Bill Klaproth (host): This is OMS Voices, an AAOMS podcast. I'm Bill Klaproth. And with me is Dr. Dan Meara, who is here to discuss medication-related osteonecrosis of the jaw or MRONJ. Dr. Meara, thank you so much for being here.

Dr. Dan Meara: Thanks for having me. Glad to be here.

Bill Klaproth (host): Yeah, absolutely. It is great to talk with you. So, let's find out about MRONJ. What is MRONJ?

Dr. Dan Meara: MRONJ is an interesting disease process. It's called medication-related osteonecrosis of the jaw, and as you alluded to, it's MRONJ. It’s a serious, but rare disease of the upper and lower jaws of the mouth. The jaws, ultimately, have exposed bone that can then become problematic for the patient.

Bill Klaproth (host): Is this where this exposed bone would come out near a tooth, you would feel it at the lower end of a tooth, or is it like literally like coming out of the gum?

Dr. Dan Meara: It could really occur anywhere. So, the patients that don't have any teeth at all can still have exposed bone or it could be in an area where there is a tooth or where there were previously teeth, maybe after an extraction. We'll get into that potentially more, some of the risk factors, but you can have it anywhere in the mouth.

Bill Klaproth (host): Okay. So then, how does MRONJ generally present? Are there symptoms or signs we should know of?

Dr. Dan Meara: Yeah. Typically so. Now, I will say that some patients, it may be asymptomatic and it might be something that their doctor picks up, the physician possibly, maybe even better their dentist. Things that they might notice though should certainly be pain would be one. Maybe some swelling, they might visualize something that appears a little abnormal, such as the exposed bone. They could maybe all of a sudden find a loose tooth that was previously not the case. So, there's a variety of symptoms that exist.

Bill Klaproth (host): You were mentioning risk factors earlier. What are the risk factors for MRONJ?

Dr. Dan Meara: Typically, the patient has to have been exposed to a medication, hence the name medication-related. So, certain types of medication put the patient at risk for developing it. So, this medication is most often recognized by individuals who have, say, osteoporosis or brittle bones. They'd be prescribed that. It's helpful to prevent further bone loss, may even improve their bone density. And that's important, why? Well, that minimizes their chance for hip fractures, even spinal compression fractures as we age, that is a big problem. So, it's a very common oral medication. But there's a subclass of patients that have some malignant disease such as multiple myeloma or something, say, metastatic breast cancer or prostate cancer where this is used to help ameliorate some of the effects of that treatment. And so, you'll have a variety of patients, but the impact is different based on why you're receiving the medication. And the most common class would be what's called a bisphosphonate.

Bill Klaproth (host): Okay. So, as someone is on medication to help them with osteoporosis that helps build the bone up, that would increase the bone in the jaw, in the mouth, and that's why you get this protrusion of potential bone in the mouth.

Dr. Dan Meara: Well, it's interesting. It's somewhat counterintuitive. So, we're trying to maintain bone. But the difference between, say, long bones, hip, other bones, is that the jawbone has bone that's at the, let's say, gum level of the mouth, that's called alveolar bone, it has more turnover. It has teeth in it. Or even if you don't have teeth, the bone's turning over. Well, how do these medications work? They prevent bone turnover, antiresorptive. That way, if the bone doesn't turn over, it can't be resorbed. If it's not resorbed, you maintain your bone density. Well, if you're not turning over in the different environment, it can lend itself to developing bone that's not healthy, what we would call necrotic bone. And that's when, you know, the disease process becomes MRONJ.

Bill Klaproth (host): Okay. So, for these people that are on these certain medications, what can be done to help prevent MRONJ?

Dr. Dan Meara: Well, I think it's important to note ahead of time the importance of these medications should be noted. They serve a purpose. So, I don't want the impression to be that, you know, you want to avoid these. If you can prevent a hip fracture, which has significant morbidity, that's worth it. We can treat the MRONJ, may be harder to treat the hip fracture. So, I think that's something we need to start. Two, if you have malignant disease, you have to have that treatment. This is kind of a non-negotiable thing. So, what do we do? We help you through it.

And so, what are the some of the thought processes? There's a chance you're going to be on this medication if you're having a discussion with your physician or your oncologist, let's have a plan ahead of time. So, one of the strategies is see your dentist, get a good evaluation and anything that's concerning at the moment, loose teeth, gum disease, teeth that need extraction, whatever it may be, needs to ideally in a perfect world be done before you initiate the medication.

Bill Klaproth (host): So then, if you find MRONJ in a patient, how do you treat it?

Dr. Dan Meara: You know, in a purest form from a clinician, there's a staging system that helps the clinician with how they're going to manage this disease process. In general terms though, if the patient comes in, and they just have some vague symptoms, but no exposed bone, which is a possibility, then they may be just seen under observation, or their dental health or oral health may be optimized. That’s step one.

However, say they come in and all of a sudden, they are having some pain and they do notice exposed bone, then it depends on where they fall in that staging classification as to what's going to happen next. So, for instance, in stage I, they have exposed bone, but they're asymptomatic. So then, in that case, probably putting them on oral rinses, maybe even a prescription rinse, versus they have stage II, same exposed bone, but now they have symptoms and pain and, matter of fact, we can see some signs of infection. What's going to happen there? Same rinses probably, same oral health hygiene, but we're going to maybe start antibiotics.

Bill Klaproth (host): Right. Okay. So, why is it best to have an oral maxillofacial surgeon do work on MRONJ?

Dr. Dan Meara: Yeah. Interesting question. I think part of it is our knowledge and understanding of the jaws and the disease process. But also, what we haven't talked about yet is there is a component here where we're going to perform surgery potentially. And as surgeons, in this environment, this is our area of expertise. That's why we are important part of the team because the next stage, if you have exposed bone, but it's progressing, then we might need to consider surgical options.

Bill Klaproth (host): Right. Absolutely. So, this has been fascinating, Dr. Meara. As we wrap up, anything else you want to add about MRONJ?

Dr. Dan Meara: I think it's just something that we need to talk more about, something that patients who have a sense about this need to talk to their doctors too about duration of treatment, not so much for the IV medications, because those are usually cancer-related. But for the oral, there is a question how long is long enough to prevent further bone loss in osteoporosis? And I've seen patients been on them for seven, 10 years. And the question is do they need them that long? So, that's something I think maybe for the future, is one item to note how long is ideal, and maybe that's patient-specific.

And second thing for people to know is the risk is still low. I don't think we really hit on that. So, if you're taking an oral medication, your global risk to somebody is less than one percent chance you're going to develop the disease, MRONJ. If you're on an IV form, the more potent form, you're still likely not much more than one percent chance, one out of a hundred that you're going to develop the disease. This is not to be scary. This is to know this is a real disease process. It can be managed and you need to have some good understanding of what you're dealing with.

Bill Klaproth (host): But it is rare. So, that's kind of the bottom line on that, right?

Dr. Dan Meara: That's right.

Bill Klaproth (host): Well, this has been great, Dr. Meara. Thank you so much for your time.

Dr. Dan Meara: I appreciate having the chance to talk with you. And hopefully, this is of interest to the patients and the public.

Bill Klaproth (host): Absolutely. Well, it sure is. Once again, that's Dr. Dan Meara. And for more information and the full podcast library, please visit MyOMS.org. And if you found this podcast interesting, please share it on your social media and don't forget to subscribe. Thanks for listening.