Thursday, 14 December 2017


An update following my previous post a couple of years ago about bisphosphonates, this post is based on a talk by Claire Curtin who spoke at the Royal College of Surgeons Special Care Dentistry Study Day. 

What is MRONJ?

'Medication Related Osteonecrosis of the Jaw' (previously BRONJ, bisphosphonates), is an area of exposed bone, or bone that can be probed through an intra-oral or extra-oral fistula, in the maxillofacial region that has persisted for more than 8 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. 

Cause is unknown, but is likely to be multi-factorial (genetics and environment). Mechanisms are likely to be:
  • Suppression of bone turnover
  • Inhibition of angiogenesis
  • Toxic effects of soft tissues
  • Inflammation
  • Infection

What medications can cause MRONJ?

1. Anti-resorptives: Bisphosphonates (These carry a life-time risk of MRONJ), Denosumab (The risk diminishes 9 months after completion of treatment)

2. Anti-angiogenics: Bevacizumab, Aflibercept, Sunitinib

These drugs are used to treat: 

  • Osteoporosis
  • Prevention of cancer complications e.g. fracture, bone pain
  • Treatment of non-malignant bone conditions e.g. Paget's
  • Slow cancer progression
  • Treatment of multiple myeloma
The incidence of MRONJ in people with osteoporosis is 0.01%-0.2%, whereas people who have cancer is around 1%. The risk is thought to increase if both types of medications are taken (and if steroids are added into the mix). 

How to Manage?

1. Identify patients at risk

  • Full medical history is key
  • Have they been prescribed any relevant medication now or in the past?
  • How long for?
  • What condition do they have?
  • Do they have a history of MRONJ?
  • Are they taking any steroids?

2. Classify the patient's risk

  • LOW RISK - taking bisphosphonates < 5 years or Denosumab < 9 months with no steroid usage
  • HIGH RISK - receiving the treatment for a malignant condition, taking bisphosphonates > 5 years, steroid usage or a previous history of MRONJ

3. Patient Education and Prevention

  • Ideally prior to any prescription of anti-resorptive or anti-angiogenics a full dental assessment and prevention regime should be implemented. 
  • Any extractions or treatment to minimise mucosal trauma should be prioritised e.g. denture eases
  • Encourage patients to cessate smoking, have a healthy and balanced diet and see their dentists for regular check ups

4. Treatment

  • LOW RISK - Carry out extractions as normal, no need for prophylactic antiseptics or antibiotics. Review in 8 weeks
  • HIGH RISK - Seek alternatives to extractions if possible e.g. RCT; otherwise carry out extractions as normal, no need for prophylactic antiseptics or antibiotics. Review in 8 weeks

5. Identify and refer suspected MRONJ cases

  • Educate patient about symptoms e.g. tingling, numbness, pain, altered sensation around the extraction socket
  • Signs are exposed bone after 8 weeks
  • Always refer if in doubt

6. Report MRONJ via the Yellow Card Scheme

Many thanks to Claire Curtin and the RCSEd for organising the study day. Please read the full guidance from SDCEP for further information. 

What do you think about the new guidance and what's your experience of MRONJ? Let me know in the comments below. 

Tuesday, 28 November 2017

Careers In Special Care Dentistry: RCSEd Study Day

Thinking of a career in Special Care Dentistry? I recently attended a study day with the Royal College of Surgeons of Edinburgh which helped me understand what options there are out there in Special Care....

Routes to Specialisation

There are 2 main ways to specialise in Special Care Dentistry:

1. Special Care Registrar Training (SPR/STR)

A 3 year training pathway which may include opportunities to do a Masters in Special Care or the RCS Diploma (see below). 

These posts at the moment are released on Oriel on a regional basis but it is planned by 2018 to be a national recruitment process much like some of the other specialities e.g. orthodontics. Posts can be purely based in the community, in secondary care or a mixture of both. Following the 3 years training you will then take Royal College Exit Exams to become a Specialist (as well as completed a portfolio, competencies etc.). 

