CE Questions The answer sheet and further instructions are located on the tear-out card that appears on page 37, or take the test online at dimensionsofdentalhygiene.com. 1. In what year were the first cases of medication-related osteonecrosis of the jaw (MRONJ) described? A. 2001 B. 2002 C. 2003 D. 2004 2. Bisphosphonates are used to treat which of the following? A. Osteoporosis B. Hypercalcemia C. Metastatic bone disease D. All of the above 3. Non-nitrogen-containing bisphosphonates have a higher risk of inducing MRONJ. True False 4. Denosumab is used to treat which of the following? A. Osteoporosis B. Bone metastasis C. Giant cell tumors D. All of the above 5. Osteoporosis is the most common nonmalignant condition that poses a risk for MRONJ. True False 6. Which route of administration for antiresorptive medications shows increased MRONJ prevalence and severity? A. Intravenous administration B. Oral intake C. Intramuscular route D. Inhalation 7. Which stage is defined as having no clinical necrotic bone? A. Stage 0 B. Stage 1 C. Stage 2 D. Stage 3 8. Which common species in the oral flora is present in MRONJ bone specimens? A. Staphylococcus aureus B. Lactobacillus C. Actinomyces D. Group A streptococcus 9. In the pre-treatment phase for both nonmalignant and cancer patients, which type of treatment should be completed to stabilize the oral cavity and remove potential sources of infection? A. Restorative B. Endodontic C. Periodontal D. All of the above 10. After a pretreatment extraction, how long should patients wait before starting antiresorptive medication? A. 1 to 2 weeks B. 4 to 6 weeks C. 6 to 8 weeks D. More than 12 weeks SECTION 1 SECTION 2 SECTION 3 patient about the consequences of abstaining from preventive dental treatment. Providers should describe MRONJ symptoms for patients to monitor including jaw pain, erythematous gingival tissue, exposed bone, nonhealing sockets, numbness, loose teeth, a foul taste in the mouth, and swelling.26 The goal of MRONJ prevention is to eliminate dental risk factors and to maintain a healthy oral environment.27 A thorough dental examination, with periodontal assessment and radiographs, should be initially completed to evaluate the patient’s current oral health and to use as a baseline ref- erence in the future if MRONJ is suspected. Table 1 was developed by the AAOMS to provide clini- cians with a general guide when treating patients on antiresorptive medications.4 Inflammatory disease presents in 50% of MRONJ cancer patients and indicates the need to com- plete high-risk dental procedures before therapy when possible.4 Preoperative and post-operative antibiotics and antimicrobial rinses can also be used to minimize MRONJ risk.4 Dental treatment recommendations for patients undergoing cancer therapy are more conserva- tive due to the higher doses prescribed. In the pre-treatment phase for both nonmalignant and can- cer patients, restorative, endodontic, and periodontal treatment should be completed to stabilize the oral cavity and remove potential sources of infection. The status of teeth with root canal therapy (RCT) should be evaluated, as MRONJ can be initiated from poorly performed RCTs. When it is suspected that a patient needs endodontic therapy, pulpal testing should be completed to obtain a proper periapical and pulpal diagnoses and to rule out MRONJ. The clinician’s skill level in performing RCT should be considered as teeth with over- or underfilled canals can lead to MRONJ.28 Existing prosthetics must be examined to minimize compression on the mucosa, which could cause ulcerations, with special attention given to the posterior lingual flange where mucosal trauma is more common. Lesions within the mucosa provide a route for bacteria to reach the bone.29 Denture stability should be optimized and relines in soft resins are possible when indicated. Additionally, patients must be cautioned to remove their dentures for 8 to 12 hours per day. When a pretreatment extraction is completed, the tooth should be removed atraumatically, and osseous healing should be complete, usually requiring 4 to 6 weeks before antiresorptive medica- tion is started.27 Every attempt to avoid extractions in patients taking high drug doses for cancer ther- apy should be made. Interestingly, drug holidays are an area of debate. Some studies suggest that drug holidays decrease MRONJ risk, while others do not observe a statistical significance in MRONJ outcomes. This continues to be an active area of investigation. Patients who need high-risk extractions and patients with new MRONJ diagnoses should be referred to an oral surgeon. MRONJ treatment decisions are dependent on the stage of progression and individual patient factors, with treatment categorized as nonoperative or operative. In conservative stage 1 therapy, antimicrobial rinses or the removal of mobile sequestrum can be used, while surgical intervention involves marginal resection of the mandible or alveolectomy in the maxilla.4 Stage 2 and 3 nonsurgical therapies include stage 1 treatments with the addition of systemic antibiotics or pain control, while surgical intervention involves mandibular segmental resection or partial infrastructure maxillectomy.4 Once a MRONJ diagnosis has been made, treatment is aimed at curing the disease and improving quality of life. Conclusion An accurate MRONJ diagnosis relies on the oral health professionals’ ability to combine aspects of the patient’s health history, clinical findings, and different imaging modalities. Dental providers must remain up-to-date on the best practices regarding MRONJ. Fur- thermore, MRONJ management is a collaborative effort of the healthcare team. Oral health professionals must work with patients and physicians to offer individualized pre- ventive and maintenance MRONJ strategies. The references that accompany this article appear with the web version at: dimensionsofdentalhygiene.com. D dimensionsofdentalhygiene.com January/February 2024 • Dimensions OF DENTAL HYGIENE 41
