Rheumatology for the Dentist PDF

**[RHEUMATOLOGY FOR THE DENTIST\ ]** **What is Rheumatology?** **[Broad Field]** - *[Includes]* **Musculoskeletal** **Disease** and **Systemic Autoimmune Conditions** - **Autoimmune** **Conditions** - **Immune System** *[attacks]* areas of the **Body** *[causing]* **Damage/Sympto...

**[RHEUMATOLOGY FOR THE DENTIST\ ]** **What is Rheumatology?** **[Broad Field]** - *[Includes]* **Musculoskeletal** **Disease** and **Systemic Autoimmune Conditions** - **Autoimmune** **Conditions** - **Immune System** *[attacks]* areas of the **Body** *[causing]* **Damage/Symptoms** - Can affect any **ORGAN** *[but also]* **Mouth**, **Eyes**, **Skin**, **Nervous** **System**, and **Internal Organs**. **What does a Rheumatologist do?** - **DIAGNOSTICS** -- **Imaging**, **Biopsy**, *[measurement]* of **Autoantibodies** - **IMMUNOMODULATORY DRUGS** -- e.g. **antibodies** *[targeting]* **Specific Parts** of the **Immune System** - **HOSPITAL** or in a **COMMUNITY SETTING** - *[often]* *[work]* **Closely** with **GPs** and **Organ-Based Specialists** - *[Conduct]* **RESEARCH** **Examples of RHEUMATOLOGICAL DISEASES** - **Degenerative -- Osteoarthritis** (**wear** and **tear** in the **joints**) - **Inflammatory** **Conditions - Gout & Rheumatoid Arthritis** - **Systemic And Connective Tissue** **Diseases - Lupus** - **Metabolic Diseases Of The Bone - Osteoporosis** - **Chronic** **Pain -** **Degenerative** - Osteoarthritis **Inflammatory** - Gout - Rheumatoid Arthritis **Systemic/CTD** - **LUPUS** **Butterfly Rash** *[that is in the]* **Sun** **Metabolic** - Osteoporosis **Why is the Dentist *[important]* in RHEUMATOLOGY?** - **Oral Manifestations** of **Disease** - As **Treatment** **Complications** - Can be an *[early]* **Presentation** of **Rheumatic Disease** - Can *[sometimes]* *[reflect]* **Disease Activity** **[CASE 1]** A **75-Year-Old Lady** *[comes]* to your **Dental Practice** *[complaining]* of **intense pain** and a **non-healing sore** in the **Mouth**. You ask her to open her mouth and notice this... **What do you WANT TO KNOW at this stage?** **Case 1 -- MEDICAL HISTORY** - **Cancer** - *[Recent]* **Dental Procedures** - **Medication** -- *[particularly]* **Cancer Anti-Angiogenic Drugs**, **Bisphosphonates**, and **Denosumab** - *[Any previous episodes]* **MEDICATION-RELATED OSTEONECROSIS (ONJ) OF THE JAW** - *[Occurs]* when **Underlying** **Jawbone** is *[not]* *[covered]* by **Gum** - *[Lack]* of **Blood Supply** *[exposes]* **Underlying Bone**, and this is **Starved** of **Oxygen** and **Dies** - *[Can occur spontaneously]* - *[Occurs]* in **Patients** taking **Bisphosphonates**, **Denosumab**, **Anti-Angiogenic Drugs** **[INCIDENCE]** - In **Cancer** **Patients** *[treated]* with **Anti-Resorptive/Anti-Angiogenic Drugs** -- 1 per 100 - In **Osteoporotic** **Patients** *[treated]* with **Anti-Resorptive Drugs** -- 1 to 10 cases per 10,000 **Medication-Related Osteonecrosis (ONJ) of the Jaw -- RISK FACTORS** - *[Any procedure]* that **Impacts** on **Bone**, e.g., **Tooth Extraction** - **Dental** and **Mucosal TRAUMA** -- **ill-fitting dentures** - **Dental Infection/Periodontal Disease** - **Cumulative dose** of **Bisphosphonate** - *[But can occu]*r **Spontaneously** **[PREVENTION]** - *[Complete]* any **Dental Work** *[prior to starting]* **Treatment** - *[Give]* **Advice** on **Optimising Oral Health** **GUIDELINES** -- **Faculty of General Dental Practice** ***https://www.fgdp.org.uk/SiD/a1-uk-guidelines-and-standards-dentistry*** **[CASE 2]** An **80-Year-Old Presents** with **Pain** *[whilst]* **Eating** and **Combing** **Her Hair** **What else DO YOU WANT to ASK HER?