Sir, there has been guidance for dentists on the prevention of medication-related osteonecrosis of the jaws (MRONJ) for several years.1 Although this guidance also included information for prescribers and dispensers, it does not appear to have been widely disseminated. Indeed, only 4% of general medical practitioners in a Birmingham study were aware of MRONJ guidelines.2 I therefore welcome the publication by the Royal College of Physicians for the multi-disciplinary team.3
MRONJ is defined as exposed bone, or bone that can be probed through a fistula, in the maxilla or mandible, that has been present for more than eight weeks.4 It is an adverse side effect of anti-angiogenic or anti-resorptive medication.1,3 The incidence of MRONJ in patients who take these medications is reported as 1% in cancer patients and 0.1% in patients with metabolic bone disease.1
There have been instances of MRONJ occurring spontaneously, but it is most common following a dental extraction.1,3,4 Prevention of MRONJ involves pre-treatment screening, extraction of teeth with poor prognosis, adjustment of prostheses and education, including oral hygiene instruction and controlling risk factors such as smoking and alcohol. This has been shown to reduce the incidence of MRONJ by up to 50%.5
Dentists have reported poor communication with other healthcare professionals and often rely on patient recall for their medical history.6 The new guidance introduces dental alert cards which are to be carried by patients and shown to their dentists.3 Referral and reply letters between oncology, dentists and maxillofacial/oral surgeons have also been produced.
We should welcome and familiarise ourselves with these new methods of communication and remember to report all cases of suspected MRONJ to the MHRA.7Reducing the incidence of MRONJ will have financial benefit for the NHS, as this is a difficult condition to manage, and for severe cases may require surgery for debridement or resection.4
References
Scottish Dental Clinical Effectiveness Programme. Oral health management of patients at risk of medication-related osteonecrosis of the jaws. 2017. Available at: http://www.sdcep.org.uk/published-guidance/medication-related-osteonecrosis-of-the-jaw/ (accessed July 2020).
Rahman Z, Nayani S, Anstey H, Murphy M J. A survey evaluating the awareness of MRONJ within the Birmingham GMP community. Oral Surg 2018. Available at:https://doi.org/10.1111/ors.12372 (accessed July 2020).
Royal College of Physicians. Medication-related osteonecrosis of the jaw: guidance for the oncology multidisciplinary team. 2019. Available at: https://www.rcplondon.ac.uk/guidelines-policy/medication-related-osteonecrosis-jaw-guidance-oncology-multidisciplinary-team (accessed July 2020).
Ruggiero S L, Dodson T B, Fantasia J et al. American Association of Oral and Maxillofacial Surgeons position paper on medication-related osteonecrosis of the jaw - 2014 update. J Oral Maxillofac Surg 2014; 72: 1938-1956.
Vandone A M, Donadio M, Mozzati M et al. Impact of dental care in the prevention of bisphosphonate-associated osteonecrosis of the jaw: a single-center clinical experience. Ann Oncol 2012; 23: 193-200.
Sturrock A, Preshaw P M, Hayes C, Wilkes S. General dental practitioners' perceptions of, and attitudes towards, improving patient safety through a multidisciplinary approach to the prevention of medication- related osteonecrosis of the jaw (MRONJ): a qualitative study in the North East of England. BMJ Open 2019;9: e029951. doi:10.1136/bmjopen-2019-029951.
Yellow Card. Report online: www.mhra.gov.uk/yellowcard; via the Yellow Card App or by emailing .
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Frazer-Cox, C. New MRONJ guidance . Br Dent J 229, 151 (2020). https://doi.org/10.1038/s41415-020-2013-9
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DOI: https://doi.org/10.1038/s41415-020-2013-9