Bill Klaproth (Host): This is an AAOMS On the Go podcast. I'm Bill Klaproth. And with me is Dr. Tara Aghaloo and Dr. Sal Ruggiero. They are here to discuss deciphering the 2022 MRONJ position paper, take-home messages and debates. Dr. Aghaloo and Dr. Ruggiero, thank you for your time today.

Tara Aghaloo, DDS, MD, PhD: Hi Bill. It's so great to be here, with you.

Sal Ruggiero, DMD, MD, FACS: Same here. It's a pleasure.

Host: Absolutely. Well, thank you both for being here. Dr. Ruggiero, I want to start with you. So if you could, could you tell us what are the major differences between the 2014 and 2022 MRONJ AAOMS position papers?

Sal Ruggiero, DMD, MD, FACS: Sure. There are really two major differences. One is the realization that inflammatory disease within the mandible and the maxilla, is really now known to be a significant cofactor as a risk for its development of MRONJ. And the next major change or it would be the introduction of what I would call a treatment algorithm that we've devised for both operative and non-operative therapies. And this I think, provided the community with a very workable roadmap, if you will for the treatment of MRONJ in all stages, including non-operative therapies well as operative therapy. And we even have separated out for upper jaw and lower jaw disease.

Host: So our OMSs more comfortable then with preventative and treatment protocols to their patients taking antiresorptive medications?

Sal Ruggiero, DMD, MD, FACS: Well, I would hope so. That was the whole purpose of these guideline papers, for the last two, at least was to reinforce the importance of prevention. Because all the data suggests that if you can prevent it with doing simple things, with according to dental hygiene and, identifying teeth that are at risk before you start them on treatment; those make a very large difference, a significant difference in the incidence of this disease.

Host: Patient education is important at this point.

Sal Ruggiero, DMD, MD, FACS: It's very important.

Host: When I was going to say, oh,

Sal Ruggiero, DMD, MD, FACS: And I think what's happened is, because patients have been traumatized if you will, by all this information in the media and elsewhere; they're oftentimes looking to us as oral surgeons for guidance as to whether or not they should continue their therapy, start therapy.

I see more and more patients now coming for consults just to discuss whether or not they should start their antiresorptive therapy for osteoporosis. So I consider that to be kind of a golden opportunity to put the relative risks into the proper perspective. To let them know that you know, the risk is exceedingly small for patients who are taking these medications for osteoporosis. And not so small, small still, but not as small as those patients who were taking the drugs for osteoporosis. And what the patients were taking it for cancer, it's much different.

Host: So, can you explain quickly the risk for taking the osteoporosis medications?

Sal Ruggiero, DMD, MD, FACS: Well, best data we have right now, there's a risk. It's way less than 1%. It's like 0.1 - 0.2% is small, really small. And for those patients who are receiving you know, higher doses of antiresorptive therapy for cancer, that risk is anywhere from one to two, 2%, 3% depends.

Host: So very low, but good to have that patient education anyway. So speaking of patient education, how can we get the word out to dentists, primary physicians and oncologists about the myths, risks, and treatment protocols for MRONJ?

Sal Ruggiero, DMD, MD, FACS: Well, having this podcast available to them it would help.

Host: I like that. a good answer, Dr. Ruggiero I like that.

Sal Ruggiero, DMD, MD, FACS: But I think having the guidelines available to the public even, in fact, I think it's still is available when you go on our website, as a free download. So that's one way of getting the word out. Presenting this information at meetings that, you know, publishing stuff like this in common journalists that the dentists are going to read is helpful. But it's been a challenge over the years, for 20 years now. And we're trying to get everybody up to the level playing field. What's happened though, that it's unfortunate is that the pendulum has swung in the other direction. Meaning that dentists are now extremely reluctant to provide care to patients who are receiving these medications, even for osteoporosis.

And, they're withholding care. When we know now that administering a preventive care means so much. And yet, a lot of these dentists don't want to treat them because they were on these medications. So there still really is a significant knowledge gap about what the real risks are and that's what our job is to try to get that message out.

Host: Absolutely. Well, thank you for that. And Dr. Aghaloo I want to ask you some questions as well. So why is there debate around treatment protocols for MRONJ?

Tara Aghaloo, DDS, MD, PhD: I think that a lot of the reason is because we're surgeons, we see that there's bone that's dead or necrotic. So of course surgery should be the answer. I mean that's how we treat patients that have radiation necrosis. And so of course the surgical therapy is on the forefront. But at the same time, there's been this move toward the non-operative therapy where patients can be managed without surgery and get pretty similar results. Some of the issues, of course, though, are that it takes longer. It requires a lot more of the patient participation. So there are definitely some barriers to both types of therapy.

Host: So then that brings up the question, if MRONJ can be treated non-operatively why would a patient choose surgery?

Tara Aghaloo, DDS, MD, PhD: Well, I mean, non-operatively often can mean many months to even years for complete disease resolution. Where surgery can be done in a matter of hours. So it's definitely the time factor. Patients with cancer can be very sick and have difficulty with being able to administer their own conservative therapy where we're asking them to do wound care and get in their mouth. And really keep things nice and clean, and keep up with their visits. So, there's a lot of difficulty when we're asking quite a lot of the patients and then the doctors to follow them for some time, right.

