Day 3-Osteonecrosis of the Jaw

Question 1

What did Dr. C not want us to confuse with medication related osteonecrosis of the jaw?

Answer 1

osteoRADIOnecrosis of the jaw from H&N radiation

Question 2

MRONJ Definition: 1) Exposed bone or bone that can be probed through an intraoral or extraoral fistula(e) in the MF region that has persisted for more than
___ weeks.

Answer 2

8

Question 3

MRONJ Definition: 2) No h/o ______ therapy (XRT) to the jaws.

Answer 3

radiation

Question 4

MRONJ Definition: 3) Current or previous treatment

with ________ or ________ agents

Answer 4

antiresorptive or antiangiogenic

Question 5

WHEN were the first cases of MRONJ coming about and what was the common thread of all of them?

Answer 5

2003….all pt were in IV bisphosphnates

Question 6

Whats a REALLY common area for MRONJ to manifest?

Answer 6

Lingual of posterior mandibular molar

Question 7

What was the main pathogen in MRONJ that the pathologist found>?

Answer 7

actinomyces

Question 8

________ oxygen restores vascularity to marginal bone does it have a significant impact on improving MRONJ?

Answer 8

hyperbaric..NO

Question 9

What is the MOST COMMONLY Rx’d ORAL bisphosphonate that started to manifest as MRONJ?

Answer 9

ALEN-DRON-ATE

Question 10

Now, other types of medications used in the treatment of osteoporosis and cancer have been shown to cause osteonecrosis, eg. _______ inhibitors and monoclonal ______, and anti-_______ drugs

Answer 10

RANK-L….monoclonal antibodies…. anti-angiogenesis

Question 11

IMPORTANT! What are the three types of ANTI-RESORPTIVE meds associated with MRONJ?

Answer 11

1. IV Bisphosphonates 2.Oral Bisphosphonates 3.RANK-ligand inhibitor-a human monoclonal antibody

Question 12

IMPORTANT besides anti-resorptive meds, what other class of drugs are associated with MRONJ?

Answer 12

Anti-Angiogenic meds

Question 13

What are the three most common cancers that metastasize to bone and therefore are treated with MRONJ associated medS?

Answer 13

BREAST, PROSTATE, LUNG

Question 14

What conditions are treated with these anti-angiogenic medications? Bone lesions of _________

Answer 14

multiple myeloma

Question 15

What are the three common ORAL bisphosphonates?

Answer 15

1. ALEN-DRON-ATE (Fosamax) 2.RISE-DRON-ATE (Actonel) 3.I-BAN-DRONATE (Boniva)

Question 16

What are the two common IV bisphosphonates?

Answer 16

1.PAM-I-DRON-ATE (Aredia) 2.ZOLE-DRON-ATE (Zometa)

Question 17

Recast is crazy- whats its unusual dose?

Answer 17

5mg/1yr

Question 18

What are the names of the 2 Rank-L inhibitors?

Answer 18

1)Denosumab 2)ProLia

Question 19

What are the two SubQutaneous bisphosphonates? How often are these administered to the Pt?

Answer 19

1)Denosumab 2)Prolia…1x/6months

Question 20

Bisphosphonates and RANK-L inhibitors act by inhibiting ________ activity.

Answer 20

osteoclast

Question 21

Osteoclasts resorb bone, releasing ______ and growth factors that stimulate circulating stem cells to differentiate into osteoblasts and create new bone.

Answer 21

BMP

Question 22

Inhibition of ________ prevents normal bone turnover, remodeling, and healing of bone when wounded.

Answer 22

osteoclasts

Question 23

_________ medications interfere with formation of blood vessels and interrupt vascular supply causing avascular necrosis

Answer 23

Anti-angiogenic

Question 24

A common indicator for MRONJ is a thick or sclerotic _________.

Answer 24

Lamina Dura (around the root of the tooth)

Question 25

Another good indicator of MRONJ is a _____ blood test which is an index of blood turnover. What is a HIGH risk result of the test?

Answer 25

CTX (Collagen Type I C-telopeptide)...less than 100 is high risk

Question 26

Dang! Our CTX blood test to look for MRONJ is not useful in these three patients:

Answer 26

1.Cancer patients 2.Methotrexate pt's 3.steriod pt's

Question 27

Are there SYSTEMIC tests to indicated MRONJ validated by OS yet?

Answer 27

NO

Question 28

What is IDEAL for treating a dental patient when they are going to go on IV bisphosphonates for cancer tx? What happens if MRONJ is already present?

Answer 28

Treat patient to control infection and inflammation in the oral cavity BEFORE going on the meds...if present prevent/control secondary infection (life long abx)

Question 29

Cessation of at-risk meds (drug ______) for patients with extended exposure (>___ years) of oral bisphosphonates or denosumab for osteoporosis/osteopenia

Answer 29

holiday...more than 4 years

Question 30

The patient has already started anti-angiogenic meds how am I going to Tx? “Nonrestorable teeth may be treated by _______ and ______ treatment of the remaining roots”

Answer 30

removal of the crown...endo (so were not messing with alveolar bone)

Question 31

INTERESTING!!! Patients who have taken an oral BP for LESS than ___ years and have NO CLINICAL RISK FACTORS: no alteration or delay in planned surgery is necessary.

Answer 31

4 years

Question 32

Patients who have taken an oral BP for LESS than 4 years and have taken CORTICOSTEROIDS or ANTIANGIOGENIC medications concomitantly: contact the prescribing provider to consider a drug ______ for at least ______ months before oral surgery. Do not restart the drug until osseous healing is complete.

Answer 32

HOLIDAY....2 MONTHS

Question 33

Patients who have taken an ORAL BP for more than 4 years with or without any concomitant medical therapy: contact the prescribing provider to consider a drug ______ for ____ months before oral surgery. Do not restart until after osseous healing is complete.

Answer 33

HOLIDAY.... 2 MONTHS

Question 34

Is the Pt on PROLIA (denosumab)? Drug holiday of ___ months recommended before surgery.

Answer 34

3 months

Question 35

Is the Pt on RECAST (Zol-En-Dron-Ate)? Its taken once per year, so what time in the year cycle do you perform dental Tx?

Answer 35

Surgery 9 months after dose, so 3 months before dose.

Question 36

``` Indications for ________: 1) Symptomatic and refractory to nonsurgical treatment 2) Pathologic fractures 3) Direct sinus communication ```

Answer 36

RESECTION of the jaw :(

Question 37

____% of patients who have MRONJ, are or can be maintained pain-free!

Answer 37

90%

Question 38

For those on _____ meds, the disease appears to be rare, less severe, and reversible with discontinuation of the med

Answer 38

ORAL

Question 39

New approaches to treatment of established MRONJ Low level _____ therapy, radiotherapy

Answer 39

LASER

Question 40

3 of the 4 diagnostic criteria for MRONJ are from the __________!

Answer 40

historical data

Question 41

What is the magic number for patients taking oral bisphosphnates?

Answer 41

4 years

Question 42

Why are IV bisphosphonates so much more likely to cause MRONJ?

Answer 42

they are 5-10x more potent!

Question 43

What are the three bisphosphonates (2 IV, 1 SQ) commonly Rx'd with chemo? (and therefore cancer Pt's may not know their whole cocktail)

Answer 43

1.Zometa (Zol-en-dron-ate...IV) 2.Aredia (Pam-i-dron-ate...IV) 3.Xgeva (Denosumab...SQ)