral BP - location of exo
- posterior mandible»_space; maxilla - concomitant oral disease
- pre-existing perio/ periapical disease»_space; good OH - systemic conditions
- comorbidities like diabetes
what are the pathophysiology for MRONJ?
- bone remodelling inhibition
- AR inhibit osteoclast formation, differentiation, function –> osteoclast dysfunction –> reduced bone resorption and remodelling –> poor wound healing - infection/ inflammation
- extracted teeth tend to be a source of infection –> pericoronitis/ PARL
- presence of inflammed environment –> exacerbates effects of AR therapy - angiogenesis inhibition by drug
- BP inhibits angiogenesis –> chronic ischemia at MRONJ sites –> avascular necrosis - innate immune dysfunction
- pt w comorbidities have higher MRONJ risk w or w/o exposure to AR
- cancer pt undergoing chemo have higher MRONJ prevalence
duration that is considered lower risk for osteoporosis pt on AR therapy
first 3 years ok
duration of AR therapy that is lower risk of MRONJ for cancer patients
< 2 years lower risk
compare risk of mronj in cancer n osteoporosis patients
- OP pt alot lower risk than cancer pt
what are the 3 criterias for case definition of MRONJ?
- currently using/ history of AR therapy
- no history of radiotherapy to jaw or metastatic jaw disease
- exposed bone that can be probed through i/o or e/o Fistula in maxillofacial region, persisted for > 8 weeks
PERSISTED FOR > 8 WEEKS IS IMPORTANT
NAME THE AR drugs and their categories
- RANKL inhibitor: Denosumab
- Bisphosphonates: Alendronate
Describe stage 0 for MRONJ
they tend to present w no clinical evidence of necrotic bone, non-specific symptoms OR clinical & radiographic findings.
Symptoms, Clinical findings, radiographic findings
Symptoms:
- Odontalgia not explained by odontogenic cause
- Dull aching bone pain, may radiate to TMJ
- Sinus pain (may be assoc w inflammation & thickening of sinus wall)
- Altered neurosensory function
Clinical findings:
- Loosening of tooth not explained by Perio
- I/o or e/o swelling
*No clinical evidence of necrotic bone
Radiographic:
- LD thickening and reduced PDL space in exo socket
- Alveolar BL not due to Perio
- Change in trabeculae pattern, slcerotic bone & no new bone in exo socket
- Osteosclerosis involving alveolar bone
THE SYMPTOMS ARE NON SPECIFIC
Features of Stage 1 MRONJ
symptoms, clinical & xray findings
- Asymptomatic
- Exposed and necrotic bone/ fistula that probes to bone
- No evidence of infection
may present w radiographic findings of stage 0, localized to alveolar bone region
Features of Stage 2 MRONJ
- Exposed & necrotic bone/ fistula that probes to bone
- Symptomatoic
- Evidence of inflammation/ infection
Xray: may present w radio findings of stage 0, localized to alveolar bone region
Features of Stage 3 MRONJ
- Evidence of infection/ inflammation
- Exposed & necrotic bone/ fistula that probes down to bone
> 1 of the following
- Extraoral fistula
- Pathological fracture
- OAC
- Osteolysis extending to inferior border of mandible/ sinus floor
- Exposed necrotic bone extending beyond region of alveolar bone
goals of dental clearance before mronj
- exo hopeless teeth (perio, unrestorable)
- treat all existing active oral infections
- caries control, scrd, oheohi
- ensure well fitted denture, no mucosal trauma
- complete all necessary elective dentoalveolar procedures
- wait 2-3 weeks for surgical site to mucosalize before beginning AR therapy for malignancy patients, ONLY IF SYSTEMIC CONDITIONS PERMIT –> may be in pain or stage 4 cancer idk
what are the 2 types of tx modalities for MRONJ
- non operative
- operative
explain steps in non-operative therapy for stage 1
- CHX wound care
- improve OH to remove biofilm from necrotic bone
- if no diseaseprogression & adequate QOL, no need surgery
explain the aims of non operative therapy for MRONJ
- focus on pt education, reassurance, control of pain & secondary infection
aims to allow for sequestration of necrotic exposed bone
once sequestra appears –> sequestrectomy (remove dead bone) –> allow for disease resolution
basically letting the dead bone exfoliate itself then remove
indications for non-operative therapy
- stage 2 & 3 MRONJ pt unsuitable for surgery (comorbidities)
- is pt able to perform good wound care? good OH? –> reduce infection & disease spread
e
explain stage 2 MRONJ doing non-operative theapyh
- CHX local wound care
- may need AB
consider operative therpay if
- non responsive to non-operative therapy
- pt cannot maintain adequate OH
indications for operative therapy for MRONJ
- for pt w advanced disease
- pt who are not responsive to conservative tx
what do they do in operative therapy for MRONJ
- marginal resection or segmental resection
stage 2 and above need give systemic antibiotics