2. Special Care Academic Clinical Fellow

As above, another 3 year training pathway but divided into 75% clinical training and 25% academic. The target following any ACF post is to secure funding for a pHD and become an academic. 

The day to day timetable is very similar to an SPR. These posts are usually funded by the university rather than a deanery. 

The Royal College of Surgeons Diploma

The Royal College of Edinburgh offer a Diploma in Special Care Dentistry for those who wish to grow their portfolio and qualification in Special Care Dentistry. The diploma is available to those who can demonstrate experience in working in a special care environment for 1 year e.g. community. The diploma consists of 4 parts:
  • Log book of clinical experience relevant to Special Care Dentistry 
  • Case presentations x 2
  • 7 Unseen Cases Exam
  • Simple Best Answer Exam

The exam takes place twice a year, the next sitting is in March. For more information see the RCSEd website

Where do Specialists work?

Of course this doesn't just apply to specialists; there are plenty of clinicians with lots of experience in Special Care Dentistry who are not on the Specialist Register, especially since SCD is the newest dental speciality! In general, there are 3 environments that specialists can work:
  • In general practice (NHS or private)
  • In community dentistry/salaried dental services
  • In secondary care e.g. dental hospital
Often, specialists may divvy up their time in more than one environment. They can also be involved in other areas of dentistry e.g. commissioning, education. Broadly, most SCD specialists work within the NHS; however, there are skills SCD have that are highly valued in the private sector too e.g. sedation skills. 

SCD is a unique speciality as it encompasses all areas of dentistry. This means that specialists will have a broad range of skills in all areas of dentistry: from surgical extractions to molar endodontics! 

Many thanks to those who spoke on the day not just about careers, but some common topics that I experience (and often need help with!) throughout my day to day life in community! 

Is a career in special care dentistry for you? Are you on a specialist training pathway? Let me know in the comments below. 

Saturday, 18 November 2017

Pathway and the Faculty for Homeless and Inclusion Health: Regional London Meeting

Last week, I attended the regional London Meeting for Pathway and the Faculty of Homeless and Inclusion Health.

What is Pathway and the Faculty?

PATHWAY is the UK's leading homeless healthcare charity. They aim to integrate care within the NHS and voluntary sectors for homeless people: from GPs, nurses, housing professionals, hospitals and of course us dentists! They help with the logistics of accessing healthcare for homeless people e.g. recovering important documents, linking to community services, registration with GPs etc. 

The Faculty for Homeless and Inclusion Health is a network of health professionals working together to help those who find accessing health care most difficult:
  • The homeless
  • Vulnerable migrants
  • Travellers
  • Sex workers
It is free to join the network if you are health professional who manages these groups of people. This will help you keep up to date with current research as well as linking with other professionals in your area who also work with these people. Click here to join!

Homelessness, Physiotherapy and Autism

The regional meeting held at UCLH covered a couple of very interesting subject matters and there was lots of discussion within the audience. 

1. Physiotherapy and patients who are homeless with Jo Dawes

Jo Dawes discussed her plans to set up a research project into access to physiotherapy for patients who are homeless and how physiotherapy treatment can positively impact a homeless person's quality of life. It was interesting to compare how different cities may have different needs for their homeless populations: Jo explained how the service in Glasgow where she previously worker, provided care for their homeless population. 

2. Autism and homelessness with Dr Paula Grant

Dr Paula Grant explored the links between autism and homelessness and presented the findings of her recent research in the area. I found this talk particularly interesting as within my day to day practice, I manage both autistic patients and the homeless. She spoke of how she found that the lifestyle of the homeless has some advantages to people who are autistic e.g. not fitting into social norms, flexibility, limited interaction with others. 

Many thanks to those who spoke at the meeting and it was fantastic to meet others who are passionate about providing health care to hard to reach groups. Homeless and Inclusion Health hold an annual conference in London, March 7/8th. Hopefully I can get to go and see some of you there. Click here for details. 

Do you treat any of these socially excluded groups? Let me know how you manage these patients in the comments section.

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