Bill Klaproth (host): This is OMS Voices, an AAOMS podcast. I’m Bill Klaproth. And with me is Dr. Joshua Lubek, who’s here to discuss confronting advanced MRONJ: surgical triumphs and challenges. Dr. Lubek, thanks for being here. 

Dr. Joshua Lubek: Thanks, Bill. It’s wonderful to be here. 

Bill Klaproth (host): Yeah. So, let’s talk about this. Can you explain this to us? What is MRONJ? 

Dr. Joshua Lubek: Sure. So, MRONJ stands for medication-related osteonecrosis of the jaws. It’s a debilitating condition that affects patients who have taken or are on certain bone deposition medicines such as bisphosphonate medications or the RANK ligand inhibiting medicines. 

Bill Klaproth (host): So, people that take these medications are at a higher risk of developing MRONJ. Is that right? 

Dr. Joshua Lubek: That is correct. They take them for many different reasons. Sometimes it is because they just don’t have enough bone density so that they run the risk of having bone fractures. The most devastating ones such as hip fractures or spinal column fractures. Other patients take them to help fight cancers. When certain types of cancers have spread to the bones, these medications are essential for stabilizing the cancers that have spread to the bone. 

Bill Klaproth (host): And when does MRONJ generally occur? Is that for someone later in life? 

Dr. Joshua Lubek: It depends on when, for what reason they’re taking it. Certainly for the patients who are taking it for osteoporosis or low bone density, yes. But for patients who are taking it for metastatic cancers that have spread to the bones, that could happen at any age. 

Bill Klaproth (host): So, I would imagine there are different stages of the disease. Can you explain the stages of MRONJ to us? 

Dr. Joshua Lubek: Sure, yeah, there are actually a number of different staging systems. Typically, I use a staging system that’s very similar to another staging system that we use in osteoradionecrosis, or that’s where bone has been affected by radiation, but we stage it from one to three or from a mild, moderate, severe or to an advanced stage from an early to an advanced stage disease. And what that involves is what symptoms a patient is experiencing, and also how much bone exposure is involved, and how much of the bone is now dead, or the medical term, necrotic. 

Bill Klaproth (host): So, for someone facing MRONJ, can you discuss the different techniques that are used for treating MRONJ? 

Dr. Joshua Lubek: So, above all, I always consider this as a quality of life disease. So, the truth is that regardless of what stage the patient has, if their overall quality of life is good, then there’s not necessarily a reason to treat aggressively. So, the patient really dictates what you are going to do. This is dependent on how much pain a patient is experiencing. Are they experiencing infections? Are they requiring lifelong antibiotics that bother them? Do they have draining what we call fistula? That means there’s a communication between the mouth and the skin of the face or the neck. Did the jaw pathologically break? Did it fracture because it’s so necrotic? Those are kind of our driving factors as to when we treat, when we don’t treat. 

Bill Klaproth (host): So, it sounds like there’s a variety of ways to address this, things like daily management and rinsing to taking medications, especially if someone has an infection, all the way to surgery. So, let’s talk about surgery. That’s gotta be the upper end of MRONJ. When surgical intervention comes in, is that right? 

Dr. Joshua Lubek: Yeah, that’s right, Bill. So, as I say, it’s really quality of life driven. What we consider conservative management, minimal types of intervention. So, patients may just have oral hygiene instructions, certain types of mouth rinses to keep the area clean. If the bone is exposed, and it’s very minimal, and the patients aren’t having too many issues, we may ask them to scrub or brush the bone with a toothbrush. They may require pain medicine, they may not. That’s the early management. Even in those cases, sometimes you may try and debride the bone mechanically with a drill or a curette or some kind of instrumentation, but very often you can just let that be. The more advanced stages are requiring generalized antibiotics, intravenous antibiotics and surgical intervention. But once again, all really depends on the patient’s quality of life and their baseline systemic disease, how sick they are from their other disease as well. 

Bill Klaproth (host): And then when it does come down to surgical intervention, can you explain more about the surgical techniques that are used? 

Dr. Joshua Lubek: When we talk about surgery, we talk about conservative surgery and then we talk about more aggressive surgery. Conservative surgery typically, so if let’s say the bone was exposed and when you look at an X-ray or you look at a CAT scan, most of the bone looks healthy and there’s just a small area of exposed bone, but it’s really causing significant pain. That may be an indication to go and try and debride or burr away some of that necrotic bone with the intention that hopefully the underlying bone will heal. The problem is sometimes it’s like the tip of the iceberg, and that you expose healthy bone, but it’s not really that healthy, if you kind of know what I mean. And by that, it’s been exposed to these medications which have a lifelong lasting effect. And so once that healthier bone gets exposed to bacteria or saliva within the mouth, it can then get infected. So it really depends on how much soft tissue you can get to cover that bone as well. That makes the difference when we’re managing conservatively. Some patients need to be on aggressive antibiotics and we often consult the infectious disease services. They may require some long-term IV antibiotics to really settle things down and then go about their way. The advanced stage, or when, for instance, I give an example, let’s say a patient pathologically broke their jaw, and by that I mean the bone was so necrotic that they show up one day, they have mobility of the jaw, and they’re in pain, it’s infected, the jaw is broken. That is an indication to surgically remove that bone. We have the ability to also reconstruct that as well. Not every patient wants to be reconstructed, but it certainly is an option. 