** **CASE 2 -- What do you think it COULD BE, and what are the WORRYING FEATURES?**  **GIANT CELL ARTERITIS (GCA)** - **Inflammation** of **Cranial Branches** of the **Arteries** *[originating]* from the **Aortic Arch** - **Extracranial** **Branches** of the **External Carotid Arteries** *[often involved]* - **Prevalence**: 1 in 400 \> 55 years - **Female** **Preponderance** **[Aetiology and Pathogenesis]** - Granulomatous Vascular Inflammation - *[Cause]* **unclear** - **Genetic** **Component** - **Infection Trigger**? **[Symptoms and Signs of GCA and Arterial Involvement]** - **[SCALP TENDERNESS] - (superficial temporal artery involvement).** - **HEADACHE** - **[JAW PAIN]** on **chewing - (Maxillary Branch Involvement) due to ischemia from poor blood supply to muscles.** - **[TONGUE PAIN]** on **chewing - (Lingual Branch Involvement).** - **VISUAL SYMPTOMS** -- **Blurred** **Vision**, **Double Vision (very important to ask about).** - **[WEIGHT LOSS]** - **FEVER** - **[WIDESPREAD INFLAMMATION ]** - **RISK OF STROKE (internal carotid artery involvement).** **[MANAGEMENT]** - **Sight Loss** in **GCA** is a **Serious Complication** - *[Can be]* **Temporary** or **Permanent** -- *[so need to specifically ask]* - **VISUAL CHANGES**: *[refer]* to **A&E** for **same-day assessment** by **Ophthalmology** **[CASE 3]** A 45-year-old lady complains of an excessively dry mouth and eyes, and on asking has joint pain. **What do you think her DIAGNOSIS could be?** **SJOGREN'S SYNDROME** - *[First Described]* by **Swedish Ophthalmologist Sjogren** in 1933 - **Systemic** **Autoimmune** **Disease** - Up to **4% population** - **Female** **preponderance** 9:1 - **Lymphocytic** **Inflammatory** *[infiltrates]* within **Exocrine Glands *[(seen on biopsy)]*** - **Salivary** and **Lacrimal Glands** *[affected]* *[Causes]* **Xerostomia** & **Xerophthalmia** - **Dry Mouth (xerostomia)** and **Eyes (Xerophthalmia)** - 1 in 70 with **primary** and 1 in 35 secondary - **[Primary]** \-\-- by *[itself]* - **[Secondary]** \-\-- *[Associated]* with an **Autoimmune Disease** (occurs secondary to this **LUPUS**) **SJOGREN'S SYNDROME -- Extra-glandular Features** - **Joint Pain** and **Arthritis** - **Muscle Pain** - **Lymphadenopathy** - **Renal Disease** - **Fatigue** - *[Increased]* **Risk** of **Lymphoma** - (*[inflammation]* of the **Nodes** *[increases]* the **Risk**) Can be **Primary** or **Secondary** to another **Disease**, e.g., **LUPUS** **[XEROSTOMIA]** - **Outside** of **Sjogren's** -- **medications** *[strong association]* with **Salivary Gland Dysfunction** - **Negative Impact** on **Quality Of Life** - *[Higher]* *[rates]* of **Dental Caries** - *[Increased]* **Mucosal Infections** - Difficulty **Chewing**, **Hoarseness** **[PERIODONTAL DISEASE]** - Increased in **RA**, **SLE**, **Systemic** **Sclerosis (Systemic Sclerosis)** - *[May be due to]* **Xerostomia** *[but also]* **Functional Limitations** -- **Brushing Teeth** - *[Challenges]* for **Oral Hygiene** - **Limited Mouth Opening** -- **TMJ disease** - **Difficulty Tolerating** - *[Increased risk]* of **Disease** - **Oral Microbiota** - **Porphyromonas** **Gingivalis** *[induce]* **Citrullination** - *[Promote]* **Auto-Antibody Development -** *[against]* **Citrullinated Proteins**  **[CASE 4]** A 25-year-old man presents to you with a history of several painful recurrent oral ulcers, and his eye is slightly red. **[What else DO YOU WANT TO ASK HIM?]