(44) Spontaneous Healing of Osteonecrosis and Their Associated Factors

Abstract: The purpose of this study was to measure the average time for spontaneous healing of patients with either medication-related osteonecrosis of the jaw (MRONJ) or osteoradionecrosis (ORN) of the jaw. Additionally, the different treatment modalities for spontaneous healing were analyzed. Few studies assess the time for spontaneous healing of mucosa, so this can serve as a marker to better aid our treatment options for osteonecrosis.

This study is a retrospective chart review from 2016 to 2019 at Parkland Memorial Hospital and University of Texas Southwestern (UTSW) Medical Center. Patient factors such as gender, age, ethnicity, medical reason for medication or radiation, comorbidities, current smoking status, disease diagnosis (MRONJ or ORN), anatomic location, MRONJ Stage 1, causative medication, radiation dosage, nonsurgical therapy, spontaneous mucosal healing, time (weeks) for spontaneous healing, surgery, and recurrence were analyzed. Surgery was defined as a procedure in the operating room. Healing was defined as full mucosal coverage with no exposed bone. Descriptive statistics were calculated using Microsoft Excel.

From 2016-2019, there were 104 patients with osteonecrosis of the jaw treated at Parkland and UTSW. Of those 104 patients, 46 were male and 58 were female. The average age was 70.3 years. 88 patients were diagnosed with MRONJ, and 14 patients were diagnosed with ORN. Seventy-four patients (71.2%) were treated with surgical therapy, while 30 patients (28.8%) were treated with nonsurgical therapy. All nonsurgical patients were diagnosed with MRONJ (Stage 1: n = 14; Stage 2: n = 12; Stage 3: n = 4). The most common morbidity for nonsurgical treatment MRONJ patients was cancer (n = 18, 60%), followed by osteoporosis (n = 12, 40%). Only 26 patients (86.7%) in the nonsurgical category had spontaneous healing of their MRONJ (8 males vs 18 females). Interestingly, 4 of the nonsurgical patients did not spontaneously heal.

For the nonsurgical patients that spontaneously healed, the average age was 73.69 years. The average time to heal was 36.5 weeks (range of 0-196 weeks). Sixteen patients (61.5%) took denosumab (14 Xgeva, 2 Prolia), 8 patients (30.7%) took bisphosphonates (6 Zometa, 2 Reclast), and 2 patients received Xeloda. The posterior mandible was the most common site (70.5%), followed by the posterior maxilla (23.5%) and anterior maxilla (5.8%), respectively. The most common nonsurgical treatment regimen was chlorohexidine (CHX) rinse twice a day with CHX-soaked Q-tip application over the necrotic bone (18 patients, 69.2%). The second most common was the previously stated therapy along with outpatient surgeon debridement of exposed bone (6 patients, 23.1%). Lastly, 2 patients (7.6%) had no therapy prescribed due to the bone previously exfoliating at the time of consult. Patients that received outpatient local debridement, on average, healed in 57 weeks.

The common nonsurgical management of MRONJ involves CHX rinses, CHX-soaked cotton swab application, antibiotics, and outpatient local debridement.1 Our study showed that, on average, conservative nonsurgical management leads to full mucosal coverage and healing in 36.5 weeks or approximately 9 months. Outpatient local debridement increased the time for mucosal healing. However, this could be due to other patient comorbidities as those are known to increase mucosal healing time.2 Further interventions and treatment modalities should be studied to decrease the time for spontaneous healing in nonsurgically managed patients.

References
1. 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;80(5):920-943. doi:10.1016/j.joms.2022.02.008
2. Anastasilakis AD, Pepe J, Napoli N, et al. Osteonecrosis of the Jaw and Antiresorptive Agents in Benign and Malignant Diseases: A Critical Review Organized by the ECTS. J Clin Endocrinol Metab. 2022;107(5):1441-1460. doi:10.1210/clinem/dgab888