Osteonecrosis – A Serious Adverse Drug Reaction
Osteonecrosis, pronounced (aa-stee-ow-nuh-krow-suhs), is a rare condition where bone tissue dies due to a lack of blood supply. As a dentist, it is important to know the potential side effects of medications your patients may be taking. Two commonly used medications for the treatment of osteoporosis and bone metastases are denosumab and bisphosphonates. While these medications are effective in improving bone density, they can also contribute to serious conditions bisphosphonate related osteonecrosis of the jaw and denosumab/Prolia osteonecrosis of the jaw, collectively known as medication-related osteonecrosis of the jaw (MRONJ).
Symptoms of Osteonecrosis of Jaw
Symptoms of osteonecrosis of the jaw can include jaw pain, swelling, or infection of the gums, exposed bone in the jaw that does not heal, loosening of teeth, and difficulty chewing or speaking. In advanced cases, numbness or a heavy sensation in the jaw may occur. Dentists should monitor at-risk patients, particularly those on medications like bisphosphonates or denosumab, for these symptoms and provide early intervention to prevent progression. Regular dental check-ups and proactive care are essential in managing and mitigating osteonecrosis of the jaw risk. Patients should be referred by their practitioners for an osteonecrosis MRI for an official diagnosis.
MRONJ and Dental Procedures
Invasive dental procedures, such as tooth extractions, orthodontics, and periodontal surgery, carry a risk of MRONJ. The risk is higher in patients who are receiving treatment with denosumab or bisphosphonates. In these patients, it is a generally accepted practice to avoid invasive dental procedures if possible.
However, there are situations where an invasive dental procedure is necessary. In such cases, there is good evidence to help guide treatment decisions.
Risk Factors and Osteonecrosis of Jaw Causes
Several risk factors have been identified for the development of medication-related osteonecrosis of the jaw (MRONJ), including:
General
High dose and/or prolonged use of antiresorptive agents (more than 3 years)
Malignant disease (multiple myeloma, and breast, prostate, and lung cancer)
Chemotherapy, corticosteroid therapy, or treatment with antiangiogenic agents
Diabetes
Dental
Dental/periodontal infection
Peri-implantitis
Unfitting removable denture
Extractions
Implant surgery
Endodontic surgery
Periodontal surgery
Regenerative bone procedures
Torus and exostosis
Pronounced mylohyoid ridge
It is important to be aware of these risk factors and to take necessary precautions. In particular, as dental professionals we need to specifically note if our patients have or have had cancer. Associated with cancer, dental professionals should take a detailed medical history to discern if patients have had any previous radiation therapy. If you need a refresher on how to take a detailed medical history, review our article here!
Common Antiresorptive Medications
Denosumab
Denosumab is a monoclonal antibody that inhibits the activity of osteoclasts, the cells responsible for bone resorption. It is used to treat osteoporosis, bone metastases, and other bone-related conditions. While denosumab has shown to be effective in reducing fractures and improving bone density, it has also been linked to ONJ.
The exact mechanism of how denosumab contributes to MRONJ is still unknown. However, it is believed that the inhibition of osteoclasts can lead to impaired bone healing and increased risk of infection. In patients receiving denosumab, it is recommended to avoid invasive dental procedures if possible, and to maintain good oral hygiene.
How common is osteonecrosis of the jaw with Prolia?
Osteonecrosis of the jaw (ONJ) is a rare but potential side effect of Prolia (denosumab), typically occurring in patients undergoing prolonged treatment, particularly those with cancer or receiving high doses. The risk is significantly lower in patients using Prolia for osteoporosis management.
Bisphosphonates
Bisphosphonates are a class of medications that inhibit bone resorption by targeting osteoclasts. They are commonly used to treat osteoporosis, bone metastases, and other bone-related conditions. While bisphosphonates have been shown to be effective in improving bone density and reducing fractures, they can also contribute to ONJ.
Some examples of bisphosphonates that you may see on a patient’s PharmaNet profile are:
Alendronate
Risedronate
Zolendronate
Pamidronate
The risk of MRONJ increases with the duration of bisphosphonate therapy. It is believed that bisphosphonates can impair bone healing and increase the risk of infection, particularly in the jaw area. Similar to denosumab, it is recommended to avoid invasive dental procedures if possible, and to maintain good oral hygiene.
