The Dental Management of Patients at Risk of Medication-Related Osteonecrosis of the Jaw: New Paradigm of Primary Prevention

Abstract

Medication-related osteonecrosis of the jaw (MRONJ) is a serious adverse reaction of antiresorptive and antiangiogenic agents; it is a potentially painful and debilitating condition that can considerably affect the quality of life of patients. Furthermore, even if its epidemiology and pathogenesis have still not been fully clarified, several risk factors related to MRONJ have been recognized in prevention protocols. Three main risk factors are as follows: (i) the type of ONJ-related medications: antiresorptive (e.g., Bisphosphonates, Denosumab) and antiangiogenic drugs (e.g., Bevacizumab, Sunitinib); (ii) the category of patient at MRONJ risk: cancer versus non-cancer patient; (iii) the typologies and timing of dental treatments (e.g., before, during, or after the drug administration). The aim of this paper is to describe the new paradigm by the Italian Society of Oral Pathology and Medicine (SIPMO) on preventive dental management in patients at risk of MRONJ, prior to and during/after the administration of the aforementioned ONJ-related drugs. In reducing the risk of MRONJ, dentists and oral hygienists are key figures in applying a correct protocol of primary prevention for pre-treatment and in-treatment patients. However, the necessity of a multidisciplinary standardized approach, with a sustained dialogue among specialists involved, should be always adopted in order to improve the efficacy of preventive strategies and to ameliorate the patient's quality of life.

Medication-Related Osteonecrosis of the Jaw: An Overview

“…Three different types of treatment strategies have been developed for the MRONJ: preventive, [79,80] medical and surgical treatments [14,81]. Preventive measures are indicated for patients who are slated for AA/AR therapy or have undergone treatment without notable symptoms of MRONJ.…”

“…Prior to initiating AR/AA treatment, the patient should be referred to a dentist for a complete clinical and radiological oral examination. It is the dentist's responsibility to evaluate the risk factors (such as dental decay, periodontal diseases and ill-fitting prostheses) for each individual patient, eliminate or decrease the risk factors, restore oral health and maintain oral health throughout and after the AA/AR treatment [79,80].…”

“…Before initiating AA/AR treatment, the oncologist should inform the patient about possible oral side effects and refer the patient to a dentist for comprehensive dental examination [79,80]. Dentoalveolar surgery remains the major risk factor for developing MRONJ and extraction increases this risk, as do periodontal or periapical pathology [13, 69,70].…”

“…All extractions and dentoalveolar surgery should be performed and the surgical sites should be allowed to heal completely. Some studies advise at least 2-3 weeks of mucosal healing, while others recommend up to 45-60 days prior to initiation of AA/AR therapy [14,79]. In the case of patients with total or partial dentures, intraoral examination for decubital areas should be performed.…”

“…If surgery cannot be avoided, chlorhexidine (CHX) mouth wash 0.12% should be started 7 days before the surgical procedure 2-3 times per day and should be continued for the next 2 weeks after the extraction. Antibiotic treatment should also be initiated before the extraction and continued afterwards, though there exists no current consensus [79] on the type, duration, onset and route of administration of the antibiotic therapy [84]. Some authors also recommend deep scaling of the remaining teeth prior to surgical interventions [72].…”