The onco-dental interface facing the challenge of bone-modifying agents

The use of bone-modifying agents (BMA) has become systematic in oncology to prevent skeletal events and reduce bone pain. However, this therapy exposes 1 to 12% of metastatic patients to a risk of medication-related osteonecrosis of the jaw (MRONJ), a complication whose morbidity heavily impacts quality of life. Although clinical guidelines recommend rigorous dental health preparation before initiating BMA, the actual integration of dental care into the oncological pathway remains incomplete and non-standardized.

The protocol consisted of the recording and full transcription of all interactions. The data were then subjected to a rigorous thematic analysis. Researchers were thus able to identify recurrences related to awareness of medication-related osteonecrosis of the jaw (MRONJ) risk, the burden represented by dental care, treatment planning strategies for this specific cohort, and the coordination of multidisciplinary care.

Thematic and dynamic analysis of the onco-dental interface

This qualitative study is based on the analysis of data collected from 30 participants. The experimental design allowed for the comparison of perspectives from 10 oncology patients (via a focus group of 6 people and 4 individual interviews) and 20 general dental surgeons (divided into 3 focus groups).

The thematic analysis highlighted four critical axes that structure the current difficulties of the care pathway:

• Medication-Related Osteonecrosis of the Jaw (MRONJ) awareness: Although the risk is documented (incidence of 1 to 12% in metastatic patients), the understanding of the issues varies. Practitioners highlight the difficulty of managing this complication, which is rare but has significant functional and psychological consequences.
• Burden of dental care: For patients, the requirement for dental fitness before initiating BMAs represents a significant logistical and financial burden. The study shows that the system still relies heavily on patient self-management to navigate between oncology and dentistry.
• Therapeutic planning strategies: The 20 practitioners surveyed report a lack of protocol standardization. Clinical decision-making remains complex in the face of the constant increase in BMA prescriptions (24.4% increase in denosumab-related expenditure over a one-year period in the UK).
• Multidisciplinary coordination: The results point to an insufficient integration of dental services within oncology centers. Communication between the oncologist and the dentist is identified as the main lever for optimization, but currently remains fragmented.

The study highlights that, despite clinical recommendations advocating for the elimination of infectious foci before any BMA treatment, the lack of established referral pathways limits the effectiveness of primary prevention of MRONJ.

The onco-dental interface put to the test of clinical reality

The results of this qualitative study, conducted among 10 oncological patients and 20 general practitioners, reveal a persistent disconnection between clinical recommendations and daily practice. Although bone-modifying agents (BMA) are now essential for preventing skeletal-related events, their associated risk of medication-related osteonecrosis of the jaw (MRONJ) — estimated between 1 and 12% in metastatic patients — remains a major challenge. The study highlights that oral cavity stabilization before treatment relies too often on the patient's personal initiative rather than on a structured care pathway.

The thematic analysis highlights four critical barriers: the lack of awareness regarding MRONJ risk, the financial and logistical burden of dental care for patients already undergoing heavy treatment, the complexity of establishing a treatment plan in this context, and the absence of real multidisciplinary coordination. For the practitioner, these results mean that risk management cannot be limited to the technical procedure; it must integrate the psychological and systemic barriers encountered by the patient.

The limitations of this work lie in its qualitative nature and the modest sample size (n=30), which prevents statistical generalization but offers an unprecedented depth of understanding regarding the stakeholders' experiences. This study confirms the existing literature on the difficulty of treating established MRONJ, reinforcing the idea that proactive prevention is the only viable strategy to guarantee patients' quality of life.

Results of the study on the onco-dental interface

This qualitative study, conducted with 10 oncology patients and 20 general practitioners through interviews and focus groups, reveals a fragmented management of MRONJ risk, which nevertheless affects 1 to 12% of metastatic patients. The results highlight a high dental care burden and a lack of standardized protocols to coordinate treatment planning between oncologists and community dentists.

In concrete terms, for the practitioner:

• Anticipate the initiation of BMAs: It is imperative to perform a complete oral and dental sanitation before starting oncological treatment to eliminate any potential infectious focus.
• Take the lead in coordination: In the absence of standardised care pathways, contact the oncology team directly to validate treatment strategies and long-term follow-up for your patients on BMAs.
• Simplify maintenance: Adapt your prevention protocols to be rigorous yet minimally invasive, in order to reduce the psychological and physical burden felt by the patient during their anticancer treatment.

Technical lexicon of the study

Bone-modifying agents (BMAs): Therapeutic agents routinely used in oncology to prevent skeletal-related events, treat hypercalcemia, and reduce bone pain or bone loss induced by anticancer treatments.

Medication-related osteonecrosis of the jaw (MRONJ): Rare oral complication affecting 1 to 12% of patients with metastatic diseases, characterized by maxillary bone necrosis that is difficult to treat and leads to significant functional and psychological morbidity.

Dental fitness: Optimal oral health status, defined by the elimination or stabilization of oral pathologies, which must imperatively be achieved before starting treatment with BMAs.

Skeletal-related events (SREs): Adverse clinical bone-related events that bone-modifying agents aim to prevent in oncological patients.

Denosumab: Bone-modifying agent whose prescription in oncology is rapidly increasing (24.4% increase in spending in the UK between 2015 and 2017), raising the number of patients at risk of MRONJ.

Onco-dental interface: Coordination and integration device for dental services within the oncology care pathway, aimed at optimizing the multidisciplinary management of patients receiving BMAs.

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