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Oral Medicine > MRONJ > Flashcards

MRONJ Flashcards

1
Q

Chemotherapy for Oral Malignancies
* used primarily for …
* may be used for …

A

Head and Neck
Squamous Cell Cancer (HNSCC) for organ
preservation in advanced disease

palliative treatment as well
as in combination with radiotherapy for
postoperative high‐risk cases.

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2
Q

Chemotherapy for HNSCC
Three possible strategies.

A
  1. Neoadjuvant therapy or induction chemotherapy.
  2. Adjuvant therapy
  3. Concurrent chemoradiation for cure or organ preservation.
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3
Q
  1. Neoadjuvant therapy or induction chemotherapy.
    (2)
A
  • Chemotherapy is administered before locoregional surgery or
    radiotherapy.
  • Sequential therapy generally refers to chemotherapy followed by
    radiation with concurrent chemotherapy.
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4
Q
  1. Adjuvant therapy
A
  • Chemotherapy and radiotherapy are
    simultaneously administered after surgery in
    high‐risk patients, reducing metastatic
    burden
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5
Q
  1. Concurrent chemoradiation for cure or organ preservation.
    * Simultaneous (2) are a definitive and
    curative treatment for instances in – tumors.
    * Radiation is used with (2) for the additive (or
    supra‐additive) radiosensitizing effect of chemotherapy to enhance the
    effectiveness of the radiation treatment.
    * considered a standard of care for tumors of the —.
A

chemotherapy and radiotherapy
laryngeal
cisplatin and 5‐fluorouracil
oropharynx

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6
Q

Types of chemotherapy agents
(5)

A
  • Alkylating agents
  • Antibiotics
  • Antimetabolites
  • Alkaloids
  • Taxanes
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7
Q
  • Alkylating agents
    (1)
A
  • cisplatin;
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8
Q
  • Antibiotics—
    (3)
A

derivatives of antimicrobial compounds from Streptomyces
eg. doxorubicin,
bleomycin
mitomycin

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9
Q
  • Antimetabolites
    (2)
A
  • methotrexate
  • 5‐fluorouracil;
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10
Q
  • Alkaloids
    (2)
A
  • vincristine
  • vinblastine;
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11
Q
  • Taxanes
    (2)
A
  • paclitaxel
  • docetaxel
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12
Q

Types of chemotherapy agents
Bisphosphonates – being used more for management of
— in addition to systemic management of
osteoporosis

A

malignancies

-
Systemic agents
-
-

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13
Q

 Antiresorptive Medications
(2)
 Antiangiogenic Medications

A

 Bisphosphonates
 RANK Ligand Inhibitors

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14
Q

Bisphosphonates
 Initially used for the treatment of (3)
 More recently, they have been used as an
adjunctive treatment of —
 Decrease — activity

A

osteoporosis,
Paget’s disease, and osteogenesis imperfecta
cancer
osteoclastic

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15
Q

Bisphosphonates (Non-Nitrogen)
 Oral only
(2)
 Primarily used for the treatment of —
 — potency
 Prevents …

A

 Etidronate – Didronel
 Clodronate – Bonefos, Clasteon, Loron

Paget’s disease
Low
osteoclast proliferation by inhibiting ATP
(adenine triphosphate) dependent enzymes

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16
Q

Bisphosphonate
(Nitrogen Containing)
 (2)
 Mechanism of action
(2)

A

Oral or IV

 Prevents binding of essential proteins to the cell
membrane leading to apoptosis
 Prevents adhesion of the osteoclasts to the
hydroxyapatite crystals by altering the cell cytoskeleton

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17
Q

Oral Nitrogen Containing
Bisphosphonates
 Approved for use in the treatment of (2)

ex (3)

A

Paget’s disease
and osteoporosis

 Alendronate (Fosamax)
 Risedronate (Actonel)
 Ibandronate (Boniva)

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18
Q

IV Nitrogen Containing
Bisphosphonates
 Used in the treatment of osteoporosis
(1)
 Used in the treatment of bone metastases
(1)

A

 Zolendronate (Reclast) – 5mg/year

 Zolendronate (Zometa) – 4mg/3 weeks
 Pamidronate (Aredia) – 90mg/3 weeks

19
Q

Antiresorptive Agents
 Denosumab (Monoclonal antibody)
 Osteoporosis –
 Bone Metastases –
 Mechanism of action
(2)

A

Prolia – 60mg/6 months
Xgeva – 120mg/4 weeks

 Tumor cell promote the release of RANK Ligand from
the osteoblast with in turn promote the production of
osteoclasts
 Denosumab binds to the RANK Ligand an prevents
osteoclast proliferation
Antiresorptive Agents

20
Q

ANTIANGIOGENIC MEDICATIONS
(2)

A

 Tyrosine kinase inhibitor
 Humanized monoclonal antibody

21
Q

 Tyrosine kinase inhibitor
(2)

A

 Sunitinib (Sutent)
 Sorafenib (Nexavar)

22
Q

 Humanized monoclonal antibody
(1)

