- Medication-related osteonecrosis of the jaw (MRONJ) is defined as exposed bone or bone that can be probed through one or more intraoral or extraoral fistulae in the maxillofacial region and that does not heal within 8 weeks, occurring in a patient who has received a bone-modifying agent (BMA) or an angiogenic inhibitor agent and has no history of head and neck radiation.
- The condition may involve the mandible or the maxilla.
- BMAs that have been linked with MRONJ principally include bisphosphonates and denosumab.
- BMAs are a key component of the management of patients with cancer with skeletal metastases.
- These medications provide a number of clinical benefits, including a reduced incidence of skeletal-related events (e.g., pathologic fractures and spinal cord compression) and reduced need for radiation or surgery to bone.
- Use of BMAs is associated with MRONJ, which occurs in approximately 1–9% of patients with advanced cancer.
- This pocket guide focuses on the prevention and management of MRONJ in patients with cancer who receive BMAs for oncologic indications.
- The pocket guide does not address BMAs used for osteoporosis, which are administered at a lower dose and carry a lower risk for MRONJ, nor does the pocket guide address the prevention or management of MRONJ due to medications other than BMAs.
- It is recommended that the term “medication-related osteonecrosis of the jaw" (MRONJ) be used when referring to bone necrosis associated with pharmacologic therapies. (Weak Recommendation; FC-Ins).
- Clinicians should confirm the presence of all three of the following criteria in order to establish a diagnosis of MRONJ: 1) Current or previous treatment with a BMA or angiogenic inhibitor, 2) Exposed bone or bone that can be probed through an intraoral or extraoral fistula in the maxillofacial region and that has persisted for longer than 8 weeks, and 3) No history of radiation therapy to the jaws or metastatic disease to the jaws. (Weak Recommendation; FC-Ins)
Coordination of Care
- For cancer patients scheduled to receive a BMA in a non-urgent setting, oral care assessment (including a comprehensive dental, periodontal, and oral radiographic exam when feasible to do so) should be undertaken prior to initiating therapy. Based on the assessment, a dental care plan should be developed and implemented. The care plan should be coordinated between the dentist and the oncologist to ensure that medically necessary dental procedures are undertaken prior to initiation of the BMA. Follow-up by the dentist should then be performed on a routine schedule (e.g., every six months) once therapy with a BMA has commenced. (Moderate Recommendation; EB-L/I)
Modifiable Risk Factors
- Members of the multidisciplinary team should address modifiable risk factors for MRONJ with the patient as early as possible. These risk factors include poor oral health, invasive dental procedures, ill-fitting dentures, uncontrolled diabetes mellitus, and tobacco use. (Moderate Recommendation; FC-Ins)
Elective Dentoalveolar Surgery
- Elective dentoalveolar surgical procedures (e.g., non-medically necessary extractions, alveoloplasties, and implants) should not be performed during active therapy with a BMA at an oncologic dose. Exceptions may be considered when a dental specialist with expertise in prevention and treatment of MRONJ has reviewed the benefits and risks of the proposed invasive procedure with the patient and the oncology team. (Moderate Recommendation; EB-I)
Dentoalveolar Surgery Follow-Up
- If dentoalveolar surgery is performed, patients should be evaluated by the dental specialist on a systematic and frequently scheduled basis (e.g., every 6-8 weeks) until full mucosal coverage of the surgical site has occurred. Communication with the oncologist regarding status of healing is encouraged particularly when considering future use of BMA (Table 2). (Moderate Recommendation; FC-Ins)
Temporary Discontinuation of BMAs Drior to Dentoalveolar Surgery
- For patients with cancer who are receiving a BMA at an oncologic dose, there is insufficient evidence to support or refute the need for discontinuation of the BMA prior to dentoalveolar surgery. Administration of the BMA may be deferred at the discretion of the treating physician, in conjunction with discussion with the patient and the oral health provider. (Weak Recommendation; IC-Ins)