Management and Prevention of Medication-Related Osteonecrosis of the Jaw (MRONJ)

Definition and Diagnosis

• The American College of Oncology defines MRONJ as present when all three criteria are met: 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 persisting for longer than 8 weeks, and no history of radiation therapy to the jaws or metastatic disease to the jaws 2, 3, 4
• The 8-week timeframe is critical in diagnosing MRONJ, as shorter durations may represent normal healing 3

Prevention Strategy: Before Starting Therapy

• The American College of Oncology recommends that all patients initiating bone-modifying agents or anti-angiogenic medications undergo comprehensive dental evaluation with orthopantomography before starting therapy, complete all necessary dental extractions and periodontal interventions, and maintain 6-month dental follow-up schedules throughout treatment to prevent MRONJ 1, 2, 3
• Patients should undergo complete dental examination with orthopantomography and intraoral radiographs, perform all necessary dental extractions, complete conservative dental and periodontal interventions, adjust prosthetics to eliminate trauma, and educate patients about lifelong daily oral hygiene commitment 1, 5, 6

Prevention Strategy: During Therapy

• The American College of Oncology recommends implementing a monitoring schedule for all patients on BMAs or anti-angiogenic therapy, including dental follow-up visits every 6 months, complete dental examination with orthopantomography and intraoral radiographs, annual orthopantomography, evaluation of oral mucosa integrity, and reinforcement of oral hygiene education 1, 5, 6
• Elective dentoalveolar surgery should be avoided during BMA treatment, and if dental surgery becomes necessary, coordination between oncologist and dental specialist is crucial 2, 3, 7

Management of Established MRONJ

• The American College of Oncology recommends referring all suspected MRONJ cases to a dental specialist experienced in MRONJ management for staging and treatment, with stages ranging from conservative therapy for Stage 1 to surgical debridement and resection for Stage 3 1, 5, 6, 4
• Medication management during MRONJ involves considering continuation versus discontinuation of BMA therapy, balancing cancer treatment needs against MRONJ progression 1

Multidisciplinary Coordination

• Essential communication pathways include oncologist providing dentist with patient's medical diagnosis and complete antiresorptive/angiogenic inhibitor profile, dentist sending diagnosis and treatment plan to oncologist, and coordinating timing if oral surgery becomes necessary 1, 5, 6