Osteonecrosis of Jaw Radiology, Cancer and Osteoradionecrosis (ORN)
Cancer is a devastating disease that affects millions of people worldwide. While the primary focus of cancer treatment is to eradicate the malignancy, certain therapies can lead to adverse effects on other parts of the body. One such complication is the development of osteonecrosis of the jaw (ONJ) and osteoradionecrosis (ORN).
These conditions are concerning side effects of cancer treatments, particularly those involving radiation therapy and certain medications, specifically bevacizumab (Avastin), everolimus, and sunitinib. Additionally, when patients have metastasis to the bones they often additionally require bisphosphonates like zolendronate or pamidronate.
Osteoradionecrosis (ORN) is another condition involving the death of bone tissue, but it specifically occurs as a consequence of radiation therapy. Patients who receive radiation therapy to the head and neck region, often for the treatment of head and neck cancer, may be at risk of developing ORN. The radiation damages the blood vessels supplying the jawbone, leading to reduced blood flow and subsequent bone death.
As previously mentioned, it is imperative to know when your patients are taking these medications or are receiving radiotherapy. Cancer patients require an empathetic and multidisciplinary approach to care; at DentalRx we emphasize creating a trusting relationship with the patient and liaising with the patient’s oncologist and associated support network.
Clinical Approach for Dentists
Preventing MRONJ is the best approach, and it starts with educating your patients about the risks associated with denosumab and bisphosphonates. Patients should be advised to maintain good oral hygiene, avoid smoking and other oral nicotine products, and have regular dental check-ups.
If an invasive dental procedure is necessary, I have compiled the most recent recommendations into an easy to use table for your convenience. It is also recommended to work collaboratively with the patient’s prescribing physician to generate a comprehensive treatment plan in regards to dental and medical therapy that may include antibiotics for prevention of osteonecrosis of the jaw.
Dental Guidelines for the Management of Patients at Risk of Osteonecrosis
Recommendations for Patients Receiving Radiotherapy
The following clinical recommendations are based on the findings of the OraRad study and other research in the field.
Patients referred for dental evaluation and management before head and neck cancer radiotherapy:
Consult a radiation oncologist for the radiation field plan for the jaws and the planned start date of RT. The parts of the jaws that receive more than 50 Gy will be at higher risk of developing osteoradionecrosis.
For teeth in areas that will receive over 50 Gy and have a poor long-term prognosis, consider dental extraction at least two weeks prior to the start of RT. Monitor to ensure adequate healing before the start of RT. Inform the radiation oncologist if the dental extractions will change the vertical dimension of occlusion, as this impacts the radiation treatment planning.
Restore active caries before RT if logistically possible; if not, restore as soon as feasible after RT.
Prescribe prescription-strength topical fluoride (e.g., 1.1% sodium fluoride toothpaste).
Educate the patient on the higher risk for salivary hypofunction, caries, gingival recession, tooth loss, osteoradionecrosis after RT, and on the importance of maintaining excellent oral hygiene.
Patients should be informed about the potential for trismus due to radiation fibrosis. Mouth opening exercises should be considered in coordination with their medical providers.
Patients who have received radiotherapy for head and neck cancer:
In the one to two months immediately following HNC RT, patients are likely to still experience ulcerations of the oral mucosa and have difficulty swallowing and related pain and nutritional compromise. Taste changes can persist for several months after RT.
Consult the radiation oncologist for the radiation field map for the jaws. The parts of the jaws that have received > 50 Gy are at higher risk of developing osteoradionecrosis.
Promptly restore caries and manage periodontal disease to avoid the need for extractions in areas that have received more than 50 Gy RT.
If an extraction becomes necessary in such an area, consider referral to an oral and maxillofacial surgeon.
For patients with hyposalivation, prescribe high-strength topical fluoride (e.g., 1.1% sodium fluoride toothpaste). Recommend strategies to manage hyposalivation and xerostomia, such as sugar-free gum, over-the-counter gels/mouth rinses, and prescription drugs that increase salivary flow (e.g., pilocarpine and cevimeline).
Reinforce to the patient the increased risk for dental disease and the importance of maintaining excellent oral hygiene and receiving routine dental care.
