Initial Management

Refer to Section 4.1 of the full guidance.

This covers the management of those patients who are about to start, or have very recently started, taking anti-resorptive or anti-angiogenic drugs.

Key recommendation

Before commencement of anti-resorptive or anti-angiogenic drug therapy, or as soon as possible thereafter, aim to get the patient as dentally fit as feasible, prioritising preventive care. 

Higher risk cancer patients should preferably undergo a thorough dental assessment, with remedial dental treatment where required, prior to commencement of the drug therapy.
(Strong recommendation; low quality evidence)

  • Advise the patient (or carer, where appropriate) that there is a risk of developing MRONJ but ensure they understand that the risk is small so that they are not discouraged from taking their medication or from undergoing dental treatment.
  • Give personalised preventive advice to help the patient optimise their oral health, emphasizing the importance of:
    • having a healthy diet and reducing sugary snacks and drinks
    • maintaining excellent oral hygiene
    • using fluoride toothpaste and fluoride mouthwash
    • stopping smoking
    • limiting alcohol intake
    • regular dental checks
    • reporting any symptoms such as exposed bone, loose teeth, non-healing sores or lesions, pus or discharge, tingling, numbness or altered sensations, pain or swelling as soon as possible
  • Prioritise care that will reduce mucosal trauma or may help avoid future extractions or any oral surgery or procedure that may impact on bone:
    • consider obtaining appropriate radiographs to identify possible areas of infection and pathology
    • undertake any remedial dental work
    • extract any teeth of poor prognosis without delay
    • focus on minimising periodontal/dental infection or disease
    • adjust or replace poorly fitting dentures to minimise future mucosal trauma
    • consider prescribing high fluoride toothpaste
  • For medically complex patients for whom you would normally seek advice, including higher risk patients who are being treated with anti-resorptive or anti-angiogenic drugs for the management of cancer, consider consulting an oral surgery/special care dentistry specialist with regards to clinical assessment and treatment planning.

N.B. Advise patients who are prescribed an oral bisphosphonate not to hold the tablet in the mouth due to risk of damage to the oral mucosa. Advise patients to follow the instructions for administration given by their doctor or pharmacist or as included in the drug information leaflet.