Stages and Diagnosis The AAOMS has staged MRONJ to reflect the progression of the disease, which informs treatment protocols.4 Stage 0 is defined by having no clinical necrotic bone. However, the patient will present with symptoms, such as dull bone pain or sinus pain, that could be accompanied by inflammation of the sinus wall. Patients might experience loose teeth not caused by chronic periodontal diseases or swelling. Radiographically, early MRONJ will have areas marked by diffuse radiopacity and pos- sible thickening of the lamina dura. The alveolar bone of where teeth were extracted in the past will have little to no bone healing.22 Stage 1 is characterized by exposed and necrotic bone or fistula that probes to the bone in patients who are asymptomatic, without signs of infection or inflammation.4 Radiographic findings are similar to stage 0. Stage 2 (Figure 1, page 28) presents clinically and radiographically as stage 1, but with signs of infection or inflammation.4 Stage 3 has all the same components of stage 2 and at least one addi- tional feature such as pathological fracture or oral antral/oral-nasal communication.4 Patients should be seen for regular recare visits to catch signs of MRONJ early. The oral health professional should consider seeing a patient at more frequent intervals than once every 6 months, depending on individual risk factors. Clinicians should also encourage patients who are experienc- ing new oral symptoms to contact their providers. Most dental providers use a panoramic radiograph to aid in diagnostics. In addition to the radi- ographic descriptions within each MRONJ stage, some studies have shown differences in the corti- cal bone, which is believed to be where MRONJ originates, between MRONJ patients and control patients, and this difference then spreads to trabecular bone.23 False positives are possible when clinicians are overly reliant on radiographs.4 For this reason, oral health professionals should consider obtaining cone-beam computed topography images when MRONJ is suspected. Additionally, magnetic resonance imaging may aid in estimating the necrotic invasion into both soft and hard tissue.5 Histologically, necrotic bone areas lack osteocytes and osteoclasts, with smaller bone pieces feeling soft due to the presence of bacteria. Usually several different types of bacteria are present that result in infection, but recent literature suggests that actinomyces, a common species in the oral flora, is present in MRONJ bone specimens.22,24 The diagnostic criteria should be used to exclude differential diagnoses of atypical neuralgia, sarcomas, temporomandibular joint disorders, odontalgia, myofascial pain, sinusitis, and fibro-osseous lesions.25 Prevention Physicians need to discuss the risk of MRONJ with patients, particularly when other potential comor- bidities are present and refer them to a dental provider prior to taking the medications. The oral health professional should take a thorough health history and confirm all diagnoses and medica- tions, including mode of administration and dosage. Because medication treatments can change within a short time, the oral health professional must update this information at every appointment. If there are questions about the patient’s health, a writ- ten medical consultation with the appropriate physician(s) is advised. This is another opportunity to educate the patient about MRONJ risk, discuss the importance of oral hygiene, and inform the SECTION 2 SECTION 3 DIMENSIONS CE 40 Dimensions OF DENTAL HYGIENE • January/February 2024 dimensionsofdentalhygiene.com Belmont Business Media Nationally Approved PACE Program Provider for FAGD/MAGD credit. Approval does not imply acceptance by any regulatory authority or AGD endorsement. July 1, 2023 to June 30, 2026 Provider ID# 317924 AGD Subject Code: 730 Belmont Business Media designates this activity for 2 credit hours of self- study continuing education units. This course is released January 2024 and expires February 2027. Belmont Business Media is an ADA CERP-recognized provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to the Commission for Continuing Education Provider Recognition at: ada.org/cerp. MRONJ Category General Guidelines Pretherapy (nonmalignant) Optimize dental health Pretherapy (malignant) Optimize dental health prior to starting antiresorptive therapy if possible During antiresorptive therapy (nonmalignant) No alteration of operative plan for most patients During antiresorptive therapy (malignant) Avoid dentoalveolar surgery if possible Consider root retention to avoid extractions Implants are contraindicated TABLE 1. General Guidelines for the Prevention of Medication-Related Osteonecrosis of the Jaw (MRONJ)* *Adapted from the American Association of Oral and Maxillofacial Surgeons
