A Survey of Medication-Related Osteonecrosis of the Jaw Reporting and Risk Assessment by Oral and Maxillofacial Surgeons

Abstract

Medication-related osteonecrosis of the jaw (MRONJ) is a well-known pathologic entity in the field of oral and maxillofacial surgery. Whether evaluating patients initiating bisphosphonate therapy, diagnosing patients with osteonecrosis, or surgically managing long-term sequelae, oral and maxillofacial surgeons (OMSs) will invariably encounter this disease. There are few studies investigating the incidence of MRONJ, and many of these studies were found to have limitations that may lead to underestimation of MRONJ prevalence. The purpose of this survey was to determine if MRONJ is being reported to any central agency by practicing OMSs, and if OMSs are reporting cases to physicians prescribing antiresorptive medications. Furthermore, the authors seek to determine if the risk of MRONJ quoted to patients is similar to the incidence reported in the literature. Using SurveyMonkey, a 26-part questionnaire (Figure 1) designed to help gain information about MRONJ and how it is approached and reported was sent via email to 6409 OMSs listed in the 2015 AAOMS directory using an automated collection system. The questions addressed practice demographics, risk stratification, number of MRONJ cases experienced, if/where OMSs reported these incidents, and how OMSs learned about reporting cases. In total, 3,172 OMSs opened the email, 879 opened the questionnaire, 170 completed part of the survey, and 602 completed the entire survey. Of the 602, only 2% have never diagnosed a patient with MRONJ. For patients undergoing a dental extraction while taking alendronate for more than 4 years to treat osteoporosis, 53.63% of OMSs quote them a risk > 1% even after a recommended 2-month drug holiday (Damm 2013). This is a complete disparity from the values quoted by studies in the AAOMS position paper that cite a disease incidence of 0.004% and prevalence of 0.1%. Using weighted averages from literature in the position paper, estimated incidence of disease with zoledronate and denosumab are 0.87% and 0.93%, respectively (Ruggiero 2014). In this survey, OMSs quoted higher levels of risk with extractions than expected when compared to the literature, including 63% quoting a risk > 1% when taking zoledronate yearly for osteoporosis when the last dose was given more than 1 year ago, 95% quoting a risk > 1% for zoledronate when used as a chemotherapeutic adjuvant, 57% quoting a risk > 1% when taking denosumab for osteoporosis when the last dose was given over 6 months ago, and 94% quoting a risk > 1% when denosumab is used as a chemotherapeutic adjuvant. Of OMSs who have either diagnosed or treated a patient with MRONJ, 85% reported the case to the prescribing physician. However, 95.2% of OMSs have never reported a case to a drug manufacturer, and 97.6% have never reported a case to the FDA. The results of this questionnaire demonstrate that OMSs are quoting a risk of MRONJ to this patient population that is at least 10-fold higher than the values reported by the current literature. These findings suggest that most OMSs believe MRONJ is a larger risk to patients taking specific medications than is demonstrated by the current literature. Furthermore, approximately 96% of OMSs are not reporting cases of MRONJ to the FDA or drug manufacturers. This lack of reporting may contribute to the gross underestimation the authors of this survey have observed in clinical practice. A retrospective cohort study could be a valuable next step in determining the risks of invasive dental surgery to this patient population.