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Guidance in Brief and Dental Clinical Guidance. Scottish Dental Clinical Effectiveness Programme ISBN 978 1 905829 30 9. First published 2017. http://www.sdcep.org.uk/published-guidance/medication-related-osteonecrosis-of-the-jaw/

The Scottish Dental Clinical Effectiveness Programme has developed many authoritative and clear clinical resources on subjects ranging from Decontamination, to Management of acute dental problems (www.sdcep.org.uk). Guidance is available in different formats including apps and posters.

Themes running through the guidance are 1) the risk of MRONJ in patients taking such drugs is low, 2) before starting drug therapy, oral health should be secured, and 3) this should be maintained by 'personalised preventive advice'. If a dentist is alarmist, this could discourage patients from taking their medication or receiving dental treatment.

At the heart of the Guidance in Brief are two flow charts; one that can be used to assign a patient to no risk, low risk or higher (note higher and not high) risk of MRONJ, and another that describes which dental procedures are appropriate for those in these different risk groups. The dental procedures are also described in narrative form for those readers who are not comfortable with flow charts. A further table lists trade names and drugs names according to whether they are a bisphosphonate (such as alendronic acid, and parmidronate disodium), a RANKL inhibitor (denosumab) or anti-angiogenic (such as bevacizumab).

Patients at higher risk of MRONJ are those 1) who are receiving anti-resorptive and anti-angiogenic drugs for cancer, 2) have been taking bisphosphonates for longer than 5 years, 3) those taking concurrently systemic glucocorticoid drugs, and 4) those with a previous diagnosis of MRONJ. If they have been taking, for osteoporosis, bisphosphonates for less than 5 years, or denosumab, with no concurrent systemic glucocorticoids, they are categorised as low risk.

For those patients categorised as low risk, straightforward extractions should be carried out in primary care. Antibiotic therapy and antiseptics are not necessary. For those at higher risk, alternatives to extraction of teeth should be explored, even if this involves 'retaining roots in the absence of infection'. However, if extractions are considered necessary in the higher risk group, these can still be performed in primary care. For higher risk cancer patients on these drugs, advice about care pathways can be sought from an oral surgeon or special care dentist. If the patient taking such drugs has any unexpected pain, numbness, altered sensation or swelling, they should seek advice from a dentist. Referral is indicated to secondary care if an extraction socket is not healed at 8 weeks or if a patient has suspected spontaneous MRONJ.