MRONJ Clinical Guidance for Dental Management

MRONJ

Medication-Related Osteonecrosis of the Jaw

Oral Health Management of Patients at Risk

Based on SDCEP Clinical Guidance | Scottish Dental Clinical Effectiveness Programme

Presentation Overview

What is MRONJ?

Causative Medications

Risk Factors & Patient Classification

Incidence & Epidemiology

Initial & Continuing Management

Key Clinical Recommendations

What is MRONJ?

Exposed bone (or bone probeable through fistula) in the maxillofacial region persisting >8 weeks in patients treated with anti-resorptive or anti-angiogenic drugs, with no history of jaw radiation or metastatic disease to the jaw.

Presentation

Exposed bone, delayed healing after extraction, pain, soft tissue swelling, numbness/paraesthesia, altered sensation. Some patients asymptomatic.

Pathophysiology

Multi-factorial: Suppressed bone turnover, inhibited angiogenesis, soft tissue toxicity, inflammation/infection, genetic & immunological elements.

Key Distinction

MRONJ is an adverse drug effect — dental treatment does not cause it, though invasive procedures can trigger it.

Causative Medications

Anti-resorptive and anti-angiogenic drugs associated with MRONJ

Anti-Resorptive Drugs

Bisphosphonates (inhibit osteoclasts):

Alendronic acid

(Fosamax®, Fosavance®)

Ibandronic acid

(Bonviva®)

Risedronate

(Actonel®)

Pamidronate disodium

(Aredia®)

Zoledronic acid

(Aclasta®, Zometa®)

Sodium clodronate

(Bonefos®)

osteoporosis, Paget's disease, cancer bone metastases

Denosumab (RANKL inhibitor)

(Prolia®, Xgeva®)

Effect wanes within 9 months of stopping

Anti-Angiogenic Drugs

Bevacizumab

(Avastin®)

Sunitinib

(Sutent®)

Aflibercept

(Zaltrap®)

Used in cancer treatment to restrict tumour vascularisation.

Risk of MRONJ increases when combined with anti-resorptive drugs.

Bisphosphonates remain in bone for years (alendronate half-life ~10 years)

Incidence & Epidemiology

Cancer Patients

~1%

1 in 100 patients

Range: 0–2.3% • Up to 100x greater risk vs placebo

2.9%

Osteoporosis Patients

0.01–0.1%

1 in 1,000 to 1 in 10,000 patients

General incidence is 1–10 per 10,000

0.15%

~60% of MRONJ cases had recent tooth extraction

Prostate cancer & multiple myeloma patients at higher end of risk range

Bevacizumab alone: ~0.2% risk (20 per 10,000)

Risk increases when anti-angiogenic + anti-resorptive drugs combined

Do NOT discourage patients from taking their medication — benefits outweigh the small MRONJ risk

Risk Factors & Classification

How to assess patient MRONJ risk

Key Risk Factors

Underlying medical condition (cancer > osteoporosis)

Type of drug (IV bisphosphonate > oral; denosumab)

Duration of therapy (>5 years = higher risk)

Concurrent systemic glucocorticoids

Dentoalveolar surgery / bone-impacting procedures

Mucosal trauma (ill-fitting dentures)

Periodontal disease / dental infection

Previous MRONJ episode

LOW RISK

Osteoporosis/non-malignant bone disease, bisphosphonates <5 years, NO glucocorticoids

Denosumab for osteoporosis, NO glucocorticoids

HIGHER RISK

Cancer patients on any anti-resorptive or anti-angiogenic drug

Bisphosphonates >5 years (any indication)

Any anti-resorptive + concurrent glucocorticoids

Previous MRONJ diagnosis

Past bisphosphonate users still assigned to risk group as if currently taking. Denosumab effect persists 9 months post-cessation.

Initial Management of Patients at Risk

What to do when a patient starts anti-resorptive or anti-angiogenic therapy

Based on SDCEP Clinical Guidance | Scottish Dental Clinical Effectiveness Programme

1

Assess & Record Risk

<p style="margin: 0 0 15px 0;">Identify drug type, duration, concurrent glucocorticoids.</p><p style="margin: 0 0 15px 0;">Assign <strong style="color: #6B3F6E;">LOW</strong> or <strong style="color: #6B3F6E;">HIGHER</strong> risk.</p><p style="margin: 0;">Record in clinical notes.</p>

2

Inform the Patient

<p style="margin: 0 0 15px 0;">Explain small but real MRONJ risk.</p><p style="margin: 0 0 15px 0;">Emphasise: do <strong style="color: #6B3F6E;">NOT</strong> stop medication. Drug holidays <strong style="color: #6B3F6E;">NOT</strong> recommended.</p><p style="margin: 0;">Record that advice was given.</p>

