Medication Related Osteonecrosis for GDPs – What You Need to Know (MRONJ) – PDP215

Teaser:
A risk in itself is taking the tooth out, so we can’t forget that actually patients on these medications can just get spontaneous MRONJ, it could just happen without taking the tooth out. So the risk is the surgery itself.

When you review at eight weeks, if you notice that there is non healing area, or you suspect it’s an MRONJ, you can yellow card it. So it’s like, you had the BNF and it used to have the actual yellow card in. Now online. So if you just Google yellow card and then you can report the adverse reaction to the medication.

Jaz’s Introduction:
If your patient is about to be prescribed something like a bisphosphonate or a biologic, it is so important that before they start these medicines, which puts them at risk of surgical complications, that you have an opportunity to do a complete assessment and decide, are there any teeth of dubious prognosis that need extracting?

Because Protruserati, prevention is better than the cure. Because today’s conversation is all about MRONJ, which is medication related osteonecrosis of the jaw. It can be quite a nasty complication and something that we should be able to just consent our patients. Like the worst thing you could do is your patient is about to start this medicine or is already on this medicine and you didn’t warn them of this relatively low but serious risk.

And we’ll go into all the incidences, prevalences, when you should extract in practice and when you should refer. That’s what this episode is about. I’m joined by an oral surgery consultant, Dr. Pippa Cullingham. And she does a wonderful job of summarizing this and a great guidance that I’m going to put in the links below is the STCEP guidance and also an American white paper for our colleagues in the U. S.

Hello Protruserati, I’m Jas Gulati and welcome back to your favorite dental podcast. No, today is not occlusion. It’s not onlays and restorative and vertical preparations. It’s Oral Surgery, and it’s not even the sexy part of oral surgery, right? It’s not like how to do the sectioning, elevating. This is medicines and their complications, and all important daily decision making.

I’ve got such an aging population that I treat, so this is very real and relatable to me. And all you general dentists around the world, you have patients who are on these medicines. And there’s always a risk calculation that we need to make. And I’m hoping this episode will give you the confidence to know when it’s safe to extract in practice. And the two main reasons that you should be referring to a specialist, perhaps in a hospital setting.

Dental Pearl
The Protrusive Dental Pearl, which is like this advice, this tip we give every PDP episode. It’s very relevant to the topic of MRONJ and BRONJ, which is bisphosphonate related osteonecrosis of the jaw. That’s the one that I was taught at dental school. But then of course, we realized that it’s not just bisphosphonates. There’s so many medicines that contribute towards this poor wound healing after extraction due to the alterational bony turnover. And we should be paying attention to this.

And the pearl is that when you have that opportunity to intercept. Like for example, they’ve just been diagnosed with a cancer, unfortunately, or they have osteoporosis and they’re about to start a bisphosphonate or another condition for which they need a biologic, which increases their risk. It is so important to do a very comprehensive assessment, which should include multiple periapicals or an OPG radiograph.

So you can see all the roots, like imagine seeing a crown, which has looked a little bit dubious and you’ve been watching it all these years has never really been symptomatic. But if a patient is about to start one of these high risk medications, it’s so important that you take a periapical radiograph or an OPG.

You need to see if it’s in the patient’s best interest to have this tooth extracted before starting this medication. So you kind of need to change your mindset a bit to let’s see how it goes versus are there any dubious teeth that we should extract before a patient starts any medication. If you can identify any silent infections or dubious prognosis teeth, think of obviously leaking crown margins, which are subgingival caries, but no signs of infection, but really those teeth ought to come out. And that conversation at least needs to be had with the patient before they start such medication.

The best time to extract is before they start the medication because there is zero risk. As soon as they start any of these medications, there will be a risk of MRONJ. And we’ll discuss in today’s episode about what increases your risk and whether there’s anything special we should be doing with our extractions. Hope you enjoy and stick around to the end. There are some CPD questions below if you’re watching this on the Protrusive Guidance app. And I’ll catch you in the outro.

Main Episode:
Dr. Pippa Cullingham, welcome to the Protrusive Dental Podcast. It’s so, so good to have you. You messaged me some months ago regarding a post that we did just about common medications. That was actually a credit to Emma, the Protrusive Student. She’s so good at sharing her notes and whatnot. And then you said you liked it, but there was a really lovely point you made. It was actually there was missing biologics and you really inspired me to connect with you and to bring you on today to talk about a really important matter that affects so many of our patients. It’s to do with BRONJ and MRONJ and all those things. And so it’s great to have you. Pippa, just tell us about yourself as a clinician, as a human, all those things as we’d like to know from our guests.

[Pippa]
So I am a consultant oral surgeon and I work at Liverpool Dental Hospital and have been a consultant here since 2016. Up to that point I was in Manchester at the dental hospital there doing my specialist training and I was an SHO all over the country. So I worked in the South West, in Birmingham, I trained in Sheffield. So professionally I’ve been all over the place but we’re fairly settled in Liverpool professionally and I live in Manchester still.