Bill Klaproth (host): So, are there risks or complications with this type of surgery? 

Dr. Joshua Lubek: There are, as with all surgeries. Surgery always has inherent risk to it. So you have to weigh the risks versus the benefits. So, if the patient’s quality of life is very poor, that they’re in constant pain, they’re not able to really eat well, they’re always having infections, it’s bothersome, they have such a foul odor coming from their mouth, it’s affecting their social interactions. Those are indications to surgically intervene. We always make sure that the patients are healthy enough to undergo surgery, and so, for instance, as I was talking about before, a lot of these medications are used to stabilize bone cancers or cancers that have spread to the bone. We do consult with their medical oncologist, and I always ask them if the patients are going to have quality and they have stable disease. So, a patient, let’s say, I’ll use the example, they may have metastatic breast cancer to the bone. So, they may have breast cancer that had spread to the bone. But they’re healthy and they’re going to be alive for another three, four years. But they just have really bad MRONJ to the point that they need surgical intervention. There’s no reason not to do surgery to improve their quality of life. 

Bill Klaproth (host): So, as we talk about surgery and MRONJ, the most advanced stage is stage 3. And I would imagine people are most concerned about that when it needs surgery or really advanced treatment. So, can you spend a little bit more time on stage 3 MRONJ and how you would go about treating that? 

Dr. Joshua Lubek: Yeah, so when we say stage 3 MRONJ, we refer to the full thickness of the bone is necrotic. That means, so as I, let’s say using the lower jaw, that means from where the bone around the teeth all the way to the lower border of the jaw, that entire bone is necrotic, it’s infected, it has an appearance on imaging that looks like that. It could be completely exposed, so that if you looked inside a patient’s mouth, you’re seeing an entire jawbone, dead jawbone, staring at you. They may have fistula. Those are the communications. So, the area gets infected and now it’s draining from inside the mouth and they have a draining fistula or a communication to the skin of the neck or the face. The other, what very often we see is there is a nerve that runs through the lower jaw that gives feeling to the lower lip and teeth, and very often in infections or in pathologic fractures, so a jaw fracture, that nerve can become affected. They say that I’m numb in that area. I can’t feel that area of my lip. Those are the advanced types of situations. It is in those situations that we have the ability or we offer the, for specific patients, the ability to resect or to remove that bad bone and then reconstruct it. If you were just to remove that bad bone, you would actually address the problem. You would get rid of the MRONJ. But, for a lot of patients, they could be facially deformed or have a cosmetic issue. And a lot of patients are not interested in that, obviously, right? You can imagine you wouldn’t want your face to collapse, a quality standpoint. And so we have the ability to reconstruct these areas very often using what’s called vascularized tissue. And what that is, is it’s a patient’s own tissue. In essence, I always, when I explain it to a patient, I say, think of it as an auto transplant. I can take tissue, so bone, muscle, I can take skin from one part of your body and I can move it to another part of the body while hooking up a blood supply and that can be used to reconstruct the jawbone. 

Bill Klaproth (host): Yeah, it’s amazing to think about reconstructing somebody’s jaw. Or treating stage 3 MRONJ, it really takes someone with experience, skill, knowledge and education for these types of surgeries. So, can you tell us about the OMS in this process and your role as an OMS in the diagnosis, treatment, and management of stage 3 MRONJ, and how you really are the experts when it comes to treating this? 

Dr. Joshua Lubek: Yeah, you’re absolutely correct. I think the OMS is essential to the diagnosis and management of MRONJ. Very often, the dentist, the medical oncologist, even the primary care physician, they may see the initial symptoms or signs of MRONJ and then they will refer it to the oral and maxillofacial surgeon. In earlier stages, there could still be more conservative management, but as the advanced stage occurs, that’s going to require specialized oral and maxillofacial surgeons to take care of the patient. I’ll give the example here at the University of Maryland. We have an MRONJ clinic, so patients can get referred to our clinic to be seen specifically for this disease and we will go over in detail the disease process, quality of life issues and then treatment options. 

Bill Klaproth (host): Well, this discussion has been very interesting, Dr. Lubek. I want to thank you for your time. Is there anything you want to add as we’re talking about treating advanced MRONJ? 

Dr. Joshua Lubek: You know, the overall summary is we have the ability to treat advanced stage MRONJ, but I think my general theme is it really is quality of life driven and the patient is really the quarterback, they’re really in the driver’s seat. Just because it looks bad on an X-ray or they’re told they have advanced stage MRONJ does not necessarily mean that you have to surgically intervene. A patient may have some symptoms, but their quality of life is good, they’re eating what they want, overall they are doing their daily activities, they’re hanging out with family and friends. Then, I tell them, surgery may make the X-ray look prettier, but it’s not going to improve their quality of life. 

Bill Klaproth (host): Absolutely, Dr. Lubek. Thank you so much for your time. This really has been informative. Thank you again. 

Dr. Joshua Lubek: Thank you. 

Bill Klaproth (host): And once again, that’s Dr. Joshua Lubek. And for more information and the full podcast library, please visit MyOMS.org. And if you found this podcast helpful, please share it on your social channels. And don’t forget to subscribe. Thanks for listening.