3

Optimise Oral Health<br><span style="font-size:20px; font-weight:400; font-family:'Source Sans Pro', sans-serif; color:#4A2A4C;">(Dental Fitness)</span>

<ul style="margin: 0; padding-left: 20px; display: flex; flex-direction: column; gap: 12px;"><li style="padding-left: 5px; line-height: 1.3;">Extract teeth of poor prognosis</li><li style="padding-left: 5px; line-height: 1.3;">Treat periodontal disease / infection</li><li style="padding-left: 5px; line-height: 1.3;">Adjust ill-fitting dentures</li><li style="padding-left: 5px; line-height: 1.3;">Appropriate radiographs</li><li style="padding-left: 5px; line-height: 1.3;">Consider high fluoride toothpaste</li><li style="padding-left: 5px; line-height: 1.3;"><strong style="color: #6B3F6E;">Cancer patients:</strong> ideally complete dental treatment BEFORE drug therapy starts</li></ul>

4

Preventive Advice

<ul style="margin: 0; padding-left: 20px; display: flex; flex-direction: column; gap: 12px;"><li style="padding-left: 5px; line-height: 1.3;">Excellent oral hygiene</li><li style="padding-left: 5px; line-height: 1.3;">Healthy diet, reduce sugar</li><li style="padding-left: 5px; line-height: 1.3;">Fluoride toothpaste + mouthwash</li><li style="padding-left: 5px; line-height: 1.3;">Stop smoking, limit alcohol</li><li style="padding-left: 5px; line-height: 1.3;">Regular dental checks</li><li style="padding-left: 5px; line-height: 1.3;">Report: exposed bone, loose teeth, pain, swelling, tingling/numbness</li></ul>

Continuing Management: Low Risk Patients

Routine dental treatment proceeds as normal. Straightforward extractions <b>CAN</b> be performed in primary care.

If extraction or bone-impacting procedure needed:

<b>Discuss risks & benefits</b> &rarr; obtain valid consent

<b>Proceed with treatment</b> as clinically indicated

<span style="color: #D69CAE; font-weight: 600;">Do NOT prescribe</span> antibiotic or antiseptic prophylaxis (no evidence of benefit for MRONJ prevention)

<b>Advise patient to contact practice</b> if experiencing unexpected pain, tingling, numbness, altered sensation, or swelling

Key Warning: 8-Week Review

Review healing strictly at <b>8 weeks</b>

If socket not healed at 8 weeks &rarr; <b>suspect MRONJ</b> &rarr; refer to oral surgery / specialist

Spontaneous MRONJ Suspected?

&rarr; <b>Refer immediately</b> to oral surgery / special care dentistry specialist

Report suspected cases to MHRA Scheme

www.yellowcard.mhra.gov.uk

Continuing Management: Higher Risk Patients

Most routine dental treatment continues as normal.

Adopt a MORE CONSERVATIVE approach before bone-impacting procedures.

STAGE 1

Explore ALL alternatives first

Can the tooth be retained (e.g. root retention in absence of infection)?

Consider endodontic therapy, periodontal treatment, coronectomy

Consult oral surgery/special care dentistry specialist for medically complex patients

STAGE 2

If extraction is the ONLY option

Discuss risks & benefits → valid consent

Proceed as clinically indicated

Do NOT prescribe antibiotic/antiseptic prophylaxis

Advise patient: report unexpected pain, tingling, numbness, swelling

8-Week Review

Review healing at 8 weeks

No healing at 8 weeks → refer to oral surgery specialist

Medically complex/cancer patients: Consider specialist consultation for clinical assessment & treatment planning.

If spontaneous MRONJ suspected: → Refer immediately

Report to MHRA Yellow Card Scheme

Key Clinical Recommendations

Always take a thorough medical history — ask specifically about anti-resorptive and anti-angiogenic drugs, past and present.

Assign and record risk level (LOW or HIGHER) for every patient on these medications.

Routine dental treatment proceeds normally for ALL patients at risk — do not withhold care.

Low risk: extractions in primary care are appropriate. Higher risk: explore all alternatives first.

Do NOT prescribe antibiotic/antiseptic prophylaxis specifically to prevent MRONJ — no evidence of benefit.

Review healing at 8 weeks post-extraction. Refer to oral surgery/special care dentistry specialist if MRONJ suspected.

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Do not discourage patients from taking anti-resorptive or anti-angiogenic medication. Benefits far outweigh the small risk of MRONJ.

Source: SDCEP Guidance, March 2017 (Reviewed and extant March 2024)