In 2014, AAOMS published a position paper on MRONJ.8
The position paper was based on a literature review and expert opinion/observations of a multidisciplinary committee including surgeons, pathologists, and oncologists. Although the authors cautioned that the position paper was informational in nature and not intended to set any standards of care, they did provide suggestions for potential prevention strategies for patients based on limited evidence, including implementation of dental screening and appropriate dental interventions before initiating antiresorptive and/or antiangiogenic therapies.8
In patients receiving antiresorptive and/or antiangiogenic medications for cancer-related indications, increased awareness, preventive dental care, and early recognition of the signs and symptoms of MRONJ may result in earlier detection.
The AAOMS committee outlined the following measures as part of early treatment planning:
- thorough examination of the oral cavity and a radiographic assessment when indicated;
- identification of acute infection and sites of potential infection to prevent future sequelae that could be exacerbated once drug therapy begins;
- patient motivation and patient education regarding dental care.
The AAOMS paper states that if “systemic conditions permit, initiation of antiresorptive therapy should be delayed until dental health is optimized” and that “This decision must be made in conjunction with the treating physician and dentist and other specialists involved in the care of the patient.” Regarding antiangiogenic therapy, the AAOMS states, “There are no data to support or refute the cessation of antiangiogenic therapy in the prevention or management of MRONJ; therefore, continued research in the area is indicated.”
A systematic review and international consensus paper from the International Task Force on Osteonecrosis of the Jaw published in early 20159
also suggests that key prevention strategies for MRONJ include elimination or stabilization of oral disease prior to initiation of antiresorptive agents, as well as maintenance of good oral hygiene. For patients whose cancer management includes treatment with denosumab or IV bisphosphonates, the Task Force recommends that “a thorough dental examination with dental radiographs should be ideally completed prior to the initiation of antiresorptive therapy in order to identify dental disease before drug therapy is initiated” and that “Any necessary invasive dental procedure including dental extractions or implants should ideally be completed prior to initiation of [bisphosphonate] or [denosumab] therapy.”
The Task Force9
also states that, “Non-urgent procedures should be assessed for optimal timing because it may be appropriate to complete the non-urgent procedure prior to osteoclast inhibition, delay it until it is necessary, or perhaps plan for it during a drug holiday; however, there are no compelling data to guide these decisions.”
A systematic review and clinical practice guideline from the American Society of Clinical Oncology (ASCO) specifically addressing the role of bone-modifying agents in metastatic breast cancer included consensus-based recommendations regarding dental therapy in these patients.16, 17
The primary recommendation is that patients maintain good oral hygiene, have preventive dental examinations before initiating therapy, and avoid invasive dental procedures whenever possible. The Update Committee consensus opinion also suggests that “in the setting of invasive dental procedures, it is advisable, whenever possible to delay the starting of therapy with bone-modifying agents until the initial bone healing process of the tooth socket bone has taken place” and that “If an invasive manipulation of the bone underlying the teeth is clinically indicated before starting bone-modifying agent therapy…initiation of bone-modifying agent therapy should be ideally delayed for 14 to 21 days to allow for wound healing, if the clinical situation permits.”