Emphasize the importance of mouth opening exercises to minimize long-term trismus secondary to radiation fibrosis. Patients with significant trismus should be encouraged to see a physical therapist.
Screen for oral candidiasis and recurrence of HNC.
Dental Management of Patients Receiving Radiation Therapy for Head and Neck Cancer
Reducing Patient Risk for Medication-Related Osteonecrosis of the Jaw
As mentioned earlier, prevention is the best approach towards MRONJ. It is best practice to remove any risk factors prior to performing invasive procedures. Overall, correcting oral hygiene, quitting smoking, and maintaining diabetic control will have a greater impact on the incidence of MRONJ than initiating a drug holiday.
Pharmacists are a great resource for helping with these modifiable risk factors. In BC, pharmacists head the smoking cessation program for patients that want to quit smoking. Pharmacists can also provide a multitude of resources and information for patients.
Reach out to us on the DentalRx app: we have a dedicated chat where you can contact a clinical pharmacist at any time. You can also find more information about osteonecrosis and other oral health conditions there as well!
Conclusion
As dental professionals, it is important to be aware of the potential complications associated with the use of denosumab and bisphosphonates. While these medications are effective in treating bone-related conditions, they can also contribute to MRONJ, a serious condition that can be challenging to manage.
By educating our patients about the risks associated with these medications and encouraging good oral hygiene practices, we can help to prevent the onset of MRONJ.
Osteonecrosis – A Serious Adverse Drug Reaction
Osteonecrosis, pronounced (aa-stee-ow-nuh-krow-suhs), is a rare condition where bone tissue dies due to a lack of blood supply. As a dentist, it is important to know the potential side effects of medications your patients may be taking. Two commonly used medications for the treatment of osteoporosis and bone metastases are denosumab and bisphosphonates. While these medications are effective in improving bone density, they can also contribute to serious conditions bisphosphonate related osteonecrosis of the jaw and denosumab/Prolia osteonecrosis of the jaw, collectively known as medication-related osteonecrosis of the jaw (MRONJ).
Symptoms of Osteonecrosis of Jaw
Symptoms of osteonecrosis of the jaw can include jaw pain, swelling, or infection of the gums, exposed bone in the jaw that does not heal, loosening of teeth, and difficulty chewing or speaking. In advanced cases, numbness or a heavy sensation in the jaw may occur. Dentists should monitor at-risk patients, particularly those on medications like bisphosphonates or denosumab, for these symptoms and provide early intervention to prevent progression. Regular dental check-ups and proactive care are essential in managing and mitigating osteonecrosis of the jaw risk. Patients should be referred by their practitioners for an osteonecrosis MRI for an official diagnosis.
MRONJ and Dental Procedures
Invasive dental procedures, such as tooth extractions, orthodontics, and periodontal surgery, carry a risk of MRONJ. The risk is higher in patients who are receiving treatment with denosumab or bisphosphonates. In these patients, it is a generally accepted practice to avoid invasive dental procedures if possible.
However, there are situations where an invasive dental procedure is necessary. In such cases, there is good evidence to help guide treatment decisions.
Risk Factors and Osteonecrosis of Jaw Causes
Several risk factors have been identified for the development of medication-related osteonecrosis of the jaw (MRONJ), including:
General
High dose and/or prolonged use of antiresorptive agents (more than 3 years)
Malignant disease (multiple myeloma, and breast, prostate, and lung cancer)
Chemotherapy, corticosteroid therapy, or treatment with antiangiogenic agents
Diabetes
Dental
Dental/periodontal infection
Peri-implantitis
Unfitting removable denture
Extractions
Implant surgery
Endodontic surgery
Periodontal surgery
Regenerative bone procedures
Torus and exostosis
Pronounced mylohyoid ridge
It is important to be aware of these risk factors and to take necessary precautions. In particular, as dental professionals we need to specifically note if our patients have or have had cancer. Associated with cancer, dental professionals should take a detailed medical history to discern if patients have had any previous radiation therapy. If you need a refresher on how to take a detailed medical history, review our article here!
Common Antiresorptive Medications
Denosumab
Denosumab is a monoclonal antibody that inhibits the activity of osteoclasts, the cells responsible for bone resorption. It is used to treat osteoporosis, bone metastases, and other bone-related conditions. While denosumab has shown to be effective in reducing fractures and improving bone density, it has also been linked to ONJ.