** **[Bechet's Disease]** - **Systemic Vasculitis** of *[unknown cause]* - **[Affects Veins and Arteries]** - **Recurrent** **Oral** and **Genital Ulcers** - **Eye disease** with *[potential]* **blindness** - **Skin** **Disease -- acne form lesions** - **Joint Pain** - **[Oral Ulcers]** - **Aphthous** -- **Painful**, **Round**, **Well-Defined Ulcers** - **Heal** with **no scar**  - *[Increased]* **Prevalence** along the **'Silk Road'** *[connecting]* **East** to **West** **[Bechet's Disease]** - *[Association]* with **HLA-B51 Immunosuppressive Agents** - *[Avoid]* **Spicy Irritating Foods** - **Viscous** **Lidocaine -- treat Symptoms** - **Prednisolone** **Mouthwash** -- *[risk]* of **Adrenal Suppression *[IF YOU SWALLOW IT]*** - **National** **Centres** in **Liverpool**, **Birmingham**, and **London** **Oral Ulcers with Facial Rash** **SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)** - **Multisystem Autoimmune Disease** - F:M -- 10:1; **Asian** & **African**. - **Autoantibodies** & **Clinical Features**: - **Rash** -- Butterfly - **Oral Ulcers** - **Joint Pain** - **Secondary Sjogren's** - *[Internal]* **Organ Involvement** - **Aetiology** -- infection, drugs, smoking, solvents, silica **[CASE 5]** **[60-Year-Old lady]** - **Rheumatoid Arthritis** - **Non-smoker** - *[Weekly]* **Methotrexate** 10mg - *[Went]* **Abroad** and **Flare** of **Disease**, was *[advised]* to **Increase** to **Daily** - *[Presents]* with **Multiple Shallow Ulcers** **[METHOTREXATE-INDUCED ORAL MUCOSITIS]** - *[Used]* for *[mainly]* **Rheumatoid** **Arthritis** but also other **Diseases** such as **Lupus** - *[Affects]* **DNA Production** -- **Antimetabolite** and **Immunosuppressant** - **Blocks Folic Acid - *[Affects]* Cell Turnover (cell division)** - **Folic Acid** *[supplementation]* **Reduces Side Effects** - **Normally Given Weekly** - **Folic Acid** *[supplementation]* *[reduces]* **Side Effects** - *[Causes]* **Oral Mucositis** and **Ulcers** -- **Dose-Dependent** - **Treatment** *[involves]* **Stopping** the **Drug** with **SUBSEQUENT** **HEALING** of **Ulcers** - *[Consider]* **Chlorhexidine** or **Difflam** **Mouthwash** **[CASE 6]** 70-Year-Old Lady *[attends]* with **JAW PAIN** and **Difficulty Chewing Food** **[SYSTEMIC SCLEROSIS]** - **Rare** **Multisystem Disease** *[characterised]* by **excessive production** and **accumulation** of **collagen** *[affecting]* **Skin** & **Internal** **Organs**: - **F\>M 7:1** - **[Microangiopathy]** -- **disease** of **Small Blood Vessels**, RP, **Digital Ulceration**, **Telangiectasia** **[Systemic Sclerosis -- FEATURES]** - **Microangiopathy** -- *[disease]* of **Small Blood Vessels** - **RP, DIGITAL ULCERATION, TELANGIECTASIA** - **Cutaneous Fibrosis** - **Skin** **Thickening**, **Perioral Furrowing -- Deep Lines around the lips** - **LUNGS** -- **Intestinal Lung Disease**, **Pulmonary** **HTN, Scarring** - **GI** -- **Reflux**, **Motility**, **Gastroparesis** - **IA** **[Systemic Sclerosis -- ORAL MANIFESTATIONS]** - **Oral Manifestations** can precede diagnosis - **Perioral** **Skin Fibrosis** -- limited mouth opening - **Xerostomia** -- increased risk of periodontal disease - **Microstomia** affects **Oral Hygiene** - **Telangiectasia** -- vascular malformations, may bleed **TMJ Disease** - **Umbrella Term** -- **muscular DISORDERS**, **Bone Changes, Ankylosis, Degeneration, Functional Limitations** - **Rheumatic Diseases** *[frequently]* **experience** **TMJ SYMPTOMS** - More than half of patients with (Juvenile Idiopathic Arthritis) - In RA: 19 to 85.7% - *[Limitation]* in **Opening, Pain** **TAKE HOME MESSAGES** - Dental Complications *[very common]* - *[Affects]* **Quality Of Life** and **Ability** to *[maintain]* **Oral Hygiene** - Dentist has an important role: - Recognising disease - Treating complications - Encourage good oral hygiene and reduce risk of infections - Signposting in early disease - Be aware of sight loss as important complication in GCA **[RHEUMATOLOGY:]** **[RHEUMATOID ARTHRITIS:]** Rheumatoid Arthritis (RA) is a chronic inflammatory autoimmune disorder that primarily affects the joints  It results in warm, painful, and swollen joints. Antibodies are targeted to the synovial membrane which they attack. **[RISK FACTORS:]** - Genetics - Genetically pre-disposed if you have the HLA-DR4 genotypes - Found in 60-70% of those with RA - Sex - Females are 3x more likely to develop RA - Age - Most likely to be diagnosed age 30-60 years of age, but can occur at any age - Smoking - Increases risk of RA by 3x - Periodontal disease - Pathogen Porphyromonas gingivalis has been impacted in aetiology of RA **[CAUSES:]** - No cause - Mix of genetics and environment to trigger the autoimmune response **Diagnosis:** - Refer to rheumatologist - Intensive history and examination - **Blood Tests:** - Full blood count - Erythrocyte sedimation rate (ESR) - C-reactive protein (CRP) - Rheumatoid factor - Present in 70% of cases - Anti-cyclic citrullinated peptide (Anti-CCP) - **Scans** - X-rays - MRI scans - Used for diagnosis and monitoring RA -- check inflammation and damage NB: Early diagnosis and initiation of treatment improves function and morbidity outcomes **[SIGNS AND SYMPTOMS:]** **[Articular Symptoms:]** - Joints Affected: - Initially, small joints are affected - Joints in hands and feet - Joints are generally affected symmetrically - Eventually, larger joints will be affected (shoulder) - Specific deformities: - Ulnar deviation - Buttonhole deformity - Swan neck deformity - Often worse in the mornings after a period of inactivity - Stiffness of joints: - Worse in the morning, after a period of inactivity - Lasts more than an hour - Similar to osteoartitis, but stiffness in OA lasts less - Swelling - Synovial membrane - Pain in joints **[EXTRA-ARTICULAR SYMPTOMS:]** - **General:** - Fever - Low appetite - Malaise - Weakness - **Neurological** - Fatigue, reducted cognitive function - **Exocrine glands** - Secondary Sjorgen's disease - **Bone** - Osteoporosis -- MRONJ medication - **Cardiovascular:** - Increased risk of atherosclerosis - Risk of stroke/MI - Anaemia - Scleritis **Acute flares in RA:** - Sudden worsening of the disease/exacerbation of symptoms - Affected joints become swollen, warm red and painful - Often interfere with everyday tasks **[TREATMENTS:]** Aim of drug therapy is to reduce symptoms and suppress inflammation, limiting joint damage and disability. There is currently no cure! Smoking reduces the efficacy of treatments **DMARDs:** - Disease-modifying anti-rheumatic drugs - Modify the whole immune system - **Primary treatment** - Reduce swelling - Lower inflammatory markers - Limits progressive joint damage - Modify the - Examples include **methotrexate** - Generally the first medicine given - Anti-metabolite - Mucositis **Biological DMARDs:** - Given to patients with very severe disease - Usually given in combination with DMARDs - Adalimumab - Mostly given by injection **NSAIDs:** - Given for pain - Lichenoid reactions **Dentistry:** - Sjogren's is the most common oral implication - Secondary - Affects exocrine glands, lacrimal + salivary - If TMJ is affected by RA - Limited opening, trismus - Restricted manual dexterity - Poor OH - Make specific toothbrush with putty - Electric toothbrushes - Avoid early morning appointments - Patients are quite stiff - Supine positioning may be uncomfortable - Methotrexate