(47) Defining Success in Surgical Management of Medically Related Osteonecrosis of the Jaw

Abstract: Medication-related osteonecrosis of the jaw (MRONJ) is a rare pathology seen in patients taking antiresorptive medications. In the 2022 AAOMS position paper on MRONJ and other papers discussing surgical success, the success parameter is defined as achievement of full mucosal coverage postoperatively with maintenance or improvement of MRONJ stage, however, no timeline for said mucosal coverage is suggested.1 For this reason, it is difficult to accurately compare strategies for achieving surgical success due to the timeline possibly being different for each study. Implementing a proper timeline for surgical success would be beneficial to compare the different treatment modalities and their relationship to achieving surgical success. One review of various in-vivo oral mucosal healing models demonstrates that human mucosa is histologically re-epithelialized following soft-tissue surgery at 29 days.2 This data, in turn, can aid in establishing a new definition of surgical success as achieving full mucosal coverage four weeks postoperatively.

A retrospective descriptive study was designed using the operating room surgical records of multiple surgeons at both the University of Texas Southwestern Medical Center and Parkland Memorial Hospital. The cases analyzed occurred between 2016 and 2023 and involved surgical therapy for MRONJ and osteoradionecrosis. The following inclusion criteria were defined: patients with diagnosed MRONJ on the pathology report and patients brought to the operating room for surgical treatment of their pathology. Data collection included demographics, the location of the pathology, the medication that induced the MRONJ, the stage of MRONJ, 4-week mucosal coverage, and disease recurrence.

A total of 60 patients met inclusion. The average age of this cohort is 69.2 years old, with females making up the majority of the patients (n = 34). Ten patients were originally placed on antiresorptive medications for osteoporosis, and 50 were placed on antiresorptive therapy for cancer-related treatment. Fifty percent the patients were diagnosed as Stage III MRONJ, while 43.3% were diagnosed as stage II, and 6.7% as stage I. Also 93.3% of patients met our proposed definition of surgical success at 4 weeks (n = 56), and of these, only 6.7% (n = 4) developed disease recurrence.

Having a ubiquitous definition of surgical success is imperative in the bigger picture of developing evidence-based protocols. With the current state of data in MRONJ surgery, authors compare their success to a timeline ranging from 4 weeks to 12 weeks. This prevents normalization of data and can result in skewing of results when comparing one surgical method to another. The authors suggest implementing a 4-week timeline for achievement full mucosal coverage and disease improvement based on in-vivo data demonstrating re-epithelialization of oral soft tissue after 29 days. The data in this study supports that a high surgical success can be reached at 4 weeks with low incidence of recurrence. Further studies can explore the in-vivo healing of soft tissue following resection of MRONJ lesions specifically to specify timelines for surgical success.

Citations:
1. Ruggiero, S. L., Dodson, T. B., Aghaloo, T., Carlson, E. R., Ward, B. B., & Kademani, D. (2022). American Association of Oral and Maxillofacial Surgeons’ position paper on medication-related osteonecrosis of the jaws—2022 update. Journal of Oral and Maxillofacial Surgery, 80(5), 920–943. https://doi.org/10.1016/j.joms.2022.02.08

2. Afra I. Toma, Julia M. Fuller, Nick J. Willett, Steven L. Goudy, Oral wound healing models and emerging regenerative therapies, Translational Research, Volume 236, 2021, Pages 17-34, ISSN 1931-5244, https://doi.org/10.1016/j.trsl.2021.06.003.