MRONJ and bisphosphonates

Question 1

Give an example of bisphosphonates

Answer 1

Alendronic acid

Question 2

Give an example of vitamin D and calcium medication

Answer 2

Adcal

Question 3

How to take a history of a pt on bisphosphonates

Answer 3

1. intro
2. MH
3. SH
4. PDH
   - any extractions prev
5. bisphosphonates

Question 4

what are the role of osteoclasts

Answer 4

break down bone irregularities

Question 5

what are the role of osteoblasts

Answer 5

lay down new bone

Question 6

what are issues with bisphosphonates

Answer 6

• bisphosphonate drugs accumulate in areas where the bone is regenerating a lot e.g. jaw
• as osteoclasts are impaired, new bone is laid down over irregular bone
• can lead to loss of blood supply to the bone
• this is called BRONJ

Question 7

what is BRONJ

Answer 7

bisphosphonate related osteonecrosis of the jaw

exposed, necrotic bone in the maxilla/mandible that has lasted over 8 weeks

pt with BRONJ must take BP and no MH of radiation to jaw

Question 8

is the pt at risk of BRONJ

Answer 8

• ordinary tx -> low risk
• XLA -> specialist referral
• oral BP -> low risk and BRONJ following an XLA is v rare
• at risk of developing other health problems if disease isn’t treated

Question 9

what are the signs/symptoms of BRONJ

Answer 9

• feeling numb, heaviness or unusual jaw sensations
• pain in jaw or a bad taste
• swelling of the jaw, loose teeth or exposed bone

Question 10

why shouldnt you stop taking bisphosphonates before tx

Answer 10

• medial benefits far outweigh risks
• medication can remain in skeletal tissue for years

Question 11

how do you assess patients risk of MRONJ

Answer 11

1. prev diagnosis of MRONJ = high risk
   (if not go to 2)
2. pt being treated with anti-resorptive or anti-angiogenic drugs for management of cancer = high risk
   (if not go to 3)
3. taking bisphosphonates or taken in past
   3a. yes
   -> bisphosphonate drug taken for more than 5 years = high risk
   ->bisphosphonate drug taken for less than 5 years
   –> pt taking systemic glucocorticoids = high risk
   –> pt not taking systemic glucocorticoids = low risk
   3b. no
   -> pt not taking denosumab or taken in last 9 months = no risk
   -> pt taking denosumab or taken in last 9 months
   –> pt being concurrently treated with systemic glucocorticoid = high risk
   –> pt not being concurrently treated with systemic glucocorticoid = low risk

Question 12

how would you do a consultation with a pt with MRONJ

Answer 12

1. assess pt’s level of MRONJ risk
2. advise pt they are at risk of MRONJ
   - emphasise risk is small
   - explain risk can be reduced through OH, reducing sugary snacks and drinks, limit alcohol intake, stop smoking
3. aim to get pt as dentally fit as feasible, extractions where required, treat routinely for scale and polish, simple restorations, recall and radiological review

Question 13

what do you do with low risk pt where procedure which impacts bone is required

Answer 13

1. discuss risks of procedure with pt to ensure valid
2. treat pt as normal for extractions and any procedures affecting bones
3. DO NOT prescribe antibiotic prophylaxis unless otherwise indicated
4. review healing
   - if extraction socket isn’t healed at 8 weeks and you suspect pt has MRONJ, refer to oral surgery specialist

Question 14

what do you do with high risk pt where procedure which impacts bone is required

Answer 14

1. aim to avoid these procedures by considering other tx options
2. if extractions/other procedures impacting bone is most appropriate option, discuss risks of procedure with pt to ensure valid consent
3. review healing, if extraction socket isn’t healed at 8 weeks and you suspect pt has MRONJ, refer to oral surgery specialist

Question 15

what do you do with any pt with evidence of spontaneous MRONJ

Answer 15

refer

Question 16

which guidelines do you refer to for MRONJ and bisphosphonates

Answer 16

SDCEP