MRONJ and ORN

Question 1

What would classify patient low-risk for MRONJ?

Answer 1

Patient being treated for osteoporosis or other non-malignant bone disease with:
either ORAL or IV bisphosphonates and NOT concurrently taking systemic glucocorticoids
treated with denosumab and NOT concurrently taking systemic glucocorticoids

Question 2

What would classify patients as being HIGH risk for MRONJ?

Answer 2

Patient being treated for osteoporosis or other non-malignant bone disease with:
oral or IV bisphosphonates for >5 years
treated with bisphosphonates or denosumab for any length of time if ALSO being treated with systemic glucocorticoids
ALL CANCER PATIENT TREATMENT with anti-resorptive or anti-angiogenic drugs
Patients with previous MRONJ diagnosis

Question 3

10 management options for MRONJ?

Answer 3

Conservative approach - monitor
Antiseptic MW
Specific OHI in relation to exposed bone e.g. irrigation
Minimal surgical debridement
Primary closure where possible
Symptomatic relief
Occasionally antibiotics
Radiology useful to establish differential diagnosis
Consultation with GMP to check if drug modification warranted
Onward referral

Question 4

4 ways MRONJ could be prevented?

Answer 4

Smoking cessation
Make patient dentally fit prior to commencing medication
OHI and excellent execution from patient
High fluoride toothpaste
Patient education

Question 5

What two drug classes puts someone at risk of MRONJ and examples?

Answer 5

Anti-resorptive - bisphosphonates
Anti-angiogenic -
RANKL inhibitor - denosumab

Question 6

What time frame, if extraction socket has not healed by, should you suspect that patient has MRONJ?

Answer 6

8 weeks

Question 7

What radiation dose puts someone at higher range of ORN?

Answer 7

60-70Gy

50-60Gy not as high

Question 8

Why do bisphosphonates increase risk of osteonecrosis?

Answer 8

They significantly inhibit the activity of osteoclasts, which means that when a tooth is extracted, the bone socket cannot properly heal and remodel, leading to exposed, dead bone tissue in the jaw due to impaired blood supply and poor wound healing

Question 9

Explain the relevance of bisphosphonates to dentistry to a patient

Answer 9

There is a risk of poor wound healing following a tooth extraction
Need to remove any teeth of poor prognosis prior to beginning drug therapy
Important to do everything possible to prevent further tooth loss in future
Reduced turnover of bone and reduced vascularity can leaf to death of bone - osteonecrosis

Question 10

Mode of action of bisphosohonates?

Answer 10

Bisphosphonate drugs slow bony turnover - they strengthen bones by preventing bone loss (by inhibiting osteoclasts) to maintain bone density.
They also decrease vascularity
Bisphosphonates accumulate in sites of high bone turnover, the jaw bone being one of them