The exact mechanism of how denosumab contributes to MRONJ is still unknown. However, it is believed that the inhibition of osteoclasts can lead to impaired bone healing and increased risk of infection. In patients receiving denosumab, it is recommended to avoid invasive dental procedures if possible, and to maintain good oral hygiene.
How common is osteonecrosis of the jaw with Prolia?
Osteonecrosis of the jaw (ONJ) is a rare but potential side effect of Prolia (denosumab), typically occurring in patients undergoing prolonged treatment, particularly those with cancer or receiving high doses. The risk is significantly lower in patients using Prolia for osteoporosis management.
Bisphosphonates
Bisphosphonates are a class of medications that inhibit bone resorption by targeting osteoclasts. They are commonly used to treat osteoporosis, bone metastases, and other bone-related conditions. While bisphosphonates have been shown to be effective in improving bone density and reducing fractures, they can also contribute to ONJ.
Some examples of bisphosphonates that you may see on a patient’s PharmaNet profile are:
Alendronate
Risedronate
Zolendronate
Pamidronate
The risk of MRONJ increases with the duration of bisphosphonate therapy. It is believed that bisphosphonates can impair bone healing and increase the risk of infection, particularly in the jaw area. Similar to denosumab, it is recommended to avoid invasive dental procedures if possible, and to maintain good oral hygiene.
Osteonecrosis of Jaw Radiology, Cancer and Osteoradionecrosis (ORN)
Cancer is a devastating disease that affects millions of people worldwide. While the primary focus of cancer treatment is to eradicate the malignancy, certain therapies can lead to adverse effects on other parts of the body. One such complication is the development of osteonecrosis of the jaw (ONJ) and osteoradionecrosis (ORN).
These conditions are concerning side effects of cancer treatments, particularly those involving radiation therapy and certain medications, specifically bevacizumab (Avastin), everolimus, and sunitinib. Additionally, when patients have metastasis to the bones they often additionally require bisphosphonates like zolendronate or pamidronate.
Osteoradionecrosis (ORN) is another condition involving the death of bone tissue, but it specifically occurs as a consequence of radiation therapy. Patients who receive radiation therapy to the head and neck region, often for the treatment of head and neck cancer, may be at risk of developing ORN. The radiation damages the blood vessels supplying the jawbone, leading to reduced blood flow and subsequent bone death.
As previously mentioned, it is imperative to know when your patients are taking these medications or are receiving radiotherapy. Cancer patients require an empathetic and multidisciplinary approach to care; at DentalRx we emphasize creating a trusting relationship with the patient and liaising with the patient’s oncologist and associated support network.
Clinical Approach for Dentists
Preventing MRONJ is the best approach, and it starts with educating your patients about the risks associated with denosumab and bisphosphonates. Patients should be advised to maintain good oral hygiene, avoid smoking and other oral nicotine products, and have regular dental check-ups.
If an invasive dental procedure is necessary, I have compiled the most recent recommendations into an easy to use table for your convenience. It is also recommended to work collaboratively with the patient’s prescribing physician to generate a comprehensive treatment plan in regards to dental and medical therapy that may include antibiotics for prevention of osteonecrosis of the jaw.
Dental Guidelines for the Management of Patients at Risk of Osteonecrosis
Recommendations for Patients Receiving Radiotherapy
The following clinical recommendations are based on the findings of the OraRad study and other research in the field.
Patients referred for dental evaluation and management before head and neck cancer radiotherapy:
Consult a radiation oncologist for the radiation field plan for the jaws and the planned start date of RT. The parts of the jaws that receive more than 50 Gy will be at higher risk of developing osteoradionecrosis.
For teeth in areas that will receive over 50 Gy and have a poor long-term prognosis, consider dental extraction at least two weeks prior to the start of RT. Monitor to ensure adequate healing before the start of RT. Inform the radiation oncologist if the dental extractions will change the vertical dimension of occlusion, as this impacts the radiation treatment planning.
Restore active caries before RT if logistically possible; if not, restore as soon as feasible after RT.
