A multi-disciplinary approach to the prevention of Medication Related Osteonecrosis

Medication related osteonecrosis of the jaw (MRONJ) is a rare adverse effect of anti-resorptive or anti-angiogenic drug therapy that can cause significant morbidity. Commonly prescribed drugs such as bisphosphonates have been associated with MRONJ.

Research shows that general medical practitioners and pharmacists have limited knowledge and awareness of MRONJ and practitioners often fail to provide advice related to it. This is thought to consequently result in poor patient awareness of the condition.

In one study, when asked to identify side effects of bisphosphonate therapy, only a minority of patients receiving IV or oral bisphosphonates were aware of the potential risk of developing osteonecrosis of the jaw.

The aim of this study was to explore the attitudes and perceptions of patients towards the multidisciplinary approach to the prevention of MRONJ.

The research team undertook qualitative interviews with a total of 23 patients; six of whom were diagnosed with MRONJ, 13 who were prescribed bisphosphonates and four patients with osteoporosis not currently prescribed any medication.

Five salient and inter-related themes emerged from the analysed data:

  • Quality of life, indicating the physical, psychological and social impact of MRONJ
  • Limited knowledge, indicating limited awareness of the condition, risk factors and preventative strategies
  • Patient specific themes, referring to the complexity of patients, polypharmacy, prioritising aspects of care and personal responsibility
  • Inter-professional management, indicating a perceived organisational hierarchy, professional roles and responsibilities, articulation of risk and communication
  • Wider context, indicating demands on NHS resources, and barriers to dental care.

The researchers concluded that MRONJ has a significant effect on the quality of life of patients diagnosed with the condition. Patients described both the physical and psychological impact and challenges related to its ongoing management.

Patients from across the three groups all had limited knowledge of the association between bisphosphonates and osteonecrosis of the jaw, and when patients possessed some knowledge, this typically came from the patient information leaflets supplied with medication or from the internet. However, given the demographics of this patient group, access to online information is potentially a challenge for some patients.

Participants described a perceived hierarchy in relation to the management of their health. They expected prescribers to utilise professional judgment on the suitability of the medication for them, and to provide information related to the adverse effects of medications.

They believed that the pharmacist has an important role in reinforcing advice and were positive towards the pharmacist’s role in providing information on medications and conducting medication reviews.

“As this condition can, in many cases, be prevented with appropriate oral health advice and preventative care, the importance of such measures should be stressed to healthcare professionals managing this particular patient group”, says Andrew Sturrock.

“Published clinical guidelines recommend that patients should be referred for dental assessment and treatment prior to initiation of bisphosphonate therapy”, says Andrew Sturrock. “But it is apparent this is not happening.”

So what can be done? “The inclusion of bisphosphonates in the MUR and NMS service specifications could provide an opportunity for reinforcement of preventative advice during the initiation stages of treatment with bisphosphonates”, says Sturrock.

“Participants were receptive to information being shared between the medical and dental services [so] further work to develop interprofessional working between pharmacy and dental professionals could be of particular benefit to this patient group.”


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