MRONJ Flashcards by Chelsea Empett

Medical Indications for Bisphosphonates

Osteoporosis
Cancer treatment-induced bone loss
Skeletal-related events in patients with malignancies that involve bone
Giant cell tumor of bone
Hypercalcemia of malignancy
Paget disease of bone

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Bisphosphonates are ____ absorbed in the GI tract

Poorly

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Bisphosphonates are excreted _____ by the kidneys

Unchanged

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Bisphosphonates have a high affinity for ______ within the bone

Hydroxyapatite

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Bisphosphonates are ____ within the bone

Inactive

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Bisphosphonates are released during ____ ____

Bone resorption

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Bisphosphonates ____ osteoclast activity and ____ osteoclast apoptosis

Inhibit; promote

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Two classes of bisphosphonates

Non-nitrogen containing BPs

Nitrogen containing BPs

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Non-nitrogen containing BPs function

Osteoclast apoptosis

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Nitrogen containing BPs: ____ mevalonate pathway and has ____ effects

Inhibits; antitumor

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Nitrogen containing BPs: What three processes do these affect?

Affect osteoclastogenesis, apoptosis and cytoskeletal dynamics

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Nitrogen containing BPs: Function of Zoledronate

Inihibits human endothelial cell proliferation

- Modulates endothelial cell adhesion and migration

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Denosumab/Prolia: Function

Acts against RANKL and inhibits osteoclast function

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Function of Antiangiogenic medications

Interfere with the formation of new blood vessels

- Used for various tumors/malignancies

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Antiangiogenic Inhibitors:

Function of Tyrosine Kinase Inhibitors

-Reduce the blood supply to the tumor thereby impacting the tumor’s ability to grow.

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“-nib”=

Tyrosine kinase Inhibitors

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“-mab”=

Monoclonal antibody

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Definition of MRONJ

Bone necrosis associated with pharmacologic therapies

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First criteria to establish diagnosis of MRONJ

Current or previous treatment with BMA or angiogenic inhibitor

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Second criteria to establish diagnosis of MRONJ

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.

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Third criteria to establish diagnosis of MRONJ

No history of radiation therapy to the jaws or metastatic disease to the jaws

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MONJ can be caused by a _____ of bone resportion

Supression

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MONJ can be caused by soft tissue ______

Toxicity

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MONJ can be caused by ___-angiogenesis and subsequent _____ vascularity

Anti; decreased

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MONJ can be caused by a local infection, with the presence of _______

Biofilm

MONJ can be caused by an exposure of the oral cavity to the _____ _____ through the teeth and PDL

Outside environment

High dose therapy for treatment of malignancy accounts for ___% of MRONJ cases

90%

The incidence of patients taking BP for osteoporosis is low, and 100 times lower with ____ patients

Cancer

What are the top two medical comorbidities leading to MRONJ

Chemotherapy and corticosteroids

What is the most common dental reason for MRONJ

Extractions

What are the two most offending meds leading to MRONJ

BPs and denosumab

A longer duration (>___ years) increases risk for MRONJ

2 years

Which route increases risk for MRONJ? IV or oral?

What type of surgery is a major risk factor for MRONJ

Dentoalveolar surgery

Is the mandible or maxilla more at risk for MRONJ? Which parts specifically?

Mandible; mylohyoid ridge, lingual tori, palatal tori

There is a ___ fold increase in risk for developing MRONJ in patients receiving IV therapy for cancer and have inflammatory dental disease

What immune suppressing conditions increase risk for MRONJ?

Diabetes, autoimmune diseases, renal dialysis

What type of chemotherapeutic agents increase risk for MRONJ?

Corticosteroids, cyclophosphamde

What are two genetic factors that increase risk for MRONJ?

- Single nucleotide polymorphism in the cytochrome P450-2C gene - MHC Class II polymorphism

MRONJ: Worse with ____ vs osteoporosis

Cancer

MRONJ: Worse with ___ meds vs. oral meds

Stage 0 MONJ

- No clinical evidence of necrotic bone | - Nonspecific symptoms or clinical or radiographic findings present.

