- Advise the patient that due to medication they are taking, there may be a small risk of developing MRONJ but ensure that they understand that the risk is low.
- Explain that MRONJ is typically diagnosed when there is exposed bone in the jaw that has persisted for 8 weeks and can occur spontaneously or after dental treatment that impacts on bone, such as an extraction. Other symptoms include loose teeth, pain, tingling, numbness, altered sensation or swelling.
- Inform patients with dental implants placed prior to commencement of drug treatment of the small risk of spontaneous MRONJ at those sites.
- Emphasise that MRONJ is an adverse effect of the drug they are taking and is not caused by dental treatment.
- Discuss the benefits of anti-resorptive and/or anti-angiogenic drugs with the patient and why it is important that they continue to take the drugs
- Anti-resorptive drugs significantly reduce the risk of fractures, and subsequent chronic pain, in patients being treated for osteoporosis.
- Anti-angiogenic drugs restrict the growth of tumour blood vessels and are an important part of some cancer treatments. Anti-resorptive drugs reduce bone pain and the risk of fractures in patients being treated for cancer.
- Drug holidays to avoid the risk of MRONJ associated with dental care are not recommended because the benefits of taking the drugs to manage the patient’s medical condition are likely to outweigh the small risk of developing MRONJ and, in the case of the bisphosphonates or denosumab, stopping the drug does not eliminate the risk of developing MRONJ.
- Discuss the overall risk of MRONJ with the patient, based on the medical condition for which they are being treated, using language that they are able to understand. Stress that the risk is small and that the disease is an adverse effect of the medication and is not caused by dental treatment.
- For patients being treated with anti-resorptive or anti-angiogenic drugs for the management of cancer, the risk of MRONJ approximates 1%, (range 0 – 2.3%) which suggests that each patient has a 1 in 100 chance of developing the disease. However, the risk appears to vary based on cancer type and incidence in patients with prostate cancer or multiple myeloma may be higher.
- For patients taking anti-resorptive drugs for the prevention or management of non-malignant disease (e.g. osteoporosis, Paget’s disease), the risk of MRONJ approximates 0.1% or less, which suggests that each patient has between a 1 in 1000 and 1 in 10,000 chance of developing the disease.
- Patients who take concurrent glucocorticoid medication or those who are prescribed both anti-resorptive and anti-angiogenic drugs to manage their medical condition may be at higher risk.
- The incidence of MRONJ after tooth extraction is estimated to be 2.9% in patients with cancer and 0.15% in patients being treated for osteoporosis.
The figure below may help you to explain the risk of MRONJ to patients. The frequency is based on the assumption that all included individuals have been exposed to a risk factor, such as a bisphosphonate.
Adapted from Risk Language and Dialects, Calman and Royston, BMJ 1997; 315:939