title: [Position paper on medication-related osteonecrosis of the jaw (MRONJ)].
abstract: It is now 12 years since the first article on medication-related osteonecrosis of the jaw (MRONJ) was reported in 2003. The recognition of MRONJ is still inconsistent between physicians and dentists but it is without doubt a severe disease with impairment of oral health-related quality of life. This position paper was developed by three Austrian societies for dentists, oral surgeons and osteologists involved in this topic. This update contains amendments on the incidence, pathophysiology, diagnosis, staging and treatment and provides recommendations for management based on a multidisciplinary international consensus. The MRONJ can be a medication-related side effect of treatment of malignant and benign bone diseases with bisphosphonates (Bp), bevacizumab and denosumab (Dmab) as antiresorptive therapy. The incidence of MRONJ is highest in the oncology patient population (range 1-15 %), where high doses of these medications are used at frequent intervals. In the osteoporosis patient population, the incidence of MRONJ is estimated to be 0.001-0.01 %, marginally higher than the incidence in the general population (< 0.001 %). Other risk factors for MRONJ include glucocorticoid use, maxillary or mandibular bone surgery, poor oral hygiene, chronic inflammation, diabetes mellitus, ill-fitting dentures as well as other drugs, including antiangiogenic agents. Prevention strategies for MRONJ include elimination or stabilization of oral disease prior to initiation of antiresorptive agents, as well as maintenance of good oral hygiene. In those patients at high risk for the development of MRONJ, including cancer patients receiving high-dose BP or Dmab therapy, consideration should be given to withholding antiresorptive therapy following extensive oral surgery until the surgical site heals with mature mucosal coverage. Management of MRONJ is based on the stage of the disease, extent of the lesions and the presence of contributing drug therapy and comorbidity. Conservative therapy includes topical antibiotic oral rinses and systemic antibiotic therapy. Early data have suggested enhanced osseous wound healing with teriparatide in those patients without contraindications for its use. The MRONJ related to denosumab may resolve more quickly with a drug holiday than MRONJ related to bisphosphonates. Localized surgical debridement is indicated in advanced nonresponsive disease and has proven successful. More invasive surgical techniques are becoming increasingly more important. Prevention is the key for the management of MRONJ. This requires a close teamwork for the treating physician and the dentist. It is necessary that this information is disseminated to other relevant health care professionals and organizations.
authors: Frauenarztpraxis, Stauderplatz 5, 9020, Klagenfurt, Österreich. svejda@aon.at.
authors: B
authors: B
authors: Svejda
authors: II. Medizinische Abteilung mit Osteologie, Rheumatologie & Gastroenterologie, Krankenhaus der Barmherzigen Schwestern, Stumpergasse 13, 1060, Wien, Österreich.
authors: Ch
authors: Ch
authors: Muschitz
authors: Universitätszahnklinik Wien, Division für Orale Biologie, Medizinische Universität Wien, Sensengasse 2a, 1090, Wien, Österreich.
authors: R
authors: R
authors: Gruber
authors: Paracelsus Medizinische Privatuniversität, Univ.-Klinik für Mund-, Kiefer- und Gesichtschirurgie, Landeskliniken Salzburg, Müllner Hauptstraße 48, 5020, Salzburg, Österreich.
authors: Ch
authors: Ch
authors: Brandtner
authors: Zahnarztpraxis, 9640, Kötschach-Mauthen, Österreich.
authors: Ch
authors: Ch
authors: Svejda
authors: Universitätsklinik für Innere Medizin I, Medizinische Universität Innsbruck, Anichstraße 35, 6020, Innsbruck, Österreich.
authors: R W
authors: RW
authors: Gasser
authors: Abteilung für Mund-, Kiefer- und Gesichtschirurgie, Klinikum Klagenfurt am Wörthersee, Feschnigstraße 11, 9020, Klagenfurt, Österreich.
authors: G
authors: G
authors: Santler
authors: Universitätsklinik für Innere Medizin, Klinische Abteilung für Endokrinologie und Stoffwechsel, Medizinische Universität Graz, Auenbruggerplatz 2, 8036, Graz, Österreich.
authors: H P
authors: HP
authors: Dimai
mesh_terms: D000068258:Bevacizumab / Q000009:adverse effects* / Q000627:therapeutic use; D059266:Bisphosphonate-Associated Osteonecrosis of the Jaw / Q000175:diagnosis* / Q000517:prevention & control / Q000628:therapy; D050071:Bone Density Conservation Agents / Q000009:adverse effects* / Q000627:therapeutic use; D001859:Bone Neoplasms / Q000188:drug therapy / Q000556:secondary; D000069448:Denosumab / Q000009:adverse effects* / Q000627:therapeutic use; D004164:Diphosphonates / Q000009:adverse effects* / Q000627:therapeutic use; D004305:Dose-Response Relationship, Drug; D012307:Risk Factors
chemical_list: D050071:Bone Density Conservation Agents; D004164:Diphosphonates; D000068258:Bevacizumab; D000069448:Denosumab
keywords: Adverse effects; Bisphosphonates; Denosumab; Osteoporosis; Preventive measures