MRONJ Flashcards
Diagostic criteria of MRONJ
History of antiresorptive (bisphosphonates and RANKL inhibitor) and antiangiogenic
No history of radiation
Exposed bone with or without symptoms
Pathogenesis of MRONJ
These medications causes
1) Inhibition of osteoclastic activity therefore impaired remodelling
2) Inflammation and infection from microtrauma or surgical procedure
3) Inhibition of angiogenesis affecting the remodelling -> avascular necrosis
Risk factors of MRONJ
- Medication factor (Based on therapeutic indication/ type of meds)
- Cancer and its related bone disease»_space; Osteoporosis
- IV BPs for Ca»_space; IV BPs for OP
- IV RANKLi»_space; IV BPs
- IV BPs»_space; Oral BPs - Disease factor
- Cancer and its related bone disease»_space; Osteoporosis
- Long term BPs for OP > Short term BPs for anticancer - Local factor
- Surgical procedure
- Mucosal bearing denture
- Periodontal/Dental dz
- Poor OH
- Mandible > Maxilla - Patient factor
- comorbids
- steroids or other immunosuppresants
- duration of medication
- tobacco and alcohol
- nutritional status
Staging of MRONJ
Stage 0 - nonspecific symptoms of pain but no exposed bone
Stage 1 - Exposed bone without symptoms or free from infection
Stage 2 - Exposed bone with symptoms and infection present
Stage 3 - Exposed bone with: Involvement of bone close to mandibular border/sinus floor; Orocutaneous fistula; Pathologic fracture
Preventive measure of MRONJ
- prevention before starting therapy
- delay starting therapy until dental health optimized
- exodontia of all poor prognosis teeth 2-3weeks prior to starting therapy
- fluoride therapy
- CHX m/w
- education about term/duration of treatment may increase risk of MRONJ by 0.21% at 4 yrs (i.e the longer usage of these meds can increase risk of mronj by 0.21% every 4 yrs)
- reinforcing continuous optimal oral hygiene - prevention of MRONJ when therapy started
- maintenance of OH
- fluoride therapy
- CHX m/w
- drug holiday 2-3 months prior to and after any dentoalveolar surgery for those taking long term Oral BPs
- post-op antibiotic (empirically: Penicillin/ clindamycin) until soft tissue has healed
- atraumatic surgical procedure
Treatment of MRONJ stage 0
Stage 0: Nonspecific symptom, no exposed bone
Observation
Symptomatic treatment - pain relief
CHX M/W
Treatment of MRONJ Stage 1
Stage 1: exposed bone without symptoms and free from infection
Local debridement
CHX m/w
Close observation 6-8 weeks
Rv the need for continued medication therapy
Treatment of MRONJ Stage 2
Stage 2: exposed bone with symptoms and presence of infection
Local debridement (sequestrectomy/ saucerization/ decortication) CHX m/w Antibiotic (Penicillin/ clindamycin) until soft tissue healing Symptomatic relief
Treatment of MRONJ Stage 3
Stage 3: exposed bone involving diffusely over to border of mandible/ maxillary sinus floor + orocutaneous fistula + pathologic fracture
Extensive surgical debridement/ Resection with recontstruction Oral antibiotics ( Penicillin/ Clindamycin) until soft tissue healing Symptomatic relief
What are medications that leads to MRONJ
Antiangiogenic - for tx of variety of cancers
- tyrosine kinase inhibitor (sunitinib, sorafenib)
- monoclonal antibodies (VEGF inhibitor, EGFR inhibitor - cetuximab)
Antiresorptive 1. for cancers that has effects on bone (multiple myeloma, breast cancers, prostate cancer) 2. Bone diseases - osteoporosis - Pagets disease - osteogenesis imperfecta - GCTs Name of antiresoptive drugs - aminobisphosphonate antineoplastics - denosumab antineoplastic - aminobisphosphonate osteoporotic - denosumab osteoporotic
What are the indications of different types of antiresoprtives and antiangiogenic?
IV BPs
- cancer related condition -> hypercalcemia
- skeleteal related metastases in breast and prostrate and lung cancer
- lytic lesions in multiple myeloma
IV BP - yearly infusion of zolendronate for OPs
IV ibandronate bonviva - every 3 months for osteoporosis
Oral BPs: for osteopenia, osteopetrosis, Pagets, osteogeneis imperfecta
RANK ligand inhibitor (denosumab)
- inihibit osteoclast function
- PROLIA (trademark)
- subcutaneously every 6 months
- to reduce hip fractures
- their effects are DIMINISHED after 6 months of treatment as they dont bind to bone
Antiangiogenic medications: GI tumour, renal cell CA, neurendocrine tumour and others.
Eg: cetuximab EGFR inhibitor; Bevacizumab VEGF inhibitor
Give the name of antiresoptive drugs
Aminobisphosphonate antineoplastics (IV monthly)
Aredia < Boniva < Zometa
(Pamidronate < ibandronate < zolendronate)
(Potency 100 < 10,000 < 100,000)
Denosumab antineoplastic (RANKLi) - IV Xgeva monthly
Aminobisphosphonate osteoporotic
- Alendronate < Risedronate < Ibandronate < zolendronate
(Fosamax < Actonel/atelvia < Boniva < Reclast)
Potency 1000 < 5000 < 10,000 < 100,000
PO weekly
Reclast IV annually
Denosumab osteoporotic
- Prolia IV 6 monthly