Prescribe prescription-strength topical fluoride (e.g., 1.1% sodium fluoride toothpaste).
Educate the patient on the higher risk for salivary hypofunction, caries, gingival recession, tooth loss, osteoradionecrosis after RT, and on the importance of maintaining excellent oral hygiene.
Patients should be informed about the potential for trismus due to radiation fibrosis. Mouth opening exercises should be considered in coordination with their medical providers.
Patients who have received radiotherapy for head and neck cancer:
In the one to two months immediately following HNC RT, patients are likely to still experience ulcerations of the oral mucosa and have difficulty swallowing and related pain and nutritional compromise. Taste changes can persist for several months after RT.
Consult the radiation oncologist for the radiation field map for the jaws. The parts of the jaws that have received > 50 Gy are at higher risk of developing osteoradionecrosis.
Promptly restore caries and manage periodontal disease to avoid the need for extractions in areas that have received more than 50 Gy RT.
If an extraction becomes necessary in such an area, consider referral to an oral and maxillofacial surgeon.
For patients with hyposalivation, prescribe high-strength topical fluoride (e.g., 1.1% sodium fluoride toothpaste). Recommend strategies to manage hyposalivation and xerostomia, such as sugar-free gum, over-the-counter gels/mouth rinses, and prescription drugs that increase salivary flow (e.g., pilocarpine and cevimeline).
Reinforce to the patient the increased risk for dental disease and the importance of maintaining excellent oral hygiene and receiving routine dental care.
Emphasize the importance of mouth opening exercises to minimize long-term trismus secondary to radiation fibrosis. Patients with significant trismus should be encouraged to see a physical therapist.
Screen for oral candidiasis and recurrence of HNC.
Dental Management of Patients Receiving Radiation Therapy for Head and Neck Cancer
Reducing Patient Risk for Medication-Related Osteonecrosis of the Jaw
As mentioned earlier, prevention is the best approach towards MRONJ. It is best practice to remove any risk factors prior to performing invasive procedures. Overall, correcting oral hygiene, quitting smoking, and maintaining diabetic control will have a greater impact on the incidence of MRONJ than initiating a drug holiday.
Pharmacists are a great resource for helping with these modifiable risk factors. In BC, pharmacists head the smoking cessation program for patients that want to quit smoking. Pharmacists can also provide a multitude of resources and information for patients.
Reach out to us on the DentalRx app: we have a dedicated chat where you can contact a clinical pharmacist at any time. You can also find more information about osteonecrosis and other oral health conditions there as well!
Conclusion
As dental professionals, it is important to be aware of the potential complications associated with the use of denosumab and bisphosphonates. While these medications are effective in treating bone-related conditions, they can also contribute to MRONJ, a serious condition that can be challenging to manage.
By educating our patients about the risks associated with these medications and encouraging good oral hygiene practices, we can help to prevent the onset of MRONJ.
Osteonecrosis – A Serious Adverse Drug Reaction
Osteonecrosis, pronounced (aa-stee-ow-nuh-krow-suhs), is a rare condition where bone tissue dies due to a lack of blood supply. As a dentist, it is important to know the potential side effects of medications your patients may be taking. Two commonly used medications for the treatment of osteoporosis and bone metastases are denosumab and bisphosphonates. While these medications are effective in improving bone density, they can also contribute to serious conditions bisphosphonate related osteonecrosis of the jaw and denosumab/Prolia osteonecrosis of the jaw, collectively known as medication-related osteonecrosis of the jaw (MRONJ).
Symptoms of Osteonecrosis of Jaw
Symptoms of osteonecrosis of the jaw can include jaw pain, swelling, or infection of the gums, exposed bone in the jaw that does not heal, loosening of teeth, and difficulty chewing or speaking. In advanced cases, numbness or a heavy sensation in the jaw may occur. Dentists should monitor at-risk patients, particularly those on medications like bisphosphonates or denosumab, for these symptoms and provide early intervention to prevent progression. Regular dental check-ups and proactive care are essential in managing and mitigating osteonecrosis of the jaw risk. Patients should be referred by their practitioners for an osteonecrosis MRI for an official diagnosis.
