pts at risk of MRONJ

Question 1

drugs associated with MRONJ

Answer 1

bisphosphonate
RANKL inhibitor - denosumab
anti-angiogenic - bevacizumab, sunitinib, aflibercept

Question 2

oral bisphosphonates

Answer 2

alendronic acid
risedronate sodium
ibandronic acid
sodium clodronate

Question 3

IV bisphosphonates

Answer 3

zolendronic acid

pamidronate disodium

Question 4

higher risk of MRONJ factors

Answer 4

prev MRONJ diagnosis
anti-resorptive/anti-angiogenic drugs for cancer
currently/have taken bisphosphonates in past for >5yrs
takin bisphosphonstes for <5yrs but concurrently txed with a systemic glucocorticoid
taking denosumab/have taken in last nine months and being concurrently txed with a systemic glucocorticoid

Question 5

low risk of MRONJ factors

Answer 5

taking denosumb/ within last 9months

bisphosphonates <5yrs

Question 6

what should be done before starting the drug or ASAP after?

Answer 6

get pt dentally fit, prioritising preventive care
prioritise care that will decrease mucosal trauma and help avoid future extractions
if complex get advice

Question 7

what should you advise pt?

Answer 7

there is a risk of developing MRONJ but that the risk is small so they should not be discouraged from taking meds or having dental tx - record advice given
preventive advice

Question 8

preventive advice to give pt

Answer 8

healthy diet and reducing sugary snacks and drinks
excellent OH
F toothpaste and mouthwash
stopping smoking
limiting alcohol intake
regular dental checks
reporting any symptoms e.g. exposed bone, loose teeth, non-healing sores/lesions, pus or discharge, tingling, numbness/altered sensations, pain/swelling ASAP

Question 9

tx for patients at low risk of MRONJ

Answer 9

perform straightforward extractions and procedures that may impact on bone in primary care
don’t provide AB or antiseptic prophylaxis unless required for other clinical reasons

discuss risk w patient to ensure valid consent
contact practice if any concerns

Question 10

tx for pts at higher risk of MRONJ

Answer 10

explore all alternatives to extraction where teeth could potentially be retained e.g. retaining roots in absence of infection
if ext remains the most appropriate tx, proceed as for low risk pts

discuss risk w patient to ensure valid consent
contact practice if any concerns

Question 11

reviewing pt after tx at risk of MRONJ

Answer 11

if extraction socket is not healed at 8 weeks and you suspect MRONJ, refer ASAP
if you suspect spontaneous MRONJ, refer ASAP