mucositis - NSAIDs: peptic ulcers/lichenoid reactions - Periodontal disease - Bi-directional relationship between RA and PD - Bisphosphonates: MRONJ **[LUPUS ERYTHEMATOUS:]** Lupus can be categorised into either **systemic lupus erythematous** (SLE) or **discoid lupus erythematous (DLE)** Lupus erythematous is a chronic, autoimmune disorder causing widespread inflammation to connective tissues. The most common type is discoid lupus erythematous, which resembles a mucocutaneous condition affecting the skin. Systemic lupus erythematous is a more severe multi-system disease. It is characterised by episodic exacerbations and periods of remission. Severity of symptoms can vary. **SLE:** SLE is a chronic autoimmune disease which affects multi-organs and is potentially fatal. There is widespread inflammation to connective tissues. **[RISK FACTORS:]** - Women in child-bearing years - 10x more likely to develop it than men - Age: 15-40 - Family history of SLE - Black, Asian or minority ethnic people **[CAUSES:]** - Autoimmune in nature - Believe it is a combination of genetic and environmental reasons - Triggers: - Viral infections - Sunlight - Smoking - Certain medicine - Hormones -- oestrogen - Certain medicines **[SIGNS AND SYMPTOMS:]** Very large of signs and symptoms. It is often a mimic of other conditions! General symptoms: - Fever + chills - Malaise - Fatigue - Weight loss - Headache **[SKIN:]** - Malar butterfly rash - Extends over cheeks and bridge of nose - Spares the nasolabial folds - Discoid rash - Disk-shaped rash - Reddened and raised patch - Can trigger alopecia -- scarring of the patch causes destruction of hair follicle - Photosensitivity - Unusual reaction and rash - Ulcerations - In nasal/oral mucosa **[MUSCLES AND BONES:]** - Polyarthritis - Pain and inflammation in multiple joints - Symmetrical - Large and small joints affected - Swelling, pain and tenderness - Morning stiffness **[CARDIOVASCULAR:]** - Pericarditis - Inflammation of pericardium - Chest pain - Endocarditis - Inflammation of endocardium - LSE: Libman-Sacks Endocarditis **[LUNGS:]** - Pleuritis - Inflammation of lung pleura - Outer lining of the lung - Lung pain **[NEUROLOGICAL]** - Cerebritis - Inflammation of the cerebrum - Can trigger seizures, psychosis, and coma Renal failure - Lupus nephritis - Often patients have protein/blood in their urine Pregnancy losses - Increases risk of miscarriages - During second trimester **[HAEMOTOLOGICAL:]** - Anaemia - Leukopenia: low white blood cell - Thrombocytopenia: low platelet **[SJROGEN'S:]** - Secondary sjrogens - Dry eyes and mouth **SOAPBRAIN MD** - Serositis - Oral ulcers - Arthritis - Photosensitivity - Blood disorder - Renal disease - Antinuclear antibodies - Immunological disorder - Neurological disorder - Malar rash - Discoid rash **[DIAGNOSIS:]** American College of Rheumatology: four or more of 11 criteria met 1. Malar rash 2. Discoid rash 3. Serositis 4. Oral ulcers 5. Arthritis 6. Photosensitivity 7. Blood disorder 8. Renal disorder 9. Neurological disorder 10. Antinuclear antibody 11. Immunological disorder Blood tests: - Anti-nuclear antibodies (ANA) - Anti-double strand DNA antibodies -- anti-dsDNA antibodies - Anti-double strand RNA antibodies -- anti-dsRNA antibodies - Raised ESR - Full blood count - Measure for leukopenia, anaemia, thrombocytopenia - Kidney and liver assessment - Urinalysis **[TREATMENT:]** No cure for lupus. The aim is to prevent flares and reduce severity/duration. NSAIDs: - Reduce fever and joint swelling/pain associated with lupus Corticosteroids: - E.g., prednisone - Decreases inflammation associated with