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. 

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