As part of my consultant role. I do a few other bits and pieces. So I’m the department lead in the hospital for oral surgery. I’m also the quality improvement lead for the hospital, for the dental hospital within our larger trust that we sit within. And so I find there’s a lot of crossover between my roles.

I’ll see an individual patient and think, hang on, maybe we can improve on that. And that links in with my specialist role, which links to my quality improvement role. So it, it all links in together. And it means that I do a bit of nonclinical and a bit of clinical alongside a small family, young family. So it’s busy, but it’s good.

[Jaz]
Amazing. And for those of you who are listening on Spotify or Apple, Pippa’s in surgery. Is this your hospital surgery?

[Pippa]
Yeah, this is in Liverpool Dental Hospital.

[Jaz]
Amazing. And so thanks so much for making time for this, actually. Interesting observation, actually. Oral surgery, like when I used to be a DCT in oral surgery at Guy’s Hospital, I noticed that a lot of the registrars were women.

And every time I see someone now getting a new post, because I know it’s very competitive, there’s only a few posts, I see a lot of women in oral surgery. And I think when you look at medicine, how surgery is often dominated by men, do you think that oral surgery is the exception? It’s quite different. I see lots of women in oral surgery. Do you observe that as well?

[Pippa]
Yeah, I had a similar observation. We have registrars training with us. We’ve got two at the moment and they sent me a photo of their recent study day. And I think probably about 80%, 90% were women of the photo of them all sitting, listening. So I do think it’s a really attractive career.

I think dentistry is an attractive career, particularly for a woman. And I think if you think about oral surgery specifically, a lot of us start as Maxfax SHOs and maybe Maxfax isn’t as attractive to women, certainly my personal opinion. So I think as an undergrad, I think it’s about 55% women to male. I think there’s a male.

[Jaz]
Yeah, I thought 60% actually, so you’re right. So there’s more women, but yeah, it’s an interesting observation, but we want to talk today about the different medications that I have aging population that I treat and on our community on the app, actually, a lot of the questions that we get are about, well, my patients on these medicines.

And I’m a little bit nervous about doing an extraction, and I can only imagine the number of referrals you get. And then, for some of these, you may be like, actually, the GDP should be doing this extraction. And for some of those, it’s like, yeah, this is a good save. I’m glad we are doing it. And maybe you see the other side whereby you kind of wish the GDP had referred this.

And so, I’d love to just go into those three types of scenarios. And before we delve into that, let’s just start with, like, definitions, right? I always heard of BRONJ, right? Bisphosphonate related, I used to, as a student, say osteoradionecrosis and they said, no, no, no, it’s radiotherapy, that’s different. So osteonecrosis of the jaw. And then MRONJ is just a wider term to encompass more medicines, right?

[Pippa]
Yeah, so increasingly there’s more medicines. So we have a new diagnosis that’s used for a group of conditions, quite wide conditions, that aren’t bisphosphonates, but they are having the same effect on the jaw or can have the same effect on the jaw.

So rather than the BRONJ or BRONJ, so bisphosphonate related osteonecrosis of the jaw, it’s been reclassified for the last 10 years or so as medication related osteonecrosis of the jaw, because we know there’s more medications that aren’t bisphosphonates that can cause that reaction in the jaw, and also they’re still emerging. So the biologic immunological medications that are newer. Some of them, we don’t know which ones, not all of them, but some of them will cause a reaction as well sometimes.

[Jaz]
Someone literally like 20 minutes before we start recording on the community mentioned about their patient and posted a radiograph about Denosumab. Is that one in consideration?

[Pippa]
Yeah. So that’s one of the similar to bisphosphonates, but it’s not a bisphosphonate medication. And actually it’s given a slightly different way. So it’s not a tablet or an injection. Well, it’s an injection, but it’s subcutaneously. So into the fat rather than IV, and it’s got a shorter half life, but yeah, it works in a similar way to bisphosphonates, although it’s not bisphosphonate, it affects the osteoclast still, it binds to one of the enzymes and stops bone turnover.

So the half life’s shorter, it’s not supposed to be as potent, and you can actually, we’ll talk about maybe timing extractions, but  Denosumab is one that you can potentially, if a patient’s still on it, time your extraction so that the half life’s lower and it’s excreted from the body. So your risk is that a little bit lower if you’re able to if the patient can defer an extraction for a little bit longer.

[Jaz]
Well, it’s really important for us to know this because sometimes our patients are about to start these medicines and we have that little window to intervene before they were to start it. Obviously, prevention is the best way to go. So before they get on the medicines and I’m sure you have a strong opinion on how perhaps in the medicinal world they are probably not doing enough to point them to dentists or maybe that’s changed.

