Practitioners should be advised that the risk of developing MRONJ following antiresorptive therapy is low and that the short-term success rate (less than 10 years) of implants in this patient population does not appear to differ from the success rate of implants in patients who have not undergone antiresorptive therapy. In summary, antiresorptive therapy is not currently a contraindication to implant therapy. Ultimately, additional studies are needed to determine whether there is a difference in treatment outcomes (Hellstein et al., 2011; Aminoshariae, Donaldson, Horan, Mackey, Kulild, & Baur, 2022). Antiresorptive medications are effective as prophylaxis and intervention for osteoporosis as well as in the management of metastatic diseases. However, as noted above, reports of non-bisphosphonate-related medication-induced osteonecrosis of the jaw have led to the designation MRONJ (Otto, et al. 2018; Ruggiero et al., 2014). To be diagnosed with MRONJ, the patient must: ● Be treated currently or have been treated previously with antiresorptive agents. ● Have exposed bone or bone that can be probed through a fistula in the maxillofacial region for a period of longer than 8 weeks. ● Have no history of radiation therapy to the jaws or obvious metastatic disease to the jaws. This condition can be misdiagnosed, and it is important to remember that exposed bone or sequestra can present in patients not exposed to antiresorptive agents (Ruggiero et al., 2014; Bansal, 2022). Absent or delayed soft tissue healing with bony exposure following dental extraction or spontaneous gingival dehiscence is a clinical sign of MRONJ (Fleisher, Kontio, & Otto, 2016; Probst, Probst, & Bisdas, 2015; Bansal, 2022). Symptoms may be negligible, mild, or severe. Most patients with MRONJ are asymptomatic, but pain may develop if the bone becomes secondarily infected. In the most severe cases, patients can experience intense pain, extensive sequestration of bone, and sinus tracts that drain to the skin surface. Initially, no radiographic manifestations are seen, but in some cases a large area of necrotic bone is evident on magnetic resonance imaging. The incidence of this condition and the causative risk factors are not well characterized. However, dental alveolar surgery and the duration of antiresorptive therapy continue to be known risk factors for MRONJ. Noted predisposing factors include periodontal disease, smoking, diabetes, glucocorticoid medication use, and prolonged antiresorptive medication therapy (Ruggiero et al., 2014; Bansal, 2022). Management Given the potentially devastating consequences of MRONJ, clinicians must be aware of the pharmacological properties of bisphosphonates and other antiresorptive medications currently available and their indications, risk factors for the development of osteonecrosis, clinical signs and symptoms, and recommendations for patient management. The American Academy of Oral and Maxillofacial Surgeons published a position paper with management recommendations for this condition in 2014 (Ruggiero et al., 2014), and more recent reviews continue to suggest similar approaches (Kilic & Doganay, 2018; Bansal, 2022). The recommendations vary according to the severity of the condition (Stage 0 is the least severe and Stage 3 is the most severe). For patients who are at risk (no apparent bone visible) following oral or intravenous bisphosphonate therapy, no treatment is indicated and the patients should be educated regarding the risks of osteonecrosis of the jaw. Patients at Stage 0 (no clinical evidence of necrotic bone, but nonspecific clinical findings and symptoms)
In 2011, an advisory committee of the ADA Council on Scientific Affairs published evidence-based guidelines to optimize the oral health of bisphosphonate-treated patients. This committee expanded previous guidelines to include information concerning other medications with antiresorptive properties because these medications can have the same effect on the oral cavity as bisphosphonates (Hellstein et al., 2011). According to the ADA Council on Scientific Affairs, there is generally no need to modify routine dental treatment solely because of the patient’s use of antiresorptive therapy (Hellstein et al., 2011). However, comprehensive dental examination should be considered before initiating antiresorptive therapy, especially in patients not receiving regular dental care. Patients should be informed of the very low risk of developing medically related osteonecrosis of the jaw (MRONJ), and precautions such as good oral hygiene and regular dental care should be taken to further reduce the potential risk. Practitioners should be aware that no validated technique currently exists to identify patients who are at an increased risk for MRONJ and discontinuation of antiresorptive agents may not eliminate the risk of MRONJ development. More recently at the World Workshop on Oral Medicine VI, controversies regarding dental management of medically complex patients were reviewed and updated recommendations included the following: MRONJ-expert recommendations trend toward proceeding with dental treatment with little to no modification in osteoporotic patients on bisphosphonates (Napeñas, 2015). Nonsurgical periodontal therapy can be performed on patients taking oral bisphosphonates, along with the generally recommended reevaluation at 4 to 6 weeks (Hellstein et al., 2011). When necessary, modest bone- recontouring techniques can be used; however, specific guidelines for periodontal surgery are not provided and, because of the risk for MRONJ, such techniques should be used judiciously based on patient need. Dental professionals should explain the risk of developing MRONJ to patients undergoing invasive surgical procedures (Hellstein et al., 2011; Aminoshariae, Donaldson, Horan, Mackey, Kulild, & Baur, 2022). They should discuss alternative treatment plans with these patients, including allowing roots to exfoliate (instead of performing extraction) in endodontically treated and decoronated teeth. Provision of bridges, partials, and dentures should be considered as an alternative to placing implants. If extractions or bone surgery are necessary, clinicians should be guided by conservative surgical principles with primary tissue closure, when feasible. During the time immediately before and after any surgical procedures involving bone, the patient should rinse gently with a chlorhexidine-containing rinse until the site has healed. The 2011 ADA advisory statement indicates that endodontic therapy is preferred to surgical manipulation for salvageable teeth (Hellstein et al., 2011; Aminoshariae, Donaldson, Horan, Mackey, Kulild, & Baur, 2022). However, the same caution is advised for endodontic surgical procedures as for oral and maxillofacial surgery. Routine restorative procedures can be performed in a patient receiving antiresorptive therapy, and prosthodontic appliances can be provided to the patient, although they should be promptly adjusted to prevent ulceration and possible bone exposure. Sufficient data is lacking with regard to implant placement in patients receiving oral bisphosphonate therapy; however, the updated ADA advisory statement indicates that patients should be advised of the risk of developing MRONJ following extensive implant procedures or guided bone regeneration to augment a deficient alveolar ridge.
Page 128
EliteLearning.com/Dental
Powered by FlippingBook