How would you assess whether a patient taking anti-resorptive or anti-angiogenic drugs is at low risk or higher risk of developing MRONJ?
Ask about past, current, or possible future use of anti-resorptive or anti-angiogenic drugs when taking a medical history.
What patients are at low risk of developing MRONJ?
- currently taking denosumab, or have taken denosumab in the last nine months
- currently taking a bisphosphonate or have taken one in the past for < 5 years
- not concurrently treated with a systemic glucocorticoid
- no previous MRONJ diagnosis
- not currently being treated with anto-resorptive or anti-angiogenic drugs for the management of cancer
What patients are at higher risk of developing MRONJ?
- previous diagnosis of MRONJ
- currently being treated with anti-resorptive or anti-angiogenic drugs for the mangement of cancer
- currently taking denosumab or have taken denosumab in the last nine months AND is concurrently treated with a systemic glucocorticoid
- currently taking a bisphosphonate drug or have taken one in the past for ** < 5 years AND** is concurrently treated with a systemic glucocorticoid
- currently taking a bisphosphonate drug or has taken one in the past for ** > 5 years**
Describe the initial management of a patient about to commence anti-resorptive or anti-angiogenic drug therapy.
Aim to get the patient as dentally fit as feasible
- advise the patient that there is a risk of developing MRONJ but ensure they understand that the risk is so small so that they are not discouraged from taking their medication or undergoing dental treatment. Record that this advice has been given
- give personalised preventive advice to optimise their oral health, emphasing the importance of:
- healthy diet and reducing sugary snacks and drinks;
- maintaining excellent oral hygiene;
- using fluoride toothpaste and fluoride mouthwash;
- stopping smoking;
- limiting alcohol intake;
- regular dental checks;
- reporting any symptoms i.e. exposed bone, loose teeth, non-healing sores or lesions, pus or discharge, tingling, numbness or altered sensations, pain or swelling as soon as possible
- prioritise care that will reduce mucosal trauma or may help avoid future extractions or any oral surgery or procedure that may impact bone:
- consider obtaining appropriate radiographs to identify possible areas of infection and pathology;
- undertake any remedial dental work;
- extract any teeth of poor prognosis without delay;
- focus on minimisng periodonntal/dental infection or disease;
- adjust or replace poorly fitting dentures to minimise future mucosal trauma;
- consider prescribing high fluoride toothpaste
- consider consulting an oral surgery/special care dentistry specialist with regards to cliical assessment and treatment planning
Describe how would you continue the management of a patient on anti-resorptive or anti-angiogenic therapy.
Carry out all routine dental treatment as normal and continue to provide personalised preventive advice in primary care.
If an extraction or anny oral surgery or procedure which may impact bone,
* discuss risk of the procedure with the patient
* ensure valid consent
Low risk MRONJ:
* perform straightforward extractions and procedures that may impact bone in primary care
* do not prescribe antibiotic or antiseptic prophylaxis unless required for other clinical reasons
Higher risk MRONJ:
* explore all possible alternatives to extraction where teeth could potentially be retained e.g. retaining roots in absence of infection
* if extraction remains the most appropriate treatment, proceed as for low risk patients
Advise the patient to contact the practice if they have any concerns ie. unexpected pain, tingling, numbness, altered sensation or swelling in the extraction area
Review healing. If the socket is not healed at 8 weeks and you suspect MRONJ, refer to an oral surgery/special care dentistry specialist
What is MRONJ?
A rare side effect of an anti-resorptive an anti-angiogenic drugs.
Defined as exposed bone, or bone that can be probed through an intraoral or extraoral fistula, in the maxillofacial region that has persisted for more than eight weeks in patients with a history of treatment with anti-resorptive or anti-angiogenic drugs, and where there has been no history of radiation therapy to the jaw or no obvious metastatic disease to the jaws.
What is the incidence of MRONJ in cancer patients treated with anti-resorptive or anti-angiogenic drugs?
1%
1 in 100
What is the incidence of MRONJ in osteoporosis patients treated with anti-resorptive or anti-angiogenic drugs?
0.01-0.1%
1-10 cases in 10,000