How do you feel that’s going in terms of general dentists having the opportunity to get rid of or extract the more dubious teeth, which may be a problem in the future? Is that communication there yet?

[Pippa]
I think it’s probably hit and miss. We have some patients that are directed to, well, we don’t see them because we’re not the primary care dentist, but they’ve definitely been advised to see their dentist for the dental check before.

That bisphosphonates start, I’d say particular cohorts are probably better. So the cancer patients tend to have a better workup, although the timeframes may be a bit more sort of urgent and compressed, but I would hope over the years it’s more reported, isn’t it? The MRONJ general’s a bit more aware of it. So I would hope that it’s improving that whoever’s prescribing that bisphosphonate medication will encourage the dentist to see the general dental practitioner.

[Jaz]
And in terms of how much of a problem this is, like for example, incidents and prevalence. These are two things that we’d like to know because it’s something that when we see a patient and I see a patient and it’s written on their medical history that they’ve been taking and running acid.

And I think back to the guidelines and I’d like to know which are the best guidelines that you’d recommend because there are a few, I believe. And so we’re good at looking at that. And then we look at the other risk factors, how long they’ve been taking it. We’re trying to do a calculation. Is this safe?

Is this not? But what I’d like to know from you is, okay, what is the general instance like? And then if you have the data available, are there some medicines or some routes that are worst offenders that we should be particularly waving a red flag when we see this medicine in a medical history?

[Pippa]
Yeah, so I’d say overall it tends to be the condition that affects the risk factor. So the patients taking a bisphosphonate or an anti-angiogenic, because that’s another group of drugs that can cause the MRONJ, tend to be slightly higher risk than maybe your osteoporosis patients that prescribed a bisphosphonate. So increasingly, it was thought that looking at larger studies that patients prescribed a bisphosphonate for cancer were at about a 1% risk of developing an MRONJ following a dental extraction.

There’s been an update, so it’s closer to 5% we think, but we’re not sure if that’s because there’s increased follow up, increased awareness, more reporting of the condition. So closer to 5% on the cancer patients. For an osteoporosis, bisphosphonate medication. It’s around 0. 1, 0. 2, so it’s a low risk.

[Jaz]
So this is for the osteoporosis cohort, right? That’s lower risk.

[Pippa]
Osteoporosis is lower risk. Yeah.

[Jaz]
So it’s the number one question for a general dentist is basically for what reason did your doctor prescribe this? And then that will give you the big clue, I guess.

[Pippa]
Yeah. So probably the cancer patients are slightly higher risk. Well, they are slightly higher risk than the osteoporosis patients. And then there’s also the thinking with bisphosphonates because it can be given annually via an IV infusion or patients can be taking it weekly with their tablet, just an oral tablet. Previously, they’ve been thought that actually the IV route was high risk and more recently the thinking is actually for osteoporosis, oral, it’s the same as IV.

[Jaz]
Okay. That’s interesting. Yeah. I didn’t know that. And then also I’m just thinking back to my undergrad days and the stat I was quoting at that point, early in my career, and maybe it’s still stuck with me now and I’m not as up to date as I should be. And I’m being, to be very honest here is that there was oral, which was like 1 in 1, 000 to 1 in 10, 000 risk. Do you remember that being quoted? And then IV was like 100,000. But then what you’re suggesting is that actually, they are wildly higher than what I’ve just said there, what the previous guidelines believed. Is that right?

[Pippa]
So if you’re osteoporosis is 0.1 that would be at 1 in 1, 000, wouldn’t it?

[Jaz]
Yes. Yes.

[Pippa]
Yeah. So it’s about the same. And yeah, 1 in 500 is 5%. You’re testing my maths now. What was that?

[Jaz]
0.05? No, it would be 0.5%. Yeah, fine. 5%, one in 20, one in 20 is quite a fair bit there. So that’s definitely something that we should be at the forefront. So the first thing you’ve already taught us is, okay, ask why they’re taking those medications. So if it’s cancer that’s higher risk, if it’s for osteoporosis. Are there any other reasons that people beyond these biologics that we need to be aware of?

[Pippa]
So the biologics are another group of medications or an immunomodulator drugs where actually quite a lot of conditions are starting to use them. So it’s maybe long term chronic conditions where they might have been on long term steroids or azathioprine to reduce an immune response just generally in the body, which has unwanted side effects. So the cleverer drugs, the more recent drugs are just targeting specific parts of an immune system to dampen down inflammation or any negative effects of the condition.

So dermatology use it quite a lot in psoriasis or eczema, severe eczema. Gastro use it for sort of the management of Crohn’s or ulcerative colitis. And then biologics are also used in cancer treatment as well.

