2014 Update Revisions for: AAOMS Strategies for patient management with or at risk for medication-related osteonecrosis of the jaw:

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1 AAOMS Strategies for patient management with or at risk for medication-related osteonecrosis of the jaw: Update Revisions for: Diagnosis, Staging, Management strategies, (our main interest) Highlights of current research. 1

2 AAOMS committee favors the NEW NAME: MRONJ: MEDICATION-RELATED OSTEONECROSIS OF THE JAWS Medications: o IV bisphosphonates: mainly for cancer-related conditions. o Oral bisphosphonates: Mainly for osteoporosis and osteopenia, occasionally for Paget disease of bone and osteogenesis imperfecta o Anti-angiogenic meds: Inhibits the formation of new blood vessels required for tumor/cancer growth. May have MRONJ if: 1) Current or previous TX with anti-resorptive or antiangiogenic agents 2) Exposed bone or bone probable through a fistula persisting for over 8 weeks 3) No history of radiation therapy to the jaws of metastatic disease to the jaws Possible false positive with: Dry sockets, sinusitis, gingivitis and periodontitis, caries, periapical pathology, odontalgia (toothache), atypical neuralgias, fibro-osseous lesions, sarcoma, osteomyelitis, TMJ disorders Definition By Mayo Clinic Staff PET scans of the brain for Alzheimer's disease A positron emission tomography (PET) scan is an imaging test that helps reveal how your tissues and organs are functioning. A PET scan uses a radioactive drug (tracer) to show this activity. The tracer may be injected, swallowed or inhaled, depending on which organ or tissue is being studied by the PET scan. The tracer collects in areas of your body that have higher levels of chemical activity, which often correspond to areas of disease. On a PET scan, these areas show up as bright spots. A PET scan is useful in revealing or evaluating several conditions, including some cancers, heart disease and brain disorders. 2

3 Risk Question: In patients exposed to antiresorptive medications, what is the risk for developing ONJ after tooth extraction (or other dentoalveolar procedures, such as implant placement or periodontal procedures)? Answer: The best current estimate for the risk of ONJ in patients exposed to oral BP after tooth extraction is 0.5%. Other risks The risk of ONJ for patients with osteoporosis exposed to oral anti-resorptive medications is approximately 100 times smaller than those treated for cancer with IV anti-resorptives. Denture wearers: one study showed a 2-fold increase of ONJ Periodontal disease Periapical pathology Higher prevalence in females (likely due to TX for breast cancer and osteoporosis) Corticosteroids Some co-morbid conditions in cancer patients associated with an increased risk are diabetes and anemia Tobacco use: inconsistently reported as a risk factor Miscellaneous facts: MRONJ more likely in the mandible (73%) than in the maxilla (22.5%) but can appear in the 2 jaws (4.5%). What about procedures other than extractions? Absent data, the committee considers the risk for ONJ after dental implant placement and endodontic or periodontal procedures that require exposure and manipulation of bone to be comparable to the risk associated with tooth extractions. With oral, when does the risk start? For patients who have taken an oral BP for less than 4 years and have no clinical risk factors, no alteration or delay in the planned surgery is necessary. This includes any and all procedures common to oral and maxillofacial surgeons, periodontists, and other dental providers. 3

4 Drug Holiday? Preventing Problems there are limited data to support or refute the benefits of a drug holiday for osteoporotic patients receiving antiresorptive therapy. However, a theoretical benefit may still apply for those patients with exposure histories over 4 years. Therefore, the committee considers to be prudent the modified drug holiday strategy of stopping the oral dose two months prior (and three months following) the invasive dental procedure. Patient should maintain good oral hygiene Elective dentoalveolar surgery does not appear to be contraindicated in patients on oral antiresorptives. Patients need to be informed of the very small risk (<1%). Avoid placing implants in patients on IV antiresorptives. With oral antiresoptives, there is possible long-term risk of implant failure. Staging and TX strategies At risk (taking antiresorptives), but no apparent necrotic bone in patients who have been treated with oral bisphosphonates. Stage 0: No clinical evidence of necrotic bone but nonspecific clinical findings, radiographic changes, and symptoms. Stage 1-3: all include exposed and necrotic bone or fistulas that probe to bone in different stages of seriousness. Refer if in stages 0-3. Summary for at-risk patients. Refer if in stages 0-3. Low risk: under 4 years: Inform patient of possible risks, no alteration or delay in planned dental TX, good oral hygiene, regular dental care. Modest risk: over 4 years Inform patient, good OH, regular dental care, aggressive TX of infection, chlorhexidine mouthwash, try to use non-surgical options, long-term risk of failure with implants, consider limited surgery (1-2 teeth) wait 2 months to evaluate before continuing, drug holiday an option (2 mo. before, 3 mo. after). TXT systemic marker of bone turnover to assess risk not validated. More research needed. How about an extraction with: no anesthetic no bleeding no sutures 4

5 10 patients 8 on IV bisphosphonates 2 on oral 10 years As band moves, PDL destroyed Resulted in extrusion Added a new band/week Occlusion adjusted as needed Mean:6 weeks (2-14) No sutures or antibiotics The mandibular first premolar and second molar before procedure. A: Clinical picture. B: Periapical radiograph. Patient: 34 years old woman places elastic around 8 and 9 to close a diastema. Four weeks later 5

6 Fall in Torrey, UT 6