Stage 1 of MRONJ

- Exposed and necrotic bone present | - Asymptomatic with no evidence of infection

Stage 2 of MRONJ

Exposed and necrotic bone present | Painful and clinical evidence of infection

Stage 3 of MRONJ

Exposed and necrotic bone present.

Non-exposed bisphosphonate-related osteonecrosis of the jaw

- History of BP use - Lack of bone exposure - Deep periodontal pockets - Drainage with or without sinus tracts - Pain - Advanced bone loss around involved teeth - Radiographic involvement: osteolytic changes

What can a pano show with MRONJ?

Can identify sequestra

MRONJ: When is CT helpful?

Useful when MRONJ is suspected in the differential diagnosis; allows for 3D reconstruction

MRONJ: The CBCT has ____ radiation than CT

Less

MRONJ: MRI can detect what?

Histopathologic changes of necrotic bone

MRONJ: What are some goals for management?

Elimination of pain Control infection Reduce progression of bone necrosis Prevent of reinfection

MRONJ: What procedure do we want to avoid if possible with active MRONJ?

Dental extractions

MRONJ: Stage 0 Suggested Treatment Strategy

- Patient education | - Systemic management, including the use of pain medication and antibotics

MRONJ: Stage 1 Suggested Treatment Strategy

- Antibacterial mouth rinses | - Clinical follow up on a quarterly basis

MRONJ: Stage 2 Suggested Treatment Strategy

- Patient education and review of indications for continued BP therapy - Symptomatic treatment with oral antibotics.

MRONJ: Stage 3 Suggested Treatment Strategy

- Pain Control - Debridement to relieve soft tissue irradiation and control the infection - Antibacterial mouth rinse - Antibiotic therapy and pain control - Surgical debridement or resection for long-term palliation of infection and pain

Three ways to prevent MRONJ

- OHI - Patient Education: MRONJ - Dental Exam and Treatment

Prevention of quality of life with patients with MRONJ include

- Patient education and reassurance - Control of pain - Control of secondary infection - Prevention of extension of lesion and development of new areas of necrosis

For patients initiating or receiving therapy for osteoporosis or a nonmalignant bone disorder for >3 years (low-dose therapy)

- Recommend non-surgical perio but modest bone recontouring may be done if needed - Prefer endo vs extraction - Dental implants are not contraindicated

For patients initiating or receiving therapy for a malignancy (high-dose therapy)

- Avoid elective surgical procedures - Consider nonsurgical endo or perio therapy for symptomatic teeth - Procedures that involve direct osseous injury should be avoided. non-restorable teeth may be treated by removal of crown and endodontic treatment of remaining roots

Treatment recommendation for those receiving oral antiresportive meds: Elective treatment is _____ contraindicated; what should we inform the patient of?

Not; small risk

There are ___ studies to show benefits of drug holidays in reducing MRONJ risk

Half life of BP drugs exceeds how many years

Treatment recommendation for those receiving oral antiresportive meds: What if I have to perform an extraction?

- Informed consent - Atraumatic technique - Primary closure - use of semipermeable membrane - CHX twice daily one week prior and continue afterwards depending on healing - Consider administration of antibiotic beginning one day prior to ext extending until completion of 7-10 day course

Oral or IV BP use is not an absolute contraindicating to placing _____

Implants

Which biomarker stood out in assessing risk for developing MRONJ?

PTH

What is the CTX test?

A potential diagnostic blood test that could be used to predict risk for MRONJ

What is looked for in CTX test? Which marker?

C-terminal cross-linking telopeptide level in blood; the first marker

What is correlated in the CTX test?

The c-terminal cross-linking telopeptide and the osteoclastic activity with clinical healing or response to surgical debridement

How is the CTX test conducted

With the morning fasting blood test

What value indicates a high risk for oral MRONJ with the CTX test?

100 pg/ml or less

CTX Test Moderate risk value

100-150 pg/ml

CTX testing minimal risk

Greater than 150 pg/ml

FOr patients taking oral BP >3 years, get CTX: | If value is below 150, what should be done?

Drug holiday After 4-6 months, repeat CTX If still below 150 -> extend drug holiday

Rate of osteoclast activity averages ____ pg/ml per month

Level of CTX in blood recovers to value in excess of 150 pg/ml in how many months?

6 to 9 months

MRONJ Flashcards

(76 cards)