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Oral Health Topics

Oncology Agents and Medication-Related Osteonecrosis of the Jaw

Key Points

  • Cancer metastases to the bone and hypercalcemia of malignancy are typically managed with antiresorptive agents (i.e., IV bisphosphonates, denosumab); a rare but serious adverse effect of these therapies is medication-related osteonecrosis of the jaw (MRONJ).
  • Antiangiogenic agents used for oncology indications include monoclonal antibodies, tyrosine kinase inhibitors, mTOR pathway inhibitors, and immunomodulatory agents; these agents have also been rarely associated with MRONJ.
  • In 2014, the American Association of Oral and Maxillofacial Surgeons (AAOMS) updated their definition of MRONJ to include all of the following criteria: (1) current or previous treatment with antiresorptive or antiangiogenic agents; (2) exposed bone or bone that can be probed through an intraoral or extraoral fistula(e) in the maxillofacial region that has persisted for more than 8 weeks; and (3) no history of radiation therapy to the jaws or obvious metastatic disease to the jaws.
  • Patients at increased risk of MRONJ include those:
    • receiving antiresorptive agents at dosages and treatment schedules associated with cancer-related indications;
    • receiving antiresorptive drugs for more than 2 years;
    • receiving antiresorptive therapy in conjunction with antiangiogenic drugs for cancer;
    • with periodontitis or dentures.
  • Although MRONJ is associated with bone-invasive dental procedures such as tooth extraction, it can also occur without dental intervention.
  • Potential strategies for managing dental patients undergoing antiresorptive and/or antiangiogenic therapies for oncology indications include a thorough oral examination with radiographs and optimization of oral health and, as clinically possible, completion of necessary invasive dental procedures, including dental extractions or implants, prior to initiation of antiresorptive and/or antiangiogenic therapy.
  • Bone Metastasis and Hypercalcemia of Malignancy
  • Medication-Related Osteonecrosis of the Jaw
  • Management Approaches for Dental Patients Receiving Antiresorptive and/or Antiangiogenic Medications for Cancer Indications
  • Antiresorptive Medications in Oncology
  • Table 1. Antiresorptive Medications Approved by FDA for Oncology Indications
  • Antiangiogenic Medications in Oncology
  • Table 2. Examples of Antiangiogenic Medications Approved by FDA for Oncology Indications
  • References
  • ADA Resources
  • Other Resources
Last Updated: July 28, 2021

Prepared by:

Department of Scientific Information, Evidence Synthesis & Translation Research, ADA Science & Research Institute, LLC.


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