MRONJ Clinical presentation for surgical and non-surgical treatment by Dr. Walter Tatch
Video Transcription:
Hello, everyone. This is Dr. Walter Tatch, a board-certified oral maxillofacial surgeon and part of the North Shore Center for Oral Facial Surgery. Magmaxillofacial surgeon and part of the North Shore Center for Oral Facial Surgery. Today, we're going to discuss a case of Mrunge that we recently treated in our clinic and just review the protocol that we usually utilize in the clinic for cases like this. Our patient is a 74 or 4-year-old female with the past medical history significant for breast cancer. She was treated with a double mastectomy. Unfortunately, the disease has progressed and metastasized to the bones. The patient has been under the care of a hematologist and an oncologist for the last five years. Her medical history is also significant for hypertension, asthma, and depression. She's been on ex-JIVA or denosumab for the last three years and has been taking it every three weeks in injections. She's also on lisinopril for her blood pressure management, vitamin D, magnesium, as well as oxycodone for chronic pain, and she's taking gabapentin for her depression. The initial presentation of the disease included mild discomfort and pain, so certainly some inflammation in the area, and Her chief complaint was inability to wear her denture because of that constant pain. This is a data gathering algorithm that has been proposed by Amas' position paper, which was published a couple of years ago on staging and initial data gathering for the cases of range.
So history and physical examination is going to be important. Obviously, that's as with the diagnosis of any disease and condition. So, for her history, we want to first establish the diagnosis in range. So this particular patient has not had any history of radiation to the head and neck. She's been on the medications that can cause medication-related osteonecrosis of the Joe, in her case, denosumab for the last three years. Denosumab is not a bisphosphonate medications, but rather a receptor, activator of It has a nuclear factor, kappa-b ligand, and it has anti-resorptive properties, specifically by inhibiting osteoclastic function. Unlike the bisphosphonates, the denosumab actually does not bind to the bone. If you stop the patient's medication for about six months, you can completely reverse the effect of denosumab. Even from Amas' position paper, the discussion of drug holiday still remains a little bit of controversial. I think the clinicians split 50/50 on the need for drug holidays for patients who are diagnosed with Mrunge. In this particular case, after discussion with the hematologist and oncologist, we could not really take the patient off the Nassimab because of her bone disease, metastatic bone disease. And so the decision was to continue rendering her treatment for Mranche while she's still continuing her injections of X-ray every three weeks.
So the radiographic Evaluation is also part of our radiographic survey, and we're going to identify the extension of the disease. And that's a really important piece of information when it comes to staging of the condition. And so after the clinical and radiographic evaluation and considering the patient's initial presentation with some discomfort and inflammation, stage 2 was assigned to Mronj's case, and the decision was to render the conservative non-surgical treatment initially for about six weeks. Based on the AMUS position paper, the recommendation is usually for cases like that, for patients to be placed on an entomicrobially mouth rinse. And one of the recommendations from AMUS is Chlorhexidine oral rinses. In our subsequent slides, we'll talk specifically about Chlorhexidine applications and our thinking process when it comes to the use of Chlorhexidine. For cases like this or for any other cases for that matter, the patient, if they present If there's any signs of infection, certainly antibiotics and penicillin would be a primary choice in that regard. Doxycycline, certainly another antibiotic that patient can be prescribed for treatment of the infection. And the secrostractomy, if the area of the bone, necrotic bone, is ready to be gently separated and removed. In this particular case, the disease extended much further than clinically visible, so no loose bony segments were identified.
And we'll reassess the patient in six weeks, where we're going to do a repeat clinical evaluation, radiographic survey, and then restage her disease at that time. A few words on the specific protocol. Again, the local wound care of the exposed bone, the recommendation is rinses with an antiseptic mouth rinse, in this case, stage 2. So we're going to reassess the patient in six weeks. If we see disease resolution, obviously, that's a successful outcome of our initial nonsurgical treatment. If they're non-responding, then either we're going to decide to continue with non-operative treatment, or if the disease is progressing or there's no resolution, we're going to decide if a surgical treatment at that point in time needs to be rendered. With the discussion on entomacrival mouth rinses, specifically, chlorhexidine is still very much considered a gold standard. Well, let's stop and think about what chlorhexidine really does. I don't think there's any dispute as far as the antimicrbial properties of chlorhexidine. They've been well-established and shown in study after study. But also what's been shown in a plethora of different studies in dental literature and beyond is the cytotoxicity of chlorhexogen. In this particular publication that I'm quoting here, which was published in 2018 in the Journal of Bone and Joint Infection, they show the cytotoxicity of chlorhexidine on human fibroblasts, myoblasts, and osteoblasts.
