Anti-resorptive medicines & Oral Surgery
Advice for dental practitioners regarding Medication-Related Osteo-Necrosis of the Jaws (MRONJ)
Nomenclature is changing as it appears that it is not only bisphosphonates that are implicated in the pathogenesis of this condition. Other anti-resorptive medicines may also be implicated.
Bisphosphonate-Related ONJ = Medication-Related ONJ = Anti-resorptive-Related ONJ = Medication-Induced ONJ
Evidence has emerged that patients taking bisphosphonate and other anti-resorptive drugs are at risk of developing MRONJ. This can occur spontaneously but more commonly following dental extractions or oral bone surgery.
Anti-resorptive medicines (including bisphosphonates) are widely prescribed in oral formulation for osteoporosis management. Patients in this category are generally regarded as being at a low-risk of MRONJ developing (incidence estimated at 1 in 10,000 to 1 in 100,000).
Bisphosphonates are also prescribed by Haematology physicians for management of skeletal effects of malignancy (multiple myeloma, bony metastatic lesions and hypercalcaemia of malignancy. Patients in this category are generally regarded as being at high-risk of MRONJ developing (incidence estimated at 1 in 10 to 1 in 100)
These risks may be increased by other factors such as steroid therapy, diabetes, chemo & radiotherapy and alcohol and tobacco use.
The risk increases with the length of time patients have been taking the drugs, with 3 years seen as a threshold point for an increased likelihood of adverse effects.
1) Dental practitioners should ask about current or past use of bisphosphonates / anti-resorptives when taking a drug history.
2) Prior to commencement of bisphosphonate / anti-resorptive therapy, prescribers should advise patients of the risks of MRONJ developing. Patients should be advised to see a dental professional promptly for assessment. All necessary dental treatment should be completed as soon as possible prioritising extractions and sub-gingival scaling. Treatment strategies and preventive advice should be designed to to minimise the need for future extractions. Poorly-fitting dentures should be replaced.
3) During bisphosphonate / anti-resorptive therapy. Patients need regular dental care and careful attention to oral hygiene and diet. Avoid extractions if at all possible. Consider RCT and crown amputation.
4) If extractions are required, fully advise the patient of the risk of MRONJ developing and obtain written consent (and provide written information - see below). Low-risk extractions can usually be performed in primary care (see following documentation). In high-risk cases and those where difficulties are anticipated, referred to oral & maxillofacial surgery would be appropriate. There is little evidence that pre-and post operative anti-biotics are effective in preventing MRONJ, although some experts have recommended their use based on risk hierarchy. Chlorhexidine mouthwash should be used twice daily during the week leading-up to the extractions and for 2 months after. The patient should be reviewed until healing has completed. Extractions should be carried out in stages allowing a 2 month disease-free follow-up period before proceeding to other parts of the mouth.
5) The typical presenting features of MRONJ are: delayed healing of socket, pain, swelling, loosening of teeth, exposed bone, paraesthesia. purulent discharge via intra-oral or extra-oral sinus. If any of these signs or symptoms then prompt referral to the OMFS department is advised.
Scottish Dental Clinical Effectiveness Programme: Oral health management of patients prescribed bisphosphonates - Dental clinical guidance
Scottish Dental Clinical Effectiveness Programme: Advice letter for patients prescribed bisphosphonates
Haematology referral letter for dental assessment
Updated T Lees 03/12/15