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Medication-related osteonecrosis of the jaw


Key sources

The following summarized guidelines for the evaluation and management of medication-related osteonecrosis of the jaw are prepared by our editorial team based on guidelines from the Multinational Association of Supportive Care in Cancer (MASCC/ISOO/ASCO 2019) and the American Cancer Society (ACS 2016). ...
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Screening and diagnosis

As per ASCO/ISOO/MASCC 2019 guidelines:
Use the term MRONJ when referring to bone necrosis associated with pharmacologic therapies.
Confirm the presence of all of the following criteria to establish a diagnosis of MRONJ:
current or previous treatment with a bone-modifying agent or angiogenic inhibitor
exposed bone or bone that can be probed through an intraoral or extraoral fistula in the maxillofacial region and that has persisted for > 8 weeks
no history of radiotherapy to the jaws or metastatic disease to the jaws
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Classification and risk stratification

Staging: as per ASCO/ISOO/MASCC 2019 guidelines, use a well-established staging system to quantify the severity and extent of MRONJ and to guide management decisions, such as:
2014 AAOMS staging system
CTCAE version 5.0
2017 International Task Force on Osteonecrosis of the Jaw staging system.
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Medical management

Conservative management: as per ASCO/ISOO/MASCC 2019 guidelines, offer conservative measures for the initial management of MRONJ, including:
antimicrobial mouth rinses
antibiotics when clinically indicated
effective oral hygiene
conservative surgical interventions (such as removal of a superficial bone spicule).

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  • Discontinuation of bone-modifying agents

Perioperative care

Perioperative planning for elective dentoalveolar surgery: as per ASCO/ISOO/MASCC 2019 guidelines, do not perform elective dentoalveolar surgical procedures (such as nonmedically necessary extractions, alveoloplasties, and implants) during active therapy with a bone-modifying agent at an oncologic dose. Consider performing procedures when a dental specialist with expertise in the prevention and treatment of MRONJ has reviewed the benefits and risks of the proposed invasive procedure with the patient and the oncology team.
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Surgical interventions

Indications for surgery: as per ASCO/ISOO/MASCC 2019 guidelines, consider performing aggressive surgical interventions (such as mucosal flap elevation, block resection of necrotic bone, or soft tissue closure) in patients with persistent symptoms or dysfunction despite initial conservative treatment.
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Preventative measures

Oral care assessment
As per ASCO/ISOO/MASCC 2019 guidelines:
Obtain oral care assessment (including a comprehensive dental, periodontal, and oral radiographic evaluation when feasible) before initiating bone-modifying agents in patients with cancer in a non-urgent setting.
Develop and implement a dental care plan based on the assessment. Coordinate the care plan between the dentist and the oncologist to ensure that medically necessary dental procedures are undertaken before the initiation of bone-modifying agent therapy. Follow-up by the dentists on a routine schedule (such as every 6 months) once therapy with a bone-modifying agent has commenced.

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  • Management of modifiable risk factors

Follow-up and surveillance

Assessment of treatment response: as per ASCO/ISOO/MASCC 2019 guidelines, ensure that the dentist/dental specialist communicates with the medical oncologist during the course of MRONJ treatment regarding the objective and subjective status of the lesion: resolved, improving, stable, or progressive. Consider making local and/or systemic treatment decisions with respect to cessation or re-commencement of bone-modifying agents depending on the clinical course of MRONJ.