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Medically Compromised Patients Oncology Pharmacology Supporting Your Practice

The Prevention and Management of Medication Related Osteonecrosis of the Jaw: Two Cases

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Today, we bring you two interesting complex cases that were treated by Dr. Erin Watson, general dentist practicing out of Princess Margaret Cancer Center, and Dr. Irwin Golosky, Endodontist in Toronto. 

Both cases deal with patients who are at higher risk for medication related osteonecrosis of the jaw (MRONJ). Educational information is also presented to frame the situation and provide relevance to the general dentist. In cases where it is possible to prevent MRONJ, treatment is somewhat straightforward. However, in other cases where there is already a risk of MRONJ, treatment is challenging and requires the tight collaboration of a good oral health team, in order to appropriately address the patient’s needs.

I hope you find the information and the cases valuable. Please share your feedback, suggestions and questions with us through oasisdiscussions@cda-adc.ca

 Until next time!

Chiraz Guessaier, CDA Oasis Manager

 

Full Case Presentation (28.22″)

 

2 Comments

  1. Marc February 3, 2018

    Thanks for the case presentation. Definitely this topic is worth putting out to the membership.

    I think case 1 tooth 37 is problematic. In a patient who will have a stem cell transplant, these lesions have a significant chance of becoming painful or abscesses during or after the course of treatment. The patient will be rendered immunosuppressed, so leaving periodical disease is an issue (regardless of whether you have coronal seal or not). The immune system is the issue here, not leakage. Taking out the tooth later (once abscesses) can then complicate and compromise her myeloma treatment.

    We should put a higher (not lower!) degree of scrutiny on endodontic status of teeth in patient populations such as this. When it fails, there will be higher risk of MRONJ than removing it before treatment. The concept of getting a few good years out of the tooth doesn’t work here, because by delaying what is quite likely inevitable (particularly in a patient such as this) we putting patients at increased risk of harm.

    I respectfully and strongly suggest our colleagues consider another approach: once it was clear that the file could not Be removed and the treatment could not be completed, then the treatment plan should have been modified and this tooth should have been removed. Ideally, by an Oral and Maxillofacial Surgeon whose practice includes management and treatment of MRONJ. At the very least, a patient in such a situation should be given consult with a suitable OMFS so that the patient is able to make a truly nformed choice.

    Reply
  2. Erin February 12, 2018

    Hi Marc, thank you for you comment.

    Regarding tooth 37, your point is a good one and illustrates the number of factors that we take into consideration and the fine balance between providing appropriate treatment to our patients versus over treatment.

    I believe you were referring to the periapical disease present on tooth 37. As you know, it is possible to see radiographic evidence of periodontal ligament widening or rarefying osteitis in teeth that have previously been endodontically treated, even when the radiographic criteria for endodontic success have been met. If we routinely removed the teeth of every patient presenting with radiographic evidence of possible periapical pathology, we would most certainly be over-treating a number of patients (Had the tooth been symptomatic, this would have been a different story). In fact, there is increasing evidence to support partial dental clearance prior to aggressive chemotherapy. An up to date example would be a systematic review published in the journal of supportive cancer care by Hong et al titled ‘A systematic review of dental disease management in cancer patients” published Feb 2017.
    That being said, had the patient been bisphosphonate naive at the time when she was seen, or had the tooth been symptomatic, it would have been removed. Certainly she is at risk of MRONJ IF the tooth fails and IF we need to extract the tooth in the future, but she was already at risk at the time she was seen. Your point about buying a few years is a good one, but on the flip side, perhaps we bought her a few years MRONJ free.
    Finally, you bring up an excellent point which is the patient’s choice, which is this case was as detailed above.

    Was this the right call? Only time will tell. For now, she made it through her transplant uneventfully and the tooth remains asymptomatic.

    Thank you again for your comment, it is difficult decisions like these that challenge us every day.

    Reply

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