lupus - Adrenal crisis Hydroxychloroquine - Anti-malarial drug - Decrease risk of lupus flare ups **[DENTISTRY:]** - Many SLE patients will have oral lesions/ulcers - Sjogren's syndrome - Decreased manual dexterity - Hydroxychloroquine: can trigger lichenoid reactions as it is an anti-malarial drug - Corticosteroids: - Anaemia: ulcerations **[Bisphosphonates and MRONJ:]** Patient who are taking anti-resorptive or anti-angiogenic drugs have a small risk of developing medication-related osteonecrosis of the jaw. **Definition:** MRONJ is defined as exposed bone, or bone that can be probed through an intraoral or extraoral fistula, in the maxillofacial region that has persisted for more than eight weeks in patient with a history of treatment with anti-resorptive or anti-angiogenic drugs and where there has been no history of radiation therapy to the jaw or no obvious metastatic disease to the jaws Majority of cases occur after a dental intervention which impacts bone, however it can occur spontaneously. Signs and symptoms: - Delayed healing following a dental extraction - Pain - Soft tissue infection and swelling - Paraesthesia - Numbness - Exposed bone **Incidence of MRONJ:** Although a rare condition, the risk in cancer patients is up to 100 times greater.  **Drugs prescribed in the UK:** **Anti-resorptive drugs:** Bone is constantly being remodelled by the action of osteoblasts, which create bone tissue, and osteoclasts which break down (resorb) bone tissue. Anti-resorptive drugs inhibit osteoclast differentiation and function, leading to decreased bone resorption and remodelling There are two main types of anti-resorptive drugs: bisphosphonates and denosumab. They are used in the management of osteoporosis, and other malignant and non-malignant conditions. **[BISPHOSPHONATES:]** Bisphosphonates reduce bone resorption by inhibiting enzymes essential to the formation, recruitment, and function of osteoclasts. Bisphosphonates have a high affinity for hydroxyapatite and persist in the skeletal tissue for a significant period of time. AA has a half-life in bone of around 10 years. Patients take the drugs orally (usually once a week) or the drugs can be given quarterly or yearly infusions. **[DENOSUMAB: ]** Denosumab is a fully human monoclonal antibody which inhibits osteoclast function and associated bone resorption by binding to the receptor activator nuclear factor K ligand (RANKL). Denosumab is administered subcutaneously every six months in osteoporosis, with a higher dose given monthly in patients with metastatic disease. Denosumab does not bind to bone and its effects on bone turnover diminish within 9 months of treatment completion. **[ANTI-ANGIOGENIC DRUGS: ]** Anti-angiogenic drugs target processes by which new blood vessels are formed and are used in cancer treatment to restrict tumour vascularisation. Not all anti-angiogenic drugs are associated with MRONJ, the ones that are: - VEGF: Vascular endothelial growth factor inhibitors -- **bevacizumab** and **aflibercept** - RTK: receptor tyrosine kinase inhibitors -- **Sunitinib** **[Classification of PATIENT RISK:]** **Dental Treatment:** - Dentoalveolar surgery or any other procedure that impacts bone, is considered a risk factor for MRONJ. - Tooth extraction is the most common event - Non-invasive procedures can cause MRONJ too: dental trauma, mucosal trauma from ill-filling dentures Duration of **Bisphosphonate** **Drug Therapy**: - The risk of MRONJ increases with the cumulative dose of the drug increases - This is due to the long half-life of the drug - Longer than 5 years of bisphosphonate medication, higher