[Jaz]
Is there a handy list of these medicines? Because quite often we see these newer ones and then we may not identify like alendronic acid has been ingrained into us. That’s an easy one to identify. Denosumab again, a lot of people talking about it, but there might be so many that we might see, which is, I mean, the main lesson there is if you see a medicine, you don’t know, Google it, like look it up. It’s just a BNF, whatever you can just first thing to do is look it up. But is there a handy resource, any guidelines that you can point us to that we should be sticking up on the inside cupboard of our surgeries?

[Pippa]
Yeah, absolutely. So the SDCEP guidance, Scottish Dental Clinical Effectiveness Partnership or Programme, they’re really robust, they’re really clear, they’re aimed at primary care, they’re evidence based as best as they can be, but also quite pragmatic in how you risk assess patients.

They’re also really supportive of that dentist being, that patient being managed in primary care, because actually, unless you’ve got a very medically complex patient that’s not okay to treat in primary care, what you do in primary care is not going to be any different to what someone does in a hospital for taking a tooth out.

So it’s probably quicker, the patient’s getting the best treatment at the right time without a lengthy referral into hospital a lot of the time. So it’s only really medically complex patients that I would consider referring or complex surgical procedures which need a bit of support from a specialist or someone with additional skills.

[Jaz]
So that’s a really lovely summary. So medically compromised and also a tricky extraction, which we’re used to referring anyway. So what you’re saying perhaps is someone has had cancer and for that’s the reason that they were given, let’s say a medicine such as it could be a bisphosphonate or it could be, what are the other ones that you mentioned? Is it methotrexate? Does that count as well?

[Pippa]
So methotrexate counts as a biologic. It’s an anti resorptive medication or anti- Yeah, anti resoprtive, I think. So yeah, that will have a similar, it is linked to MRONJ. It can have a similar effect. Yeah.

[Jaz]
So we’re on that for a reason of cancer. So automatically we identify, okay, this is a potentially higher risk patient, but the extraction is not particularly difficult and they’re not medically compromised. Would you recommend general dentists to take out the tooth or, because often we’re scared and we refer. Do you think that’s an inappropriate referral? What guidance could you provide us?

[Pippa]
I wouldn’t class it as inappropriate. I think often it’s the sort of the unknown, the sort of uncertainty, not wanting to do the wrong thing, not wanting to have a complication that maybe you don’t want to deal with. So I absolutely understand the reason for referral. Maybe a methotrexate patient, maybe a rheumatoid arthritis patient. So long term, chronic, might have other comorbidities, so could be on long term steroids, which ups their risk a little bit. I would always encourage maybe a dentist to ask for advice or support.

I don’t know in the local area if there’s someone that they can just email or phone or get a bit of advice because that’s far better for the patient than them ending up in this lengthy referral system. But yeah, if it’s a tooth they can take out. If it’s a patient that’s safe to be treated in primary care so there’s no, the cancer patients, if they’re undergoing chemotherapy, may have some blood issues with the bloods that you might want managed somewhere else or might want to investigate it before taking the tooth out. But for say a chronic rheumatoid arthritis patient on methotrexate, who maybe hasn’t had that much long term steroids or no other complicating factors. I’d take that out in primary care.

[Jaz]
Okay, great. And it’s nice to have that. But if in doubt, reach out to someone who can help you. The local area team, the local hospital. So for me, that’s like Royal Berkshire Hospital. They’ve got the OMFS department which can often give us advice and whatnot. So that’s a very sensible way to go. You mentioned already steroids increasing your risk.

I remember smoking is linked to increasing your risk. Are there any other things that we should be looking out for that, okay, on balance, all the holes are lining up in terms of the Swiss cheese model and then medically compromised, trickier extraction on this bisphosphonate for cancer, but also has been smoking and steroids and it’s all like becoming a higher risk. Any other things that we’re missing out in terms of things that also increase your risk.

[Pippa]
So, I think a risk in itself is taking the tooth out. So we can’t forget that actually patients on these medications can just get spontaneous MRONJ. It could just happen without taking the tooth out. So the risk is the surgery itself.

But it could also be things like poor fitting dentures, unmanaged perio, mucosal trauma. Just generally a mouth that could be improved is always going to lower a risk of a patient. Other things like the length of a bisphosphonate medication, so the risk seems to increase a little bit once a patient’s been on a bisphosphonate medication for over five years.

And I think, again, it might be a bit patchy, but the risk assessment and the monitoring by GPs or whoever’s prescribing that bisphosphonate medication seems to be happening a little bit more. So what are the benefits of a patient staying on a bisphosphonate for over five years if, say, it’s for osteoporosis. Have they gained the benefit in five years and can they be removed from it?

But then we have to consider that actually the half life of bisphosphonate, Alendronic acid, is about 10 years. It binds so well to hydroxyapatite that it stays in the bone. So even when they’ve been on it for five years, the effects are long lasting. So if you know a patient has taken it previously, but isn’t currently prescribed it, that you still have to factor it into your risk assessment as if they’re still taking it.

