(30) Is Upfront Surgical Resection of Stage II MRONJ More Cost Effective than Non-surgical Therapy?

Thursday, September 15, 2022

1:30 PM – 3:00 PM CDT

Figure 1: Cost Outcomes

Figure 2: Cost of Different Disease States

Figure 3: Monte Carlo Analysis

Presenting Author(s)

Andrew Griebel, DMD

Department of Oral and Maxillofacial Surgery Resident
UIC
Chicago, Illinois, United States

Co-Author(s)

Benjamin L. Palla, DMD, MD

Resident
University of Illinois at Chicago
Chicago, Illinois, United States
Michael Miloro, DMD, MD, FACS

Professor and Head
University of Illinois at Chicago
Chicago, Illinois, United States
KO

Katharina Obermeier, DMD

Resident
Ludwig-Maximilians-Universitat
Munchen, Bayern, Germany
SO

Sven Otto, DMD, MD, PhD

Professor and Head
Ludwig-Maximilians-Universitat Department of Oral and Maxillofacial Surgery
Munchin, Bayern, Germany

Disclosure(s):

Andrew Griebel, DMD: No financial relationships to disclose

Benjamin L. Palla, DMD, MD: I do not have any relevant financial / non-financial relationships with any proprietary interests.

Michael Miloro, DMD, MD, FACS: I do not have any relevant financial / non-financial relationships with any proprietary interests.

Katharina Obermeier, DMD: I do not have any relevant financial / non-financial relationships with any proprietary interests.

Sven Otto, DMD, MD, PhD: I do not have any relevant financial / non-financial relationships with any proprietary interests.

Abstract: The 2022 AAOMS update on medication-related osteonecrosis of the jaws (MRONJ) acknowledged the benefit of surgical intervention in its algorithm for the treatment of early stage disease.1 Surgical intervention, when appropriate, has been shown in the literature to have predictably high success rates, close to 95%.2,3 By comparison, non-surgical treatment has significantly lower success rates when defined as mucosal closure. Medical treatment also risks disease progression, and prolongation of exposed, infected and necrotic bone can significantly affect a patient’s quality of life.4

The purpose of this study is to answer the following question: In patients with MRONJ stage II, is upfront surgical resection, when compared to non-surgical therapy, a more cost-effective treatment option? We utilized a Markov model to estimate the direct and indirect treatment costs.

The Markov model was developed with TreeAge Pro Healthcare 2022. The model ran for 20 years with 1-year-cycles on a 60-year-old subject with stage II MRONJ. There were five disease states: healthy, MRONJ 0, MRONJ I, MRONJ II, and MRONJ III. There were two treatment arms, surgical (marginal resection) vs. non-surgical therapy (medication). Direct surgical costs were calculated using the 2022 Physician Fee Reference (75th percentile). Non-surgical treatment direct costs (follow-up, medications, imaging) and indirect costs (quality of life, loss of employment) were determined from existing literature (Figure 1). Direct surgical costs for MRONJ II was $9,541.00. State-specific costs of non-surgical treatment was $300.00 for MRONJ 0, $688.71 for MORNJ I, $708.71 for MRONJ II, and $1,981.71 for MRONJ III. Indirect costs for non-surgical treatment included decreased quality of life (QoL) based on reported EQ-5D surveys.4

The results show that surgical treatment had higher costs but was more effective. The incremental cost-effectiveness ratio (ICER) is 650.39, demonstrating that surgical treatment has higher effectiveness and is worth the higher price. The cost effectiveness analysis is most sensitive to changes in surgical cost. However, even with 125% increase in surgical cost ($21,467.25), the ICER is 5,000, which is still smaller than the ICER threshold of 50,000, demonstrating surgery remains acceptable on cost-effective grounds. The non-surgical costs were largely due to the stage III MRONJ in cases where MRONJ II disease progression occurred (Figure 2). On secondary analysis utilizing a Monte Carlo simulation of 1,000 samples, surgery remained more effective with over 99.9% probability, with the cost-distribution showing moderate overlap (Figure 3).

Treatment decisions for MRONJ should be patient specific, and surgical therapy may not be appropriate in cases of significant morbidities that may preclude operative treatment.1 However, if patients are amenable to surgical intervention, it is a more cost-effective treatment based on the Markov model analysis.

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 Off J Am Assoc Oral Maxillofac Surg. 2022;80(5):920-943.
2. Carlson ER, Basile JD. The Role of Surgical Resection in the Management of Bisphosphonate-Related Osteonecrosis of the Jaws. J Oral Maxillofac Surg. 2009;67(5):85-95.
3. Williamson RA. Surgical management of bisphosphonate induced osteonecrosis of the jaws. Int J Oral Maxillofac Surg. 2010;39(3):251-255.
4. Miksad RA, Lai K, Dodson TB, et al. Quality of Life Implications of Bisphosphonate‐Associated Osteonecrosis of the Jaw. The Oncologist. 2011;16(1):121-132.