The results show that chlorhexidine dilution of more than 0. 02 %, and In the paradox, it's 0. 12%. So for any exposure duration, had cell survival rate of less than 6% relative to untreated control. So the conclusion of this paper was that the clinically used concentration of caryoacetam permanently holds cell migration and significantly reduces survival in vitro fibroblasts, myoblasts, and osteoblasts. Let's stop and think for a second. In this particular case, we're treating the carotid bone. We're treating bone that's exposed bone, that a non-vital bone. So the use of a mouth rinse that has the potential to kill more bone is really counterintuitive in my opinion. So for cases like this, what we use is what we call a Mrunge In-Office Protocol, and it includes the use of Stalvia Life oral rinse and the gel. Just a few words about StellaLife products in general. We've adapted it a number of years ago and used it for a number of different clinical cases, not just the Mrunge-related treatment. But in this particular, for the purpose of this discussion, we're talking about the Mranche here. So our protocol includes the placement of patient on StellaLife Rinse three times a day.
So they're going to rinse for about a minute, a minute and a half, and expect to read. Then StellaLife Gel is going to be applied to the surgical wound, and right after the rinse. And the patient is going to be asked not to eat or drink for about 10, 15 minutes after the application. And the idea here is to allow enough time for the product to be adequately absorbed and for the efficacy of the product, really, to allow the full efficacy of the product. The normal saline rinse is also going to be part of the daily protocol for the patient. When we're saying normal saline rinse, essentially, it's a homemade solution that we recommend for the patients to take a glass of warm water, put a quarter teaspoon of salt, and dissolve it. And the saline rinses are going to be used by patients essentially throughout the day in between the application of StellaLife product and after each meal throughout the day. A few more specifically on Stellar Life Rinsing the Gel. Stellar Life Rinsing the Gel is basically a plant-based product, and it has 14 different ingredients, active ingredients. They're all plant-based or homeopathic, and they're designed to decrease swelling, bruising, and pain.
The Mouth Rinsing specifically has four active ingredients that has been shown in multiple studies, good antimicrobial efficacy. I wanted to quote here this study that was done by Dr. Kuzakis and his group and published in 2021 in a peer-review journal, and it essentially compared the clorhexidin to cell life oral rinse. The findings of the paper show that herbal extract, which is Stel Life oral rinse, did not demonstrate toxicity to fibroblasts and oral stem cells when applied to clinically relevant exposure time, and also showed similar antimicrobial properties against gram-negative anaerobic bacteria. And so based on all this information, StellaLife Oral Rinse, and for that matter, StellaLife Oral Gel, completely makes sense to use in cases, specifically for a conservative treatment of runge cases. So again, the conservative protocol is the Stalife rinse and the gel applications three times a day, normal saline rinses throughout the day, antibiotic prescription as needed based on the case-to-case presentation, and then we're going to reassess the patient in six weeks. So when the patient comes back in six weeks, unfortunately, the disease has not resolved. She continues to have some pain associated with the exposed endocrine bone and had subsided to some degree, and she is still unable to wear her denture and therefore unable to investigate her food.
At this point in time, we're going to make a decision. We're going to restage it. It's still going to be stage 2 based on the clinical radiographic presentation. We're going to make a decision. If we were going to continue with a conservative treatment, we're going to go ahead and provide patient with a surgical care. In this particular case, because the patient was having symptoms, because she was unable to masticate her food properly and was losing weight, and she was hectic to begin with, the decision was made to go ahead and render a surgical treatment. The surgical treatment It will involve resection of the necriotic bone to the healthy and bleeding bone. Again, the disease is still within the alvulus, so we're going to do partial ovulaectomy in this case. We're going to use a Bucal fat pad, which is a great source of vascularity to cover the deep peg. We'll also use the LPRF in this case as well, and close the surgical wound primarily. Postoperatively, the patient is still going to continue with the doxycycline use of the antibiotics. So they're still on doxycycline twice a day, pain management based on the patient's needs.
And then the StellaLife Rinse and Gel to be applied, as we discussed, in the conservative non-surgical treatment three times a day. And the most difficult part for this patient is to continue not using the denture as it renders her difficult investigating and chewing food. But for the purpose of local healing of this wound, it's going to be extremely important for her not to wear the denture for at least the three weeks during the initial healing phase. When the patient comes back in three weeks for follow-up, we can see that the carotid area of the bone has resolved. The primary closure is healing quite nicely. They still have a couple of sutures remaining in the area that are going to essentially just about ready to fall out. At this point in time, we can have the patient already start wearing the denture with a proper reline. She's going to be referred to her general dentist for that. Then also, I recommend this intermittent use of oral care products, of Stalaf oral care products, where the patient will continue using in her particular case, because now she is able to wear a denture after rinsing with Stalife oral rinse, you can put the gel in the intact way of the denture and apply it right over that area to allow for continuous healing in that The patient will come back to see us in a month for checkups.
After that, continue seeing patients every three months for the next six months, and then biannually, and then finally, annually, to assure that complete resolution and no recurrence takes place or a new disease develops in other areas. Once again, this was Dr. Walter Tj, and this is a clinical presentation on Mrunge non-surgical and surgical treatment. Thank you.