An impossible choice: MRONJ vs ORN? The difficulties of the decision-making process for head and neck cancer patients on long-term anti-angiogenic medication

With increasing medical complexity of patients, including the widespread use of bisphosphonates and the increased incidence in head and neck cancer diagnosis, there are ever more difficult decisions to be made within restorative dentistry. The most morbid dental complication to avoid with both the use of bisphosphonate and radiotherapy to the jaws is necrosis of the jaws, ideally by avoiding dental extractions, usually for the entirety of the patient's lifetime. If these patients undergo a dental assessment before commencing such medical treatments, there is a window of opportunity for both dental extractions of teeth with a poor/hopeless prognosis and for appropriate emphasis on prevention. Treatment planning at this stage has the goal of avoiding further dental extractions completely in the future. However, not all patients have an ideal care pathway. This article describes a case with an impossible choice to be made with significant time pressure and during the most vulnerable of times in a patient's life. The short-, medium- and long-term challenges posed are discussed.