the risk Other **Concurrent Medication**: - Chronic systemic glucocorticoid use has been reported to increase the risk of MRONJ when taken with anti-resorptive drugs - Anti-angiogenic drugs + antiresorptive drugs together also increase the risk of MRONJ **[TREATMENT:]** - Patients being treated with anti-angiogenic drugs or anti-resorptive drugs (or both) **for cancer** are always considered to be at higher risk of MRONJ - Patients being treated for osteoporosis/other non-malignant disease of the bone, the assessment is more complex: - Any additional risk factors - Length of time of bisphosphonates (over 5 years)­ - Chronic use of systemic glucocorticoids  **MANAGEMENT of MRONJ:** **Initial Management:** There is some evidence to suggest that preventative dental care can decrease the risk of oral complications and reduce need for extractions/treatment that affects bone. Giving personalised oral hygiene advice is recommended **Low risk patients:** Carry out all routine dental treatment as normal and continue to provide personalised dental advice. - Healthy diet - Excellent oral hygiene - Stopping smoking - Limiting alcohol - Regular dental checks If an extraction or another procedure that impacts bone is required: - Discuss the risks and benefits associated with treatment with the patient - Proceed with the treatment as clinically indicated - Do not prescribe antibiotic/antiseptic prophylaxis - Advise the patient to contact practice if they have: - Pain, tingling, numbness, altered sensation or swelling - Review healing, if the extraction socket is not healed in 8 weeks and you suspect a patient has MRONJ, refer to oral surgery **Higher risk patients:** - For medically complex patients for whom you would normally seek advice, consider consulting oral surgery - If extraction is indicated, explore all alternatives where teeth could potentially be retained - If extraction remains the most appropriate: - Discuss the risks and benefits associated with treatment with the patient - Proceed with the treatment as clinically indicated - Do not prescribe antibiotic/antiseptic prophylaxis - Advise the patient to contact practice if they have: - Pain, tingling, numbness, altered sensation or swelling - Review healing, if the extraction socket is not healed in 8 weeks and you suspect a patient has MRONJ, refer to oral surgery Explaining **MRONJ** to patients: - Explain the small risk of MRONJ, mostly occurring after extractions but can occur spontaneously - Drug holidays are not recommends, benefits of the drugs outweigh the risk of MRONJ - Increased risk if: - Being treated for cancer - Bisphosphonates for over 5 years - Previous history of MRONJ - Anti-resorptive drugs/anti-angiogenic drugs with systemic glucocorticoids **[Stages of MRONJ:]** **[STAGE 0]**: at risk category **[STAGE 1]**: Exposed bone/fistula that probes into bone that is asymptomatic -- **no sign of infection** - Symptomatic treatment with oral antibiotics - Oral antibacterial mouth rinse - Pain control - Debride to relieve irritation **[STAGE 2]**: As stage 1, with evidence of infection and pain - Symptomatic treatment with oral antibiotics - Oral antibacterial mouth rinse - Pain control - Debride to relieve irritation **[STAGE 3]**: Stage 2 plus one or more of the following - Exposed and necrotic bone extending beyond the region of alveolar bone -- resulting in pathological fracture, extra-oral fistula - Osteolysis extending to the inferior border of the mandible/sinus floor - **TREATMENT**: - Antibacterial mouth rinse - Pain control - Antibiotics - Surgical debridgement/resection for long term palliative care