A

 Bevacizumab (Avastin)
ANTIANGIOGENIC MEDICATIONS

23
Q

ANTIANGIOGENIC MEDICATIONS
 Mechanism of action
(1)
 Used in the treatment of (3)

A

 Recognizes and blocks vascular endothelial growth
factor (VEGF), a protein necessary for angiogenesis

gastrointestinal tumors,
renal cell carcinomas,
and neuroendocrine tumors

24
Q

Drug Related Risks
 Potency
(5)
 Duration
 Increased risk after —

A

 Oral non-nitrogen containing bisphosphonates
 Oral nitrogen containing bisphosphonates (0.4% to 4%)
 IV bisphosphonates (4% to 12%)
- Aredia
- Zometa
 XGEVA
 IV bisphosphonates plus an antiangiogenic medication

18 months

25
Q

Local Risk Factors
 Surgery/trauma
(3)

A

 Dental extractions
 Osseous surgery (periodontal, apicoectomy)
 Implant placement

26
Q

Local Risk Factors
 Anatomy
(3)

A

 Mandible vs. Maxilla (2:1 ratio)
 Tori, exostoses
 Mylohyoid ridge

27
Q

Demographic Factors
 Age
(1)
 Race
(1)

A

 9% increased risk of MRONJ with each passing decade

 Caucasian

28
Q

Systemic Factors
 Primary cancer diagnosis
(2)
 Concurrent (2) diagnosis

A

 Multiple myeloma – highest risk
 Breast cancer – 2nd highest risk

osteopenia or osteoporosis

29
Q

Prior to starting therapy
(3)

A

 Extract non-restorable and questionable teeth along
with alveoplasty, tori removal, etc.
 Complete necessary periodontal therapy
 Complete any endodontic and restorative work

30
Q

Wearing Removable Appliances
(4)

A

 Limit the amount of use
 Place silicone liners if necessary (GC reline)
 Educate the patient
 3 month recall intervals

31
Q

While on
Antiresorptive/Antiangiogenic Agent
Therapy
If any surgery or invasive procedures are
necessary, a – month “drug holiday”
should be completed prior to therapy and
use of the antiresorptive/antiangiogenic
agents should not be started again until
after osseous healing has occurred

A

3

32
Q

Denosumab and the Body
 Osteoclasts decreased by –% in 3 days
 ½ life of denosumab is – days
 –% degraded in 2 months
 Denosumab only affects the …

A

85
25
80
RANK ligand
 Not incorporated in the bone

33
Q

The Denosumab Vacation
 2 month presurgical holiday
(1)
 Average 4 month postsurgical holiday (ideally 8
months)
(1)

A

 80% degradation

 No needed alteration in denosumab therapy if planned
correctly

34
Q

Predicting Complications?
CTX testing
 Measures serum levels of —
 Marker for — activity
 Normal is —
 — or less is at risk for MRONJ

A

C-terminal telopeptide
osteoclastic
>300 (average 400-550)
150

35
Q

 Measures serum levels of C-terminal telopeptide
(1)

A

 Metabolite of bone matrix degradation

36
Q

AVOIDING COMPLICATIONS
 If possible, when there is a significant risk for MRONJ
or previous/current MRONJ present, avoid all — if possible
 Even if teeth are not restorable by traditional
methods, roots can be retained by …

A

surgical procedures

completing RTC
and covering with composite or amalgam to avoid
extraction

37
Q

Diagnosis of MRONJ
3 things necessary
(3)

A

 Current or previous antiresorptive medication therapy
 Exposed necrotic bone for longer than 8 weeks
 No history of radiation to the jaws

38
Q

If MRONJ is present:
 Stage 0
(2)
 Treatment
(2)

A

 No exposed bone, but pt. is symptomatic
 Radiographic changes may be present

 Periodic monitoring
 Systemic management (antibiotics and pain meds)

39
Q

If MRONJ is present:
 Stage 1:
(1)
 Treatment:
(3)

A

 Bone is exposed, asymptomatic, no infection present

 Monitor closely for the first 8 weeks
- If no change, monitor every 3 months
 Meticulous home care
 Antimicrobial oral rinses
- Peridex

40
Q

If MRONJ is present:
 Stage 2:
(1)
 Treatment:
(3)

A

 Exposed bone with associated pain and erythema
 Purulent exudate may be present

 Same treatment as Stage 1
- Addition of systemic antibiotics(Penicillin, Clindamycin,
Doxycycline)
 Pain Management
 Superficial debridement to relieve soft tissue irritation

41
Q

If MRONJ is present:
 Stage 3:
 Exposed bone with pain and one of the following:
(3)
 Treatment:
(3)

A

 Pathologic fracture
 Extra-oral fistula
 Necrotic lesion extends to the inferior border

 Surgical debridement or resection
 Antibiotic therapy
 Possible hyperbaric oxygen?

42
Q

Forteo
(3)

A

 Resolve MRONJ in osteoporotic patients
 May be used to treat osteoporosis
 Contraindicated in pts. with bone metastases or
previous radiation (risk of osteogenic sarcoma)

43
Q
A

Oral Medicine (13 decks)

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