[Jaz]
And you mentioned earlier about denosumab being a bit different. So it’s well known that it’s got such a long half life, andronic acid, therefore if they stopped taking it two years ago, but they were IV, they were taken for cancer reasons that we still include them in the high risk category.

But like you said, if the tooth is simple to extract and there’s no other additional factors, as long as we consent our patient, we tell them we can take it out in practice. That makes perfect sense to me. But in denosumab, it’s something different. You said that perhaps they can come off it. Tell us more about that.

[Pippa]
So I wouldn’t ever advise, without the guidance of whoever’s prescribing that drug, that a patient stops it. Because I think it’s really important if we think about why a patient’s taking it. It’s for really good reason. So for osteoporosis, they’re taking it to reduce their incidence or probability of having a fracture, which the comorbidity of a fracture in an osteoporotic patient is high. So the risks of fracture and the results of that is we just don’t want that to happen. So they’re taking it for really good reason. You want to keep them on it for their bones, but it can have a small risk of this medication related osteonecrosis of the jaw if we need to take a tooth out. So I think context and pragmatism is really important.

They’re on it for a good reason, but yeah, some things can be mitigated. So if it’s a tooth that needs to be taken out and it’s a patient who’s on denosumab. And they have it every nine months. Say they’re at month seven, that’s probably a very good time to start thinking about taking the tooth out so that you can take the tooth out at month seven or eight. They’ve got two to four weeks to heal and then they have their next injection for the denosumab. But actually, even if they’re still on the denosumab, they had it recently. It’s a low risk.

[Jaz]
Okay. So denosumab is in the lower risk category. Like you said, I think you said it was subcutaneously given. It’s important to recognize it in medical history, but if it’s just denosumab and no other factors involved in terms of medically compromised, difficult extraction, steroids, et cetera, then that is something that, although ideally to time it, seven months after the first dose, that if they genuinely need the tooth out, it’s unrestorable that to do your usual local measures and not have to necessarily refer it unless there’s a good reason to.

[Pippa]
Yeah, absolutely. And we appreciate that sometimes patients are in pain. They just need that tooth out. It’s the definitive treatment. So it’s the advice that you give to patients that you recognize and consent that there’s a small risk that the area might not heal or might be slower to heal, but it’s the risks and the benefits, isn’t it?

You’re in pain from that tooth and that tooth needs to be taken out and taking that tooth out is the best thing. Equally, you’re on a medication, which I don’t want you to stop. You need to keep taking it and even stopping it now for bisphosphonate won’t reduce your risk so keep taking it if that’s what your medical practitioner advises.

[Jaz]
For those higher risk patients that you get referred and you think yeah good thing the GDP referred here because they got all the risks there .There are 5% or even more basically and it’s a tricky extraction so more trauma and therefore more likely is there like, nothing that you, obviously you try and do it as atraumatically as possible. There’s no drugs or there’s no additional therapies that are used to decrease their risk, or is it managed in any special way in your hands?

[Pippa]
So before taking a tooth out, so you’ve just identified a slightly higher risk patient that needs a tooth taken out, I’d still say unless there’s a reason for them to be treated in the hospital, so complex procedure or very medically compromised, not necessarily the bisphosphonate drug or equivalent that they’ve been prescribed.

There’s nothing I’m going to do that differently that a GDP can’t do unless it’s a difficult surgical procedure. So no, I think I’d always emphasize a pre op cortisol mouthwash and post op mouthwashes. I’d take it out as atraumatically as you can, which obviously you do for every patient anyway, but actually the SDCEP is encouraging dentists to take teeth out in primary care.

It doesn’t mention any weird and wonderful techniques that we need to be using. It’s just a straightforward extraction as you normally would. If I was really worried about it, I might think about maybe using a periotome or maybe sectioning a multi rooted tooth just to make it as, sort of atraumatic as possible. But if a dentist doesn’t feel comfortable doing that in practice, then just a normal extraction technique is absolutely fine using luxators, elevators, forceps. And then you can hear different things. So if you’ve got a flap up, primary closure is great, but I wouldn’t raise a flap specifically to get primary closure.

You can maybe suture across the socket just to approximate the gingiva a little bit more, just to encourage that mucosal coverage. But other than that, post op, mouthwashes, encouraging good oral hygiene, and a review appointment at eight weeks because the MRONJ’s diagnosis will only be made at eight weeks if you haven’t got full healing.

[Jaz]
Okay, that’s a good one. So there’s no necessary reason to review them earlier unless you think they just generally need it. But eight weeks is a good point to reassess and and what are you looking for? Usually we’re hoping that it’s healed by then, of course, but I remember Chris Sproat I used to be under him as a trainee in Guy’s and he described it as looking like porridge. Any comments in terms of what additional features we’re looking for that thing that, okay, this doesn’t quite look right. This needs a referral.