MRONJ and Dental Procedures
Invasive dental procedures, such as tooth extractions, orthodontics, and periodontal surgery, carry a risk of MRONJ. The risk is higher in patients who are receiving treatment with denosumab or bisphosphonates. In these patients, it is a generally accepted practice to avoid invasive dental procedures if possible.
However, there are situations where an invasive dental procedure is necessary. In such cases, there is good evidence to help guide treatment decisions.
Risk Factors and Osteonecrosis of Jaw Causes
Several risk factors have been identified for the development of medication-related osteonecrosis of the jaw (MRONJ), including:
General
High dose and/or prolonged use of antiresorptive agents (more than 3 years)
Malignant disease (multiple myeloma, and breast, prostate, and lung cancer)
Chemotherapy, corticosteroid therapy, or treatment with antiangiogenic agents
Diabetes
Dental
Dental/periodontal infection
Peri-implantitis
Unfitting removable denture
Extractions
Implant surgery
Endodontic surgery
Periodontal surgery
Regenerative bone procedures
Torus and exostosis
Pronounced mylohyoid ridge
It is important to be aware of these risk factors and to take necessary precautions. In particular, as dental professionals we need to specifically note if our patients have or have had cancer. Associated with cancer, dental professionals should take a detailed medical history to discern if patients have had any previous radiation therapy. If you need a refresher on how to take a detailed medical history, review our article here!
Common Antiresorptive Medications
Denosumab
Denosumab is a monoclonal antibody that inhibits the activity of osteoclasts, the cells responsible for bone resorption. It is used to treat osteoporosis, bone metastases, and other bone-related conditions. While denosumab has shown to be effective in reducing fractures and improving bone density, it has also been linked to ONJ.
The exact mechanism of how denosumab contributes to MRONJ is still unknown. However, it is believed that the inhibition of osteoclasts can lead to impaired bone healing and increased risk of infection. In patients receiving denosumab, it is recommended to avoid invasive dental procedures if possible, and to maintain good oral hygiene.
How common is osteonecrosis of the jaw with Prolia?
Osteonecrosis of the jaw (ONJ) is a rare but potential side effect of Prolia (denosumab), typically occurring in patients undergoing prolonged treatment, particularly those with cancer or receiving high doses. The risk is significantly lower in patients using Prolia for osteoporosis management.
Bisphosphonates
Bisphosphonates are a class of medications that inhibit bone resorption by targeting osteoclasts. They are commonly used to treat osteoporosis, bone metastases, and other bone-related conditions. While bisphosphonates have been shown to be effective in improving bone density and reducing fractures, they can also contribute to ONJ.
Some examples of bisphosphonates that you may see on a patient’s PharmaNet profile are:
Alendronate
Risedronate
Zolendronate
Pamidronate
The risk of MRONJ increases with the duration of bisphosphonate therapy. It is believed that bisphosphonates can impair bone healing and increase the risk of infection, particularly in the jaw area. Similar to denosumab, it is recommended to avoid invasive dental procedures if possible, and to maintain good oral hygiene.
Osteonecrosis of Jaw Radiology, Cancer and Osteoradionecrosis (ORN)
Cancer is a devastating disease that affects millions of people worldwide. While the primary focus of cancer treatment is to eradicate the malignancy, certain therapies can lead to adverse effects on other parts of the body. One such complication is the development of osteonecrosis of the jaw (ONJ) and osteoradionecrosis (ORN).
These conditions are concerning side effects of cancer treatments, particularly those involving radiation therapy and certain medications, specifically bevacizumab (Avastin), everolimus, and sunitinib. Additionally, when patients have metastasis to the bones they often additionally require bisphosphonates like zolendronate or pamidronate.
Osteoradionecrosis (ORN) is another condition involving the death of bone tissue, but it specifically occurs as a consequence of radiation therapy. Patients who receive radiation therapy to the head and neck region, often for the treatment of head and neck cancer, may be at risk of developing ORN. The radiation damages the blood vessels supplying the jawbone, leading to reduced blood flow and subsequent bone death.
As previously mentioned, it is imperative to know when your patients are taking these medications or are receiving radiotherapy. Cancer patients require an empathetic and multidisciplinary approach to care; at DentalRx we emphasize creating a trusting relationship with the patient and liaising with the patient’s oncologist and associated support network.
