Preventing, identifying, and managing medication-related osteonecrosis of the jaw: a practical guide for nurses and other allied healthcare professionals

Abstract

Background Medication-related osteonecrosis of the jaw (MRONJ) is an infrequent, but potentially serious, adverse event that can occur after exposure to bone-modifying agents (BMAs; e.g., bisphosphonates, denosumab, and antiangiogenic therapies). BMAs are typically used at higher doses to prevent skeletal-related events in cancer patients and at lower doses for osteoporosis/ bone loss. MRONJ can cause significant pain, reduce quality of life, and can be difficult to treat, requiring a multiprofessional approach to care. Methods We reviewed the literature and guidelines to summarize a practical guide on MRONJ for nurses and other allied healthcare professionals. Results While there is a risk of MRONJ with BMAs, this should be considered in relation to the benefits of treatment. Nurses and other allied healthcare professionals can play a key role alongside physicians and dentists in assessing MRONJ risk, identifying MRONJ, counseling the patient on the benefit-risk of BMA treatment, preventing MRONJ, and managing the care pathway of these patients. Assessing patients for MRONJ risk factors before starting BMA treatment can guide preventative measures to reduce the risk of MRONJ. Nurses can play a pivotal role in facilitating multiprofessional management of MRONJ by communicating with patients to ensure compliance with preventative measures, and with patients' physicians and dentists to ensure early detection and referral for prompt treatment of MRONJ. Conclusions This review summarizes current evidence on MRONJ and provides practical guidance for nurses, from before BMA treatment is started through to approaches that can be taken to prevent and manage MRONJ in patients receiving BMAs.

Associated characteristics and treatment outcomes of medication-related osteonecrosis of the jaw in patients receiving denosumab or zoledronic acid for bone metastases

“…The other characteristics significantly associated with developing MRONJ in this study were older age (>65 years), and tooth extraction before and after starting BMAs. These results are consistent with the findings of previous reports [17][18][19][20][21][22][23]. Since tooth extractions just before starting BMAs did not reduce the risk of developing MRONJ in this study, earlier dental consultation and dental treatment should be considered after patients are diagnosed with cancer.…”

“…The incidence of MRONJ was significantly higher in the denosumab group than in the zoledronic acid group (12.6 vs 4.4%, P = 0.006). The median (IQR) number of treatment courses was significantly longer for patients who developed MRONJ than for those who did not (16 [12][13][14][15][16][17][18][19][20][21][22][23][24] vs 6 [2-11], P < 0.001).…”

“…MRONJ causes significant pain and reduces the quality of life; therefore, multidisciplinary team care that enables appropriate monitoring and referral to a dental specialist for close follow-up and assessment of early-stage MRONJ is recommended [18][19][20][21]. Several risk factors for MRONJ have been reported including medication-related risk factors (such as BMAs, antiangiogenic agents, systemic steroids, and time of exposure of those medications), patientrelated risk factors (older age, diabetes mellitus, smoking), and oral health-related risk factors (oral infections and periodontal disease, poor oral health, implants, tooth extractions, and dentoalveolar surgery before and during the treatment) [18][19][20][21][22][23]. Dental examination before the initiation of treatment with BMAs is recommended for minimizing the risk of MRONJ [18][19][20][21]24].…”

Tooth extractions in patients with cancer receiving high-dose antiresorptive medication: a randomized clinical feasibility trial of drug holiday versus drug continuation

“…cancer disease and other medication, which the large confidence intervals also reflect. However, reduced patient-reported health state has frequently been associated with MRONJ in the literature 2,29 , which is only partly in accordance with the findings in the present trial. Only one of the four patients diagnosed with MRONJ reported a [13] decreased health-state after MRONJ diagnosis.…”

“…Cytostatic agents have been associated with development of MRONJ 2,28 . Two of the four patients who developed MRONJ were treated both with intravenously prescribed antimitotic agents and glucocorticoids.…”