[Pippa]
So at eight weeks, I would want to see full mucosal coverage that if you have a good feel around the area, it’s not tender. You can’t feel any loose bits, any crunch, and you can’t probe down to bone at all.

There’s no pain, swelling, pus coming out. The patient isn’t describing any sort of numbness or altered sensations. So that’s the kind of thing I’m looking for. But at eight weeks, if that is there, I would consider that a diagnosis of If the patient hasn’t had radiotherapy previously, that’s probably worth caveating as well.

‘Cause as you said earlier, it’s not in patients that have got radiotherapy. That sort of presentation in a patient that’s had radiotherapy is more likely to be an osteo radionecrosis. I would say at eight weeks. If you are seeing not full mucosal coverage, if you can probe down to bone, if it doesn’t feel quite right, if the patient doesn’t feel like the area’s healed.

If you can feel a bit of tenderness, I’d refer for a second opinion, but up to that point. If you’d referred before the extraction, the hospital wouldn’t have done anything different anyway. So it’s just reassuring that you’ve done the right thing. If a tooth needed to come out, it needed to come out. No one would have done anything differently. But the best place for the MRONJ or potential MRONJ to be assessed is in the hospital.

[Jaz]
I imagine there are some GDPs and I think that logic. There’s a naughty thing that once a trainer taught me, okay? And I know it’s not true and I don’t practice this, but it was I remember listening at the time thinking, hmm, is that the right thing or not?

Probably not. So basically, the naughty thing was, if ever you touch bone, i. e. you’re doing some form of surgical and you’ve drilled a bit of bone away, then maybe to prevent an infection, give antibiotics, like prophylactically, right? And so, am I right in saying that’s not a done thing, right?

[Pippa]
I wouldn’t recommend it for preventing MRONJ. There’s no definitive evidence that would support it. And I think we’re living in an era where we’ve got the answer.

[Jaz]
When I was taught this, Pippa, it was just generally any extraction, any patient, if you touch bone, give antibiotics, which I never employed, because it didn’t seem like following the guidelines. But yeah, a lot of people may think that, okay, if someone’s high risk of MRONJ, could there be a place for antibiotics, but you just covered it now, but actually we don’t need to do anything above and beyond the local measures. Of course, you mentioned the course of a mouthwash before and afterwards and good home care and good instructions from our patients, but we don’t need antibiotics. And this is a nice little message to reassure that we don’t need to be thinking about giving antibiotics.

[Pippa]
No, I’d really go anti antibiotics for the management of this. There’s no definitive evidence. And if you think about the antibicrobial resistance that we’re trying to fight at the moment, prescribing antibiotics for no given reason just increases problems down the line.

And you’ve got the risk whenever you prescribe anything, that the patient might have an adverse reaction to it, and you don’t really want that on your- so no, no evidence to antibiotics. If you were to delve into, the evidence of MRONJ, so there’s an American white paper that gets reviewed every few years.

It is mentioned that antibiotics can be used to prevent MRONJ, but the SDCEP guidance, based in the UK, aimed at primary care, really robust guidance, don’t suggest it at all, so I would err off antibiotics. Unless there’s another reason why you might want to give it but that patient is probably in the hospital.

[Jaz]
Very good to know and one thing that we haven’t covered yet was interesting is if the tooth is a dubious prognosis but if the patient’s other features like they look half themselves got good oral hygiene and the tooth is potentially restorable still although it might be tricky but still restorable yes, it might have really bulbous, curly roots, but that’s going to pose a difficult, difficult extraction.

The endodontist might have a good crack at it and still try and keep that tooth. Is this a conversation that you’re having with patients to try and convince them that, okay, let’s go down the rehabilitative restorative route to prevent that trauma in the first place?

[Pippa]
I think it’s looking at that risk. So doing the risk assessment on the patient of risk of MRONJ versus risk of taking the tooth out. And actually, if you’ve got a patient who’s about to start bisphosphonates, so they’ve not got anything in their system now. So the risk of MRONJ is negligible, none. It might be worth having the conversation about actually is now the time that we take that poor prognosis tooth out because the risk is none.

Whereas in six months, a year, five years. it’s going to be higher. So that’s the conversation before they start the bisphosphonate. If they’re currently on an anti resorptive, an anti angiogenic, or one of these biologic medications, it’s looking at that SDCEP risk assessment, which is really nicely done in a flow diagram.

So I’d encourage dentists to have a little look at that. And actually, if they’re low risk, SDCEP don’t suggest discussing other options, like trying to maintain retained roots without infection or anything like that, low risk, they say, carry on with the extraction. If they’re higher risk, so it tends to be patients with existing MRONJ, or patients that have been on the bisphosphonates for a little bit longer, or the cancer patients prescribed some of the medications, slightly higher risk, then it’s worth considering whether teeth can be maintained, retained, endodoned, cut off and overdenture, or something like that. It’s only that higher risk really where I consider that conversation as long as the patient’s well informed of their risk, whether they’re low or higher.

