An Update on Medication-Related Osteonecrosis of the Jaw in Patients with Osteoporosis

Abstract

Medication-related osteonecrosis of the jaw (MRONJ) is a feared complication of anti-resorptive or anti-angiogenic therapy, presenting with non-healing areas of bone, which may form de novo or after dental intervention. The condition primarily affects patients under the care of oncologists and rheumatologists. Patients using these medications under the care of rheumatologists are predominantly being treated for osteoporosis, a highly prevalent condition causing considerable morbidity and mortality in the European population. In the two decades since the condition was first described, there has been considerable progress in the understanding of the pathophysiology of the condition, although this remains incomplete. Additionally, clinicians may now benefit from long-term follow-up data to give a more evidence-based approach to MRONJ risk stratification. At present, there is considerable variation between guidelines produced by advisory groups. This paper focuses exclusively on the osteoporotic cohort, and aims to review recent findings to explore the differences in risk profiles between osteoporotic and oncological cohorts, as well as between different anti-resorptive medications. Further sections discuss prevention and management of MRONJ in osteoporosis, including the timing of tooth extraction, and consider the direction of future research. The findings suggest that patients with osteoporosis treated with bisphosphonates carry an extremely low risk of MRONJ, although denosumab presents a higher risk. Nevertheless, the reduced fracture rate from prompt treatment with anti-resorptives likely outweighs the risk of MRONJ. Dental hygiene should be optimised to reduce risk, and tooth extraction should take place in a timely fashion, with no convincing evidence to support the use of drug holidays. Treatment at present favours a surgical approach, with potential roles for antibiotics, but at present there is insufficient evidence for other medical adjuncts.