In the most recent American Association of Oral and Maxillofacial Surgeons’ Position Paper on Medication-Related Osteonecrosis of the Jaw - A 2022 Update, readers may have noted the mention of a new implicated medication.
Romosozumab is a new monoclonal antibody used for fracture prevention in osteoporotic patients. In Australia, the brand name of this medication is Evenity. It is given via subcutaneous injections monthly and takes about three months to reach a steady-state concentration. As the effect of romosozumab wanes, the drug is recommended to be ceased after 12 months, and transition to an antiresorptive therapy is required to preserve bone mass.
Romosozumab works via the Wnt pathway by binding to and inhibiting sclerostin, resulting in increased bone formation and decreased bone resorption. Sclerostin is produced by osteocytes and has bone resorptive effects; if sclerostin is blocked, bone density increased.
Adverse events may include arthralgia, muscle spasms and headache, injection- site reactions and hypersensitivity. Cardiovascular adverse effects have been reported, and Romosozumab should not be used in patients who have had a stroke or myocardial infarction in the previous year. MRONJ has been reported. At this stage, there is a paucity of data on the association and risk estimate of MRONJ associated with Romosozumab, although it is reported to be lower than that of Denosumab and more aligned with that of bisphosphonates. More research is required.
Patients who are about to commence therapy on Romosozumab and other implicated medications should be counselled regarding MRONJ risk. Preventive oral care methods combined with effective oral health practices are associated with a lower rate of MRONJ. It is strongly recommended that patients see a dentist prior to therapy to ensure that any teeth of questionable prognosis are assessed and extracted if necessary, with adequate healing time. Any dental prosthesis should be well fitting in order to reduce trauma. Dental screening, prophylaxis, oral hygiene instruction, tobacco and alcohol cessation counselling, and timely treatment is recommended to reduce risk.
References available and feedback welcome via amanda@pomds.com.au
Further reading
Oral and Dental Expert Group. Therapeutic guidelines: oral and dental. Version 3. Melbourne: Therapeutic Guidelines Limited; 2019.
Ruggiero SL, Dodson TB, Aghaloo T, Carlson ER, Ward BB, Kademani D. American Association of Oral and Maxillofacial Surgeons’ Position Paper on Medication-Related Osteonecrosis of the Jaws-2022 Update. J Oral Maxillofac Surg. 2022 May;80(5):920-943. doi: 10.1016/j.joms.2022.02.008. Epub 2022 Feb 21. PMID: 35300956.
Teoh, L.; Moses, G.; Nguyen, A.P.; McCullough, M.J. Medication-related osteonecrosis of the jaw: Analysing the range of implicated drugs from the Australian database of adverse event notifications. Br. J. Clin. Pharmacol. 2020, 87, 2767–2776.
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