[Jaz]
I have a patient who had radiotherapy in the angle of mandible, and there’s a lower right second molar, which had just the most bulbous curvaceous roots. And so although there’s not much structure to put crown on it, that was like as a root field by a specialist and just sealed over. It’s been going strong for many years now. But that’s a high risk of radionecrosis in that patient. I think that’s a good move in that kind of, if it was more simple atraumatic, then might be a different conversation. But you know, very nasty looking roots. So there is a place for that kind of conversation. Would you agree that perhaps radiotherapy in the jaw is a different conversation, higher risk, higher stakes?

[Pippa]
Incidence wise, the risk of ORN following a dental extraction is, is 5% to 6% off the top of my head. It’s not something I’ve looked up just to come to this conversation. But again, that has loads of factors as well. So it’s when was the radiotherapy? So the closer to the time of the procedure, the lower the risk, because the effects of radiotherapy happen over many years. So if you’ve got a patient that had-

[Jaz]
That’s interesting. You would think that actually is counterintuitive. Yeah. Okay.

[Pippa]
Yeah. So if the patient had radiotherapy last month, you’re probably going to get away with a lower risk extraction. If they had it 10 years ago, that effect of the radiotherapy, the reduced vascular structure in the jaw, the reduced healing capacity, everything’s fibrosed, they don’t heal well.

So the length of time from radiotherapy to extraction is one thing to consider. Also things to consider, the dose of the radiotherapy, how many fractions, how long it was done over. So that has an impact, so different radiotherapy regimes and where that radiotherapy or where the primary cancer was targeted, so things like laryngeal, sort of ENT procedures, you’re probably going to be, if it’s anterior mandible, if it’s maxilla, not in the field of the radiotherapy, again it’s targeted now, they wear a mask, it’s all a bit more narrow, they try and limit the exposure of radiotherapy to other parts of the head and neck.

If it was a base of term carcinoma, if they radiotherapy and the angle of the mandible is right in the beam, then yeah, you’re higher risk, aren’t you? So it’s just thinking about all of these things, but I would, any patient with radiotherapy, to be honest, I would probably err to refer.

[Jaz]
That’s a very sound advice, I think, because he’s got his own risks and there’s more data to be collected in terms of, okay, can I see the map of where the radiation was? And sometimes in hospital it is useful to have that. I’ve been seeing recently colleagues posting radiographs of roots being resorbed away. And then what they’re finding is that there are certain medicines implicated in that. Slightly different, obviously, I don’t think that comes anywhere near the diagnosis of MRONJ or maybe it does, I don’t know. But is this something that you’re seeing being referred in to you?

[Pippa]
Not that I can comment on. I can’t really think of any cases I’ve seen like that, to be honest. So I’d be interested to read a little bit more about that. Do you know, do they know what medication it’s linked to?

[Jaz]
Well, I felt as though they were saying denosumab. I felt as though I saw that come up, and then a few people have been saying that, oh, they’ve noticed a few of these, but I was wondering if you’d seen anything like this, because I haven’t seen it yet myself. So something that’s just creeping, some conversations happening basically, but of course that’s a bit different.

In terms of just final tips for general dentists then, is a nice summary is don’t be so scared, because if you do a correct risk assessment, like you said, the fascinating thing is that the oral surgery department is not going to do anything different to what you could do. And as long as there’s no heart issues, severe asthmatic, medically compromised, then go ahead and local measures, perhaps a suture, like you said, a cross suture, no need for antibiotics, and have that just conversation. Anything that’s important to say in the realms of consenting a patient appropriately.

[Pippa]
I think it’s a conversation just to highlight that they’re on a medication that’s really good for their medical management, whether that’s the rest of their bones for osteoporosis, whether it’s for the management of their cancer or the management of their Crohn’s or any other sort of psoriasis condition, chronic condition.

But we are seeing that sometimes patients don’t heal, you don’t heal particularly well having had a tooth out and there is a low risk that that area might be slow or not heal. That may not cause them any problems. So actually, MRONJ doesn’t have to be symptomatic. They may just have just an open area that they manage to maintain, manage to keep clean and that the hospital would probably keep under review just to check it doesn’t progress and hopefully it resolves with time.

With time, what we hope is that the jaw starts sort of walling itself up off and that you get little loose bits of bone that work their way out, a little sequestry, and that allows the area to heal. So that’s the best case scenario if you do get an MRONJ. And I think that’s the discussion for the patient, that you need this tooth out, and that the risk is low.