Clinical Approach for Dentists
Preventing MRONJ is the best approach, and it starts with educating your patients about the risks associated with denosumab and bisphosphonates. Patients should be advised to maintain good oral hygiene, avoid smoking and other oral nicotine products, and have regular dental check-ups.
If an invasive dental procedure is necessary, I have compiled the most recent recommendations into an easy to use table for your convenience. It is also recommended to work collaboratively with the patient’s prescribing physician to generate a comprehensive treatment plan in regards to dental and medical therapy that may include antibiotics for prevention of osteonecrosis of the jaw.
Dental Guidelines for the Management of Patients at Risk of Osteonecrosis
Recommendations for Patients Receiving Radiotherapy
The following clinical recommendations are based on the findings of the OraRad study and other research in the field.
Patients referred for dental evaluation and management before head and neck cancer radiotherapy:
Consult a radiation oncologist for the radiation field plan for the jaws and the planned start date of RT. The parts of the jaws that receive more than 50 Gy will be at higher risk of developing osteoradionecrosis.
For teeth in areas that will receive over 50 Gy and have a poor long-term prognosis, consider dental extraction at least two weeks prior to the start of RT. Monitor to ensure adequate healing before the start of RT. Inform the radiation oncologist if the dental extractions will change the vertical dimension of occlusion, as this impacts the radiation treatment planning.
Restore active caries before RT if logistically possible; if not, restore as soon as feasible after RT.
Prescribe prescription-strength topical fluoride (e.g., 1.1% sodium fluoride toothpaste).
Educate the patient on the higher risk for salivary hypofunction, caries, gingival recession, tooth loss, osteoradionecrosis after RT, and on the importance of maintaining excellent oral hygiene.
Patients should be informed about the potential for trismus due to radiation fibrosis. Mouth opening exercises should be considered in coordination with their medical providers.
Patients who have received radiotherapy for head and neck cancer:
In the one to two months immediately following HNC RT, patients are likely to still experience ulcerations of the oral mucosa and have difficulty swallowing and related pain and nutritional compromise. Taste changes can persist for several months after RT.
Consult the radiation oncologist for the radiation field map for the jaws. The parts of the jaws that have received > 50 Gy are at higher risk of developing osteoradionecrosis.
Promptly restore caries and manage periodontal disease to avoid the need for extractions in areas that have received more than 50 Gy RT.
If an extraction becomes necessary in such an area, consider referral to an oral and maxillofacial surgeon.
For patients with hyposalivation, prescribe high-strength topical fluoride (e.g., 1.1% sodium fluoride toothpaste). Recommend strategies to manage hyposalivation and xerostomia, such as sugar-free gum, over-the-counter gels/mouth rinses, and prescription drugs that increase salivary flow (e.g., pilocarpine and cevimeline).
Reinforce to the patient the increased risk for dental disease and the importance of maintaining excellent oral hygiene and receiving routine dental care.
Emphasize the importance of mouth opening exercises to minimize long-term trismus secondary to radiation fibrosis. Patients with significant trismus should be encouraged to see a physical therapist.
Screen for oral candidiasis and recurrence of HNC.
Dental Management of Patients Receiving Radiation Therapy for Head and Neck Cancer
Reducing Patient Risk for Medication-Related Osteonecrosis of the Jaw
As mentioned earlier, prevention is the best approach towards MRONJ. It is best practice to remove any risk factors prior to performing invasive procedures. Overall, correcting oral hygiene, quitting smoking, and maintaining diabetic control will have a greater impact on the incidence of MRONJ than initiating a drug holiday.
Pharmacists are a great resource for helping with these modifiable risk factors. In BC, pharmacists head the smoking cessation program for patients that want to quit smoking. Pharmacists can also provide a multitude of resources and information for patients.
Reach out to us on the DentalRx app: we have a dedicated chat where you can contact a clinical pharmacist at any time. You can also find more information about osteonecrosis and other oral health conditions there as well!
Conclusion
As dental professionals, it is important to be aware of the potential complications associated with the use of denosumab and bisphosphonates. While these medications are effective in treating bone-related conditions, they can also contribute to MRONJ, a serious condition that can be challenging to manage.
By educating our patients about the risks associated with these medications and encouraging good oral hygiene practices, we can help to prevent the onset of MRONJ.
