# Resective Surgery versus Debridement in Stage 2 Medication-Related Osteonecrosis of the Jaw
###### Abstract  
The aim of this study is to analyze surgical and functional outcomes in order to verify the applicability of surgical treatment guidelines as foreseen by MASCC/ISOO/ASCO 2019. Patients affected by stage 2 MRONJ refractory to conservative management were grouped if underwent surgical resection (Group A) or debridement (Group B). Health-related quality of life was evaluated by using the European Organization for Research and Treatment of Cancer questionnaires, QLQ-C30 and H&N35. Statistical analysis was performed using Wilcoxon/Mann-Whitney test, Kaplan-Meier test, Cox regression model and Cox multivariate regression. Group A showed higher complete healing cases vs. group B. Recurrence rate difference in group A vs. group B was statistically significant. Debridement is an unfavorable prognostic factor when compared to surgical resection (\(p=0.0032\), HR 4.9). Quality of life mean values showed a marked improvement in Group A and a slight improvement in Group B. Debridement has 4.9 times more risk to develop recurrence when compared to surgical resection. A more satisfactory quality of life was shown in patients subject to resective surgery with an improving trend from baseline. Debridement patients showed more variability of results and an overall negative trend at the end of the 6-month follow-up.  
MRONJ; medication-related osteonecrosis of the jaw; BRONJ; debridement; resective surgery +
Footnote †: journal: Medical-Related Osteonecrosis of the jaw; BRONJ; debridement; resective surgery +
drug or association treatments), and route of administration [7; 8; 9; 10]. Appraisal of the United States Food and Drug Administration's Adverse Event Reposting System (FAERS) revealed the highest risk for intravenous bisphosphonates, followed by denosumab and oral bisphosphonates, while bevacizumabab showed a more favorable profile [7; 11].  
Etiopathogenesis is multifactorial: age, sex, genetics, comorbidities, metabolic status, obesity, steroids assumption, xerostomia, poor oral hygiene, infection, and inflammation status of the oral cavity have been advocated to play a role [12; 13; 14]. Although it is still debated in the literature, dental infections are believed to impact more than other factors [15]. Presence of