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A Spoonful of Oral Medicine

Dr Amanda Phoon Nguyen

BDSc (UniMelb), MRACDS (GDP), DClinDent (Oral Med) (UWA), MRACDS (OralMed), Cert ADL, FOMAA, FPFA, FICD

Oral Medicine Specialist

Perth, Western Australia

Welcome to A Spoonful of Oral Medicine, where I dish up bite-sized chunks of oral medicine targeted toward health professionals!

This does not constitute personalised medical advice. Please do not use images without credit.

Please enjoy, and I do hope to hear from you! 

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  • Writer's pictureAmanda Phoon Nguyen

How many medications can you name that are implicated in MRONJ?

Medication-related osteonecrosis of the jaw unrelated to bisphosphonates and denosumab—a review. King, Tanna and Patel. OOOO 2019;127:289299

1. Drug Class: Monoclonal antibodies. Suffix “-mab”


Bevacizumab (Avastin)

Adalimumab (Humira)

Infliximab (Remicade)

Rituximab (Rituxan)

Commonly prescribed for: Rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, Crohn’s disease, ulcerative colitis, osteoporosis

Comment: Increased risk when coupled with bone-modulating therapies.

In 2011, European Medicines Agency issued warning linking bevacizumab to ONJ and reported 55 cases in approximately 800,000 patients.

2. Drug Class:Tyrosine kinase inhibitors

30 TKIs have been approved for use, 8 are implicated in ONJ.

Suffix “-nib”

Examples: Suntinib (Sutent)

Imatinib (Gleevec)

Sorafenib (Nexavar)

Pazopanib (Votrient)

Axitinib (Inlyta)

Regorafenib (Stirvarga)

Cabozantanib (Cometriq)

Commonly prescribed for: Hematologic malignancies such as leukaemias, renal cell carcinomas, gastrointestinal stromal tumours , soft tissue sarcomas and neuroendocrine tumours.

Comment: Thought to be implicated via antiangiogenic effects

In review by Zhang et al of ONJ cases reported to FDA between 2010 and 2014, 418 cases were TKI- related.

Risk heightened with concurrent use of antiresoptives.

3. Drug Class: Mammalian target of rapamycin inhibitors

Suffix “-limus”

Examples: Everolimus (Afinitor)

Temsirolimus (Torisel)

Commonly prescribed for: Renal cell cancer, neuroendocrine cancer, breast cancer, lymphoma, organ transplantation

Comment: Implicated in ONJ with its sole use and when used in conjunction with bisphosphonates.

FDA FAERS study highlighted risk.

4: Drug Class: Variant fusion proteins

Suffix “-cept”

Examples: Afibercept (Zaltrap, Eylea)

Commonly prescribed for: Renal cell carcinoma, macular degeneration and macular edema.

Comment: Has antiangiogenics effects and also inhibits VEGF.

Case reports and clinical trial report risk and drug has a safety warning regarding ONJ risk.

5. Drug Class: Radiopharmaceuticals

Example: Radium 223 (Xofrigo)

Comment: Used to localize and manage bone metastases, sometimes in combination with chemotherapy.

Thought to have an additive effect when combined with other bone-modulating therapies in the development of MRONJ.

Most reports have patients with previous bisphosphonate exposure.

6. Drug Class: Disease modifying anti rheumatic drug

Example: Methotrexate

Commonly prescribed for: Rheumatoid arthritis, psoriatic arthritis, Crohn’s disease

Comment: The addition of MTX to bisphosphonate therapy is a well recognized risk factor. Sole use of MTX has also been implicated.

7. Drug Class: Corticosteroids

Example: Predisolone

Commonly prescribed for: Numerous reasons

Comment: 2 case reports in mandible

8. Drug Class: Selective estrogen receptor modulators

Example: Raloxifene (Evista)

Commonly prescribed for: Breast cancer, to maintain bone density in post menopausal women

Comment: Link not fully established however concerns raised.

1 case report


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