Medication-Related Osteonecrosis of the Jaw: An Institution's Experience

This retrospective study was conducted to evaluate the outcomes associated with the management of patients who were treated surgically for medication related osteonecrosis of the jaw (ONJ) during the past 7 years in the Oral and Maxillofacial Surgery Department at Case Western Reserve University in Cleveland, OH.

Patient information (including age, sex, medication exposure, and medical comorbidities) was obtained from the Oral and Maxillofacial Surgery Department at Case Western Reserve University patient data base. Two major inclusion criteria were used for patient selection. The first criterion was whether the patient had received medication associated with ONJ. The second criterion was whether the patient consented to surgical intervention to treat the ONJ. The surgical interventions that were considered in this study were either marginal or segmental resections – local debridements were not considered.  

Twenty-one patients (5 males and 16 females) with an average age of 66.47 years, (range of 40yrs to 90yrs) met the inclusion criteria. Two patients had a history of oral bisphosphonates use, while the other 19 had a history of intravenous bisphosphonates exposure as well as exposure to other chemotherapeutic agents. These patients received the intravenous medications for the management of breast, prostate, colon and lung cancers or multiple myeloma. The parameters analyzed throughout the patient group were the past medical and past surgical histories, the existence, if any, of an inciting event that led to ONJ, the microbiologic culture, the pre- and postoperative antibiotic treatment, the surgical outcome and the complications of the procedure.

One patient (4.76%) had only the maxilla affected, eighteen patients (85.71%) had osteonecrosis involving only the mandible, and two patients (9.52%) had both the maxilla and the mandible affected. All 3 maxillary lesions were treated with marginal resection. Of the 18 mandibles treated, 9 (50%) were treated with segmental resection, and the other 9 (50%) were treated with marginal resection. To this date, 2 patients (9.52%) have been reconstructed with Anterior Iliac crest graft. All the specimens were cultured intraoperatively. Out of the 21 patients, 13 patients (61.90%) had a bacterial overgrown - Actinomyces and Escherichia being the most prevalent species. Two patients (9.52%) had wound dehiscence complicated by hardware exposure and needed a second surgical procedure to achieve primary closure of the surgical site; these two patients went on to uneventful healing and one subsequently had bone grafting and placement of an implant retained prosthesis in the graft site. The other 19 (90.47%) patients had uneventful healing.              

These patients remain a treatment challenge due to the complex interactions of impaired host immunity and virulent bacteria. However, this observational study suggests that resection of the non-viable bone, as in the management of classic osteomyelitis, is a reliable and predictable treatment option for this patient population.

References:

1. Carlon ER, Schlott B. Anti-Resorptive Osteonecrosis of the Jaws. Facts forgotten, Questions Answered, Lessons Learned. Oral Maxillofacial Surg Clin N Am 26(2014) 171-191.
2. Stanton DC, Balasanian E. Outcome of surgical management of bisphosphonate-related osteonecrosis of the jaws: review of 33 surgical cases. Journal of Oral and Maxillofacial Surgery, 2009, 67(5):943-950.
3. Carlson ER, Basile JD. The role of surgical resection in the management of bisphosphonate-related osteonecrosis of the jaws. Journal of Oral and Maxillofacial Surgery, 2009, 67(5):85-95.
4. Williamson RA. Surgical Management of Bisphosphonate induced Osteonecrosis of the Jaws. Int J Oral Maxillofacial Surgery 2010, 39: 251-255.
5. Baur DA, Altay MA, Flores-Hidalgo A, Ort Y, Quereshy FA, Chronic Osteomyelitis of the Mandible: Diagnosis and Management – An Institution’s Experience over 7 Years, Journal of Oral and Maxillofacial Surgery (2014), doi: 10.1016/j.joms.2014.10.017.