Close collaboration between dental care providers and the cancer care team was identified as a key component for prevention and management of medication-related osteonecrosis of the jaw (MRONJ) in patients with cancer, according to an expert panel convened by the Multinational Association for Supportive Care in Cancer (MASCC)/International Society of Oral Oncology (ISOO) and the American Society of Clinical Oncology (ASCO). Their clinical practice guideline update was published in the Journal of Clinical Oncology.

The incidence of MRONJ in patients with cancer is estimated to be between 1% and 9%. Clinical sequelae of this frequently difficult-to-treat condition include significant pain and quality of life detriments.

For the purposes of this clinical practice guideline update, MRONJ was defined by the MASCC/ISOO/ASCO Expert Consensus Panel as the persistence — longer than 8 weeks — of exposed bone or bone accessible through a fistula in either the maxilla or the mandible of patients with a current or previous history of receiving oncologic doses of bone modifying agents (BMA), such as bisphosphates or denosumab, or an anti-angiogenic agent, who do not have a history of either metastatic disease to the jaws or the delivery of radiation therapy to the jaws.  However, due to the limited evidence regarding the association between anti-angiogenic agents and MRONJ, the guideline recommendations were restricted to patients receiving BMA.

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This guideline update was based, in part, on a systematic review of the related literature, in which 132 studies published between January 2009 and December 2017 — which included 10 randomized controlled trials, 75 retrospective studies, and 47 prospective studies — were deemed appropriate for inclusion. However, “due to the limitations of the available evidence, the guideline relied on formal consensus for most recommendations,” the guideline authors noted.

In addressing clinical questions related to the prevention and management of MRONJ in patients with cancer, recommendations from the Expert Consensus Panel included the following:

  • Administration of BMA in a nonurgent setting should be proceeded by development and implementation of a dental care plan that involves both the dental care provider and the oncologist.
    • Modifiable risk factors for MRONJ (eg, poorly controlled diabetes, loose-fitting dentures, smoking) should be identified, and patients should be educated regarding optimal dental care.
    • Regular, routine dental care prior to and every 6 months during period of BMA administration.
    • In most cases, performance of elective dentoalveolar surgery should be avoided during treatment with a BMA.
  • Ideally, MRONJ staging should be performed by a clinician with experience in the management of the condition.
    • A well-established system, such as the Common Terminology Criteria for Adverse Events (CTCAE) 5, should be used.
  • Initial management of MRONJ should involve conservative measures, including mouth rinses, and conservative surgical treatment, such as removal of a superficial bone spicule, as well as treatment with antibiotics, if considered appropriate.
  • Use of aggressive surgical treatment (eg, mucosal flap elevation, block resection of necrotic bone, soft tissue closure) in the management of refractory MRONJ should be restricted to patients with symptomatic exposure of bone, and performed only following careful consideration of associated risks and benefits by the patient and members of the care team.
  • Temporary discontinuation of BMA therapy in patients with suspected MRONJ may be considered, and should involve discussions between the patient and members of the care team, including the dental care provider, although evidence regarding the risks and benefits of BMA discontinuation vs BMA continuation is weak.
  • The status of MRONJ following conservative or aggressive interventions should be determined jointly by the dental provider(s) and the oncologist.

The MRONJ panel members encourage the creation of predictive tools for early recognition of MRONJ, such as bone turnover and genetic markers.

They further noted that the ability to identify patients at increased risk for MRONJ allows the prescribing physician to adjust the BMA dose. Such tools would also allow dentists to stratify patients’ risk before dental surgical procedures.

Reference

Yarom N, Shapiro CL, Peterson DE, et al. Medication-related osteonecrosis of the jaw: MASCC/ISOO/ASCO clinical practice guideline [published online July 22, 2019]. J Clin Oncol. doi: 10.1200/JCO.19.01186