ADC Practice Question — Bisphosphonate / antiresorptive therapy — MRONJ

Given the high MRONJ risk, is extraction the best approach for this non-restorable tooth?

Pharmacology questions in the ADC written exam test applied prescribing decisions, not rote recall of drug names. This exam-level vignette tests your ability to work through clinical details and arrive at the correct management.

Mr. Kenneth Marsh, a 70-year-old man with metastatic prostate cancer, has been receiving IV zoledronic acid every 3 months for the past 2 years for bone metastases. He presents with a dull ache from his lower right first molar. On examination, tooth 46 has a deep carious lesion with periapical tenderness and a periapical radiolucency on radiograph. The tooth is deemed non-restorable. He also takes docetaxel chemotherapy and dexamethasone. Given the high MRONJ risk, is extraction the best approach for this non-restorable tooth?

A. Stop the zoledronic acid for 3 months (drug holiday) before extracting to reduce MRONJ risk
B. Never extract teeth in patients on IV bisphosphonates — the tooth must be left in situ regardless of symptoms
C. Yes — extract immediately as the tooth is causing pain and delay will worsen the infection
D. Consider endodontic treatment if feasible to avoid extraction; if extraction is necessary, use atraumatic technique with informed consent about MRONJ risk
E. Prescribe prophylactic antibiotics before extraction to prevent MRONJ

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Sources cited

Therapeutic Guidelines v4 Odell's 3rd & 4th Ed IADT 2020 Code of Conduct CMS (Evans) Infection Control + more

Show the answer and cited explanation

Correct answer: D

According to TG, precautions for high MRONJ-risk patients include: informed consent, minimise trauma and periosteum stripping, suture mucosal flaps, consider root retention techniques to avoid extraction, and monitor until healed. TG states antibiotic prophylaxis is NOT recommended for MRONJ prevention. TG states there is no evidence drug holidays reduce MRONJ risk.

Source: Ch 23: High MRONJ risk — consider alternatives to extraction, informed consent, atraumatic technique

Remy's study tip — For pharmacology vignettes, read the patient’s medical history and allergies BEFORE looking at the drug options.

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Extract key clinical data from the stem before reading options. There are usually 3–4 critical variables that determine the correct answer.

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Given the high MRONJ risk, is extraction the best approach for this non-restorable tooth?

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