We’ll keep an eye on you, but we’ll get the tooth out and we’ll see how you go with it. And if they have questions or you don’t feel comfortable with their expectations in practice, then maybe think about referring to a specialist.

[Jaz]
Amazing. I think that’s a great conversation to have. And the worst thing we do is not have this conversation and miss the medicine. And medically, legally, that’s a minefield. So the top tip is if you haven’t seen a medication before, just check it out because it could be in these. And then there’s nuance coming all the time, basically. Any particular noteworthy things you want to mention regarding the newer medicines or things to watch out for, common mistakes a GDP might make when they’re referring, any concerns that they have?

[Pippa]
No, so I’d say things to look out for, they tend to, I mean, they’re so variable now and some of the biologics we know have caused MRONJ reactions but that sort of MRONJ, but that tends to be case reports. So they’re not, it’s not consistent necessarily. So if there’s a suspicion that a patient is on a biologic, look it up and just confirm what that is in the BNF.

Again, probably not going to do anything differently. If you can comfortably treat the patient in practice. But when you review at eight weeks, if you notice that there is non healing area or you suspect it’s an MRONJ, you can yellow card it. So it’s like, you had the BNF and it used to have the actual yellow card in, now online.

So just Google yellow card and then you can report the adverse reaction to the medication. So it just helps to add to that evidence of medications that might be causing these reactions. As you said, if you don’t don’t know what a medication is on the medical history, look it up in the BNF, just so you know.

And then you can annotate it, can’t you on the records and just say what it is. But the groups of these medications, obviously the Alendronate. The Zoledronate, so eight at the end, some of the Angiogenics, a mab or nib. So Sunitinib or Ben. They’re long names, but they end with MAB or denosumab. So NIBS, MABS, and stronates.

Yeah, I’d just be a little bit cautious of. Yeah, but anything else you don’t know, look up. The focus on prevention, so when they get the patient who’s about to start up bisphosphonate, the prevention and the fluoride oral hygiene diet advice, basically trying to maintain a dentition that you may want to take out a tooth that has a poor prognosis given their risk of MRONJ following dental extraction may increase.

And also just thorough assessments, so taking radiographs to assess if you’ve got that sort of heavily restored crown tooth that you’ve just been looking at for 10 years. Maybe just take a PA of it and just make sure that it looks okay underneath before they start.

[Jaz]
Great. Nice summary. So Pippa, thank you so much for a lovely summary. I’m going to make the SDCEP guidelines available. Also the white paper because it’s difficult. It’s nice to see for our American colleagues how they are managing it as well. So I’ll put that all in the show notes. This episode is CPD and CE eligible. So thank you for your contribution to that. If anyone wants to reach out to Pippa, check her out on the Protrusive Guidance app, and it’d be nice to get real life, oral surgery, sort of experiences from you.

And I think it’s great. Everything you’re doing in this really sweet of you to message and just raises very important topic that affects us in GDP land every single day and then help us to mitigate those risks. But the biggest takeaway for me was it was twofold. One was that you guys don’t do anything that much differently.

And so there’s got to be a medically compromised reason to refer a tricky extractions that was encouraging as a GDP who quite likes doing extraction. So it’s good to keep it in house as long as you’ve had those conversations. And also the radiotherapy thing that actually the sooner you had the radiotherapy, the less risk you are.

I didn’t actually know that. So that was a good takeaway from me. So, Pippa, thank you so much for that.

[Pippa]
Thank you very much for having me.

Jaz’s Outro:
There we have it guys. Thank you so much for listening all the way to the end. Thank you again to my guest, Dr. Pippa Cullingham for giving a very nice overview. And as promised, if you scroll below, whether it’s on Protrusive Guidance or YouTube, wherever, I’ll put the links to the two main guidelines.

If you’re in the UK, SDCEP, US is the white paper it’s really important to look at what guidelines are in your country. Cause like you saw in our conversation with antibiotics, it can be a bit different. And those on Protrusive Guidance on a paid plan, you can answer the questions to get your CPD or CE credits.

We are a PACE approved provider and excitingly later on in the year, we’re going to be having a core month. So we’re going to actually covering the core CE. So in the UK, for example, it is mandatory for us to do certain things like radiation or cancer diagnosis, medical emergencies. So we’re getting to a stage where we’re going to be providing core CPD, which is so important.

We’re going to do it in a way to make it fun and engaging and an easy listen. And you get to just do a big fat tick on that mandatory CPD as well. The mission is to make it the best mandatory CE that you’ve ever done. So watch this space. And it’s a great time to join Protrusive Guidance on one of our paid memberships.

If you haven’t already, cause there’s so much to come as well as the entire backlog of 300 plus hours of CPD available. Thank you so much for watching all the way to the end. I appreciate it. Don’t forget to give us that thumbs up and subscribe and I’ll catch you same time, same place next week. Bye for now.