Osteonecrosis

Question 1

osteonecrosis

Answer 1

patients to be considered to have Anti-resorptive agent related osteonecrosis of the jaw:
- current/previous tx with anti-resorptive drugs
- exposed bone that persists >8 weeks
- no history of radiotherapy or obvious metastic bone diseases of the bone

Question 2

predisposing factors

Answer 2

inhibition of bone remodelling
inflammation/infection
anti-angiogenesis
soft tissue toxicity
immune dysfunction

Question 3

clinical features

Answer 3

pain
exposed bone
swelling
numbness

Question 4

MRONJ stage 0

Answer 4

no clinical evidence of necrotic bone
non-specific clinical findings, radiographical changes and symptoms
systemic management – including the use of pain medication and antibiotics

Question 5

MRONJ stage 1

Answer 5

exposed necrotic bone
pts are asymptomatic
no evidence of infection
antibacterial mouth rinse
clinical follow up
patient eduction and review of indications

Question 6

MRONJ stage 2

Answer 6

exposed and necrotic bone/fistulae that probes the bone
associated with infection
pt presents with pain and erythema in the region of the bone
symptomatic tx with oral antibiotics
oral antibacterial mouth rinse
debridement to relieve soft tissue irritation and infection control.

Question 7

MRONJ stage 3

Answer 7

exposed and necrotic bone
pts present with pain and infection
exposed and necrotic bone extend beyond the region of the alveolar bone
pathological fracture, E/O fistula, OAC, osteolysis extending to the inferior border of the mandible of the sinus floor
antibacterial mouth rinse
antibiotic therapy and pain control

Question 8

histological features

Answer 8

loss of bone architecture
the absence of proper Haversian system
presence of necrotic spots of non-mineralized tissue
areas of empty osteocytic lacunae next to the areas of hypercellularity
presence of resorption pits with rare osteoclast like cells and presence of bacteria and of an inflammatory infiltrate

Question 9

management

Answer 9

extract any teeth with poor prognosis
reduce periodontal infection
adjust or replace poorly fitting dentures

Question 10

anti-angiogenic medication

Answer 10

tyrosine kinase inhibitors (sutent)
vascular endothelial growth factor inhibitors (avastin/zaltrap)

Question 11

Low risk

Answer 11

pts being treated for osteoporosis/non-malignant diseases of the bone with oral bisphosphonates for <5 years
pts who are non concurrently being treated with systemic corticosteroids or other immunosuppressants
pts being treated for osteoporosis or other non-malignant diseases of the bone with yearly infusions of IV bisphosphonates for <5yrs
Pts being treated for osteoporosis or other non-malignant diseases of the bone with RANKL inhibitors eg denosumab

Question 12

high risk

Answer 12

pts being treated for osteoporosis or other non-malignant diseases of the bone with oral bisphosphonates/yearly infusions of IV bisphosphonates for >5 yrs
pts being treated for osteoporosis or other non-malignant diseases of bone with bisphosphonates or RANKL inhibitors
pts taking anti-resorptive or anti-angiogenic drugs as part of management