Host: But definite benefits for surgical treatment it sounds like.

Tara Aghaloo, DDS, MD, PhD: Yeah, there really are risks and benefits to both. So the conversation really should not be which one is better. It should be presenting both options to the patient and their family and their support system; and along with the surgeon, deciding on what's best for that individual patient.

Host: Absolutely. That makes sense. So how should OMSs work with dentists to see patients for routine dental care when they are at risk for MRONJ?

Tara Aghaloo, DDS, MD, PhD: That's a good question. What I do a lot is I have a pre-antiresorptive visit with the patient to really go over their risk, get some more advanced imaging, like a cone-beam CT scan, and then have their dentist see them for the routine maintenance. If they develop osteonecrosis, then I'm seeing the patients once every three or four months. And then if they have issues in the interim with any of the teeth that are involved or other dental care that needs to be done, then their dentist is taking care of that. So a team effort.

Host: So then what is the specific role for the OMS in assessing or reducing MRONJ risk and treating patients who have developed MRONJ?

Tara Aghaloo, DDS, MD, PhD: I think education is really big. It can go anywhere from the patient thinking that their cancer is getting worse and has spread because the dentist looks in the mouth and says, oh my gosh, what is that? I've never seen that before. And the number of times that I have a patient coming in and saying that their dentist has said that, is quite high. And so, educating the dentist. I think it's important for us to speak to our local societies and make sure that all dentists are up to snuff on all that. Of course our recent graduates of dental schools have a lot of that in their regular curriculum. But if you graduated you know, 15, 20 years ago, you may not have gotten that in school. And so I think people are maybe a little bit more fearful of treating patients with that.

And as Sal said, they're often reluctant to provide even care where there's not going to be any risk to the patient at all. And you certainly don't want that to happen.

Host: Dr. Ruggiero said there is a knowledge gap there as well. Very interesting. So, Dr. Ruggiero, then why has the focus on moved away from antiangiogenic medications?

Sal Ruggiero, DMD, MD, FACS: Well that's really came out as doing the process of doing that literature search for the 2022 guidelines. And what we we did was we tried to limit our data search, literature search to, to randomized clinical trials and trials that have lots of patients in them.

And, when we looked at the data for these anti-angiogenics, there really wish no additional foundation for us to consider that these drugs were really a problem. Most of the data was limited small case series, or larger case series, but not great data. So because of that, we've kind of deemphasized the role that the antiangiogenics have. Now, that's not to say that there may not be a risk, there might and that's one of the topics that needs to have further study. But right now, the data doesn't really support that this can be a significant risk. The other thing is that one of the unique scenario that if, and I think this is true. If patients are receiving anti-resorptive therapy, for cancer, let's say, and they're also receiving a concomitant treatment with an antiangiogenic, that I think is a little bit of an issue. And that's the one scenario where we did see a little blip in one study was risk was a little higher, but it has to be sorted out with a better, got to design studies.

Host: So do you anticipate other medications will lead to similar clinical disease processes? Like immunotherapeutics or monoclonal antibodies?

Sal Ruggiero, DMD, MD, FACS: I mean, it's possible. The thing is, you know, there've been a bunch of case series that have looked at all of these other drugs, corticosteroids, tyrosin, kinase inhibitors, anti-angiogenics, some of the immunotherapies; but not in a way that we can kind of make the conclusion that there's an absolute risk, right. And we said this today, in our presentation, is that this is an area where future research is definitely needed. It is possible that these drugs might be an issue, but we don't know yet.

Host: Absolutely. Well, this has been a fascinating discussion. I want to wrap up with getting final thoughts from each of you. Dr. Aghaloo, let's start with you. What would you like to add?

Tara Aghaloo, DDS, MD, PhD: I would like to add that I think as OMSs, it's really our job to educate the patients, educate the oncologists and the primary care physicians that are prescribing these medications. And educate the dentists that we're working with. So really we're the quarterback in trying to really prevent and treat this disease. So we need to be out there educating everyone.

Host: Absolutely. Thank you for that. And Dr. Ruggiero, final thoughts from you.

Sal Ruggiero, DMD, MD, FACS: I will echo what Dr. Aghaloo said. Absolutely. And I think final chapter has not been written. I mean, our knowledge base with this entity continues to evolve over time. So, there might be another update in, you know, 3, 4, 5 years. And that's fine. As long as we have new data, that's going to improve our understanding and our treatment algorithms. So it's a process.

Host: It's a process. Right. Well, thank you both for your work in this area. We really appreciate it.

And once again, that is Dr. Aghaloo and Dr. Ruggiero. And for more information, visit aamos.org/positionpapers to review the MRONJ position paper, or, you can visit aamos.org/jobs to read it in the journal. And if you enjoyed this podcast, please share it on your social channels and be sure to subscribe, so you don't miss an episode. Thanks for listening.