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Published by MASCC/ISOO/ASCO · ASCO modified Delphi formal consensus method
Medication-related osteonecrosis of the jaw (MRONJ) is a complication that occurs in 1% to 9% of advanced cancer patients receiving bone-modifying agents (BMAs). It is characterized by exposed, unhealed bone in the maxillofacial region. The guideline seeks to establish standardized definitions, preventive strategies, and management algorithms to optimize oral care and patient outcomes.
Key Takeaways
This systematic review is an update to a previous MASCC/ISOO review published in 2010, expanding the search strategy to incorporate denosumab-related research from January 2009 to December 2017.
It is recommended that the term medication-related osteonecrosis of the jaw be used when referring to bone necrosis associated with pharmacologic therapies.
Clinicians should confirm the presence of all three of the following criteria to establish a diagnosis of MRONJ: (1) current or previous treatment with a BMA or angiogenic inhibitor, (2) exposed bone or bone that can be probed through an intraoral or extraoral fistula in the maxillofacial region and that has persisted for longer than 8 weeks, and (3) no history of radiation therapy to the jaws or metastatic disease to the jaws.
Coordination of care. for patients with cancer who are scheduled to receive a BMA in a nonurgent setting, oral care assessment (including a comprehensive dental, periodontal, and oral radiographic exam when feasible to do so) should be undertaken before initiating therapy. Based on the assessment, a dental care plan should be developed and implemented. Follow-up by the dentist should then be performed on a routine schedule, for example every 6 months once therapy with a BMA has commenced.
Modifiable risk factors: members of the multidisciplinary team should address modifiable risk factors for MRONJ with the patient as early as possible. These risk factors include poor oral health, invasive dental procedures, ill-fitting dentures, uncontrolled diabetes mellitus, and tobacco use.
Elective dentoalveolar surgery: elective dentoalveolar surgical procedures (eg, nonmedically necessary extractions, alveoloplasties, and implants) should not be performed during active therapy with a BMA at an oncologic dose. Exceptions may be considered when a dental specialist with expertise in the prevention and treatment of MRONJ has reviewed the benefits and risks of the proposed invasive procedure with the patient and the oncology team.
Dentoalveolar surgery follow-up: if dentoalveolar surgery is performed, patients should be evaluated by the dental specialist on a systematic and frequently scheduled basis (eg, every 6 to 8 weeks) until full mucosal coverage of the surgical site has occurred.
Temporary discontinuation of BMAs before dentoalveolar surgery: for patients with cancer who are receiving a BMA at an oncologic dose, there is insufficient evidence to support or refute the need for discontinuation of the BMA before dentoalveolar surgery. Administration of the BMA may be deferred at the discretion of the treating physician, in conjunction with discussion with the patient and the oral health provider.
A well-established staging system should be used to quantify the severity and extent of MRONJ and to guide management decisions. Options include the 2014 American Association of Oral and Maxillofacial Surgeons staging system, the Common Terminology Criteria for Adverse Events version 5.0, and the 2017 International Task Force on Osteonecrosis of the Jaw staging system for MRONJ. The same system should be used throughout the patient’s MRONJ course of care.
Optimally, staging should be performed by a clinician who is experienced with the management of MRONJ.
Initial treatment of MRONJ. conservative measures comprise the initial approach to treatment of MRONJ. Conservative measures may include antimicrobial mouth rinses, antibiotics if clinically indicated, effective oral hygiene, and conservative surgical interventions, for example, removal of a superficial bone spicule.
Treatment of refractory MRONJ. aggressive surgical interventions (eg, mucosal flap elevation, block resection of necrotic bone, or soft tissue closure) may be used if MRONJ results in persistent symptoms or affects function despite initial conservative treatment. Aggressive surgical intervention is not recommended for asymptomatic bone exposure.
For patients who are diagnosed with MRONJ while being treated with BMAs, there is insufficient evidence to support or refute the discontinuation of the BMAs. Administration of the BMA may be deferred at the discretion of the treating physician, in conjunction with discussion with the patient and the oral health provider.
During the course of MRONJ treatment, the dentist/dental specialist should communicate with the medical oncologist the objective and subjective status of the lesion—resolved, improving, stable, or progressive. The clinical course of MRONJ may affect local and/or systemic treatment decisions with respect to cessation or recommencement of BMAs.
Clinical Topic
Medication-Related Osteonecrosis of the Jaw (MRONJ)
Objectives
To provide guidance regarding best practices in the prevention and management of medication-related osteonecrosis of the jaw (MRONJ) in patients with cancer.
Target Patient Population
Adult patients with cancer who are receiving bone-modifying agents (BMAs) for any oncologic indication.
Diagnostic Criteria
(1) Current or previous treatment with a BMA or angiogenic inhibitor, (2) exposed bone or bone that can be probed through an intraoral or extraoral fistula in the maxillofacial region and that has persisted for longer than 8 weeks, and (3) no history of radiation therapy to the jaws or metastatic disease to the jaws.
Target Providers
Therapeutic Area
OncologyGuideline Scope
Inclusion Criteria
Exclusion Criteria
Care Settings
System: ASCO modified Delphi formal consensus method
Evidence Distribution
Contraindications
Monitoring Guidance
Dentist follow-up should be performed on a routine schedule (e.g., every 6 months) during BMA therapy. If dentoalveolar surgery is performed, evaluation by a dental specialist is needed every 6 to 8 weeks until full mucosal coverage occurs.
Difficulty
advanced
Learning Paths