MASCC/ISOO/ASCO
Medication-Related Osteonecrosis of the Jaw
Ce document comprend 13 recommandations, 187 références, 6 tableaux et 1 figure.
Contenu en anglais
Synthèse
Medication-related osteonecrosis of the jaw (MRONJ) is a complication that occurs in 1% to 9% of advanced cancer patients receiving bone-modifying agents (BMAs). It is characterized by exposed, unhealed bone in the maxillofacial region. The guideline seeks to establish standardized definitions, preventive strategies, and management algorithms to optimize oral care and patient outcomes.
Messages clés
Comprehensive oral and dental assessments should ideally be completed prior to initiating BMA therapy.
Elective dentoalveolar surgery is contraindicated during active therapy with an oncologic dose of BMAs.
Initial treatment for MRONJ should rely heavily on conservative measures like antimicrobial mouth rinses and effective oral hygiene.
Refractory or highly symptomatic MRONJ can be managed with aggressive surgical interventions, but asymptomatic bone exposure should not be aggressively treated.
Interdisciplinary communication among oncologists, dentists, and dental specialists is paramount in defining the status of the lesion (resolved, improving, stable, progressive) and dictating ongoing BMA therapy.
Nouveautés de cette version
This systematic review is an update to a previous MASCC/ISOO review published in 2010, expanding the search strategy to incorporate denosumab-related research from January 2009 to December 2017.
Recommandations
Clinical Question 1
It is recommended that the term medication-related osteonecrosis of the jaw be used when referring to bone necrosis associated with pharmacologic therapies.
Patients concernés: Oncology patientsSituation: Bone necrosis associated with pharmacologic therapies
Clinicians should confirm the presence of all three of the following criteria to establish a diagnosis of MRONJ: (1) current or previous treatment with a BMA or angiogenic inhibitor, (2) exposed bone or bone that can be probed through an intraoral or extraoral fistula in the maxillofacial region and that has persisted for longer than 8 weeks, and (3) no history of radiation therapy to the jaws or metastatic disease to the jaws.
Patients concernés: Oncology patients with suspected bone necrosisSituation: Diagnosis of MRONJ
Clinical Question 2
Coordination of care. for patients with cancer who are scheduled to receive a BMA in a nonurgent setting, oral care assessment (including a comprehensive dental, periodontal, and oral radiographic exam when feasible to do so) should be undertaken before initiating therapy. Based on the assessment, a dental care plan should be developed and implemented. Follow-up by the dentist should then be performed on a routine schedule, for example every 6 months once therapy with a BMA has commenced.
Patients concernés: Patients with cancer scheduled to receive a BMA in a nonurgent settingSituation: Prevention of MRONJ
Modifiable risk factors: members of the multidisciplinary team should address modifiable risk factors for MRONJ with the patient as early as possible. These risk factors include poor oral health, invasive dental procedures, ill-fitting dentures, uncontrolled diabetes mellitus, and tobacco use.
Patients concernés: Patients with cancer receiving BMAsSituation: Prevention of MRONJ
Elective dentoalveolar surgery: elective dentoalveolar surgical procedures (eg, nonmedically necessary extractions, alveoloplasties, and implants) should not be performed during active therapy with a BMA at an oncologic dose. Exceptions may be considered when a dental specialist with expertise in the prevention and treatment of MRONJ has reviewed the benefits and risks of the proposed invasive procedure with the patient and the oncology team.
Patients concernés: Patients receiving active therapy with a BMA at an oncologic doseSituation: Prevention of MRONJ
Dentoalveolar surgery follow-up: if dentoalveolar surgery is performed, patients should be evaluated by the dental specialist on a systematic and frequently scheduled basis (eg, every 6 to 8 weeks) until full mucosal coverage of the surgical site has occurred.
Patients concernés: Patients who undergo dentoalveolar surgery while on BMAsSituation: Post-surgical monitoring for MRONJ
Temporary discontinuation of BMAs before dentoalveolar surgery: for patients with cancer who are receiving a BMA at an oncologic dose, there is insufficient evidence to support or refute the need for discontinuation of the BMA before dentoalveolar surgery. Administration of the BMA may be deferred at the discretion of the treating physician, in conjunction with discussion with the patient and the oral health provider.
Patients concernés: Patients with cancer receiving a BMA at an oncologic dose requiring dentoalveolar surgerySituation: Pre-surgical BMA management
Clinical Question 3
A well-established staging system should be used to quantify the severity and extent of MRONJ and to guide management decisions. Options include the 2014 American Association of Oral and Maxillofacial Surgeons staging system, the Common Terminology Criteria for Adverse Events version 5.0, and the 2017 International Task Force on Osteonecrosis of the Jaw staging system for MRONJ. The same system should be used throughout the patient’s MRONJ course of care.
Patients concernés: Patients diagnosed with MRONJSituation: Staging of MRONJ
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