(31) Presence or Absence of Extraoral Fistula in Stage III Medication-Related Osteonecrosis of the Jaws: Is there a Difference in Postoperative Disease Resolution?

Abstract: Purpose
This study aimed to determine if there is a difference in postoperative disease resolution among patients treated surgically for mandibular Stage III medication-related osteonecrosis of the jaw (MRONJ) that present with an extraoral fistula compared to patients with no extraoral fistula. The null hypothesis was that no significant difference exists in the postoperative disease resolution among patients with Stage III MRONJ regardless of extraoral fistula presence.

Methods
A retrospective cohort analysis was conducted of patients that received surgical treatment for medication-related osteonecrosis of the jaws from 2016 to 2020 at the University of Texas Southwestern Medical Center. The inclusion criteria was mandibular Stage III MRONJ as defined by the American Academy of Oral and Maxillofacial Surgeons (AAOMS).1 Patients that did not meet the criteria as defined by the AAOMS position paper, smokers, and all other stages of MRONJ were excluded. The recorded patient data included: age, sex, presence of fistula, reason for antiresorptive medication (cancer vs. osteoporosis), immunosuppressive medications at presentation, and surgical technique performed (marginal vs. segmental resection). All patients who presented with extraoral fistulas were treated with a fistulectomy at resection. All patients were prescribed chlorhexidine mouth rinse and systemic antibiotics when indicated at the initial consult visit. Postoperative disease resolution was defined as complete mucosal coverage without clinical symptoms at the 3 months postoperative visit.2 Means and standard deviations were used for continuous data. Chi-squared analysis and t-tests were performed between the cohorts and their respective outcomes. Values of p < 0.05 were considered statistically significant. The primary predictor variable was the presence of extraoral fistula, and the primary outcome variable was disease resolution at 3 months.

Results
Twenty-one patients met the inclusion criteria, ten with a fistula at presentation and 11 with no fistula. The average age of the fistula group was 76.5 years (SD 6.2) and 71.1 years (SD 9.7) in the no fistula group. There was no significant difference in age between the two groups (p = 0.14). There were 4 males (40%) and 6 females in the fistula group, with 1 male (10%) and 10 females (91%) in the no fistula group. Seven patients (70%) in the fistula group and 9 patients (82%) in the no fistula group received antiresorptive medications for cancer treatment. Nine patients (90%) in the fistula group and 7 patients (64%) in the no fistula group were receiving immunosuppressive medications at presentation. Five patients were treated with segmental, and 5 patients were treated with marginal resections in the fistula group. In the no fistula group, 6 were treated with segmental, and 5 were treated with marginal resections. There was no significant difference in the surgical technique performed (p = 0.83). In the fistula group, 2 patients had delayed postoperative disease resolution, while 3 in the no fistula group had delayed postoperative disease resolution. There was no significant difference in postoperative disease resolution between the two groups (p = 0.69).

Conclusions
This study suggests there is no difference in postoperative disease resolution among patients treated surgically for mandibular stage III MRONJ that present with or without an extraoral fistula.

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 80.5:920-943, 2022

[2] Giudice A, Barone S, Diodati F, Antonelli A, Nocini R, Cristofaro MG. Can Surgical Management Improve Resolution of Medication-Related Osteonecrosis of the Jaw at Early Stages? A Prospective Cohort Study. J Oral Maxillofac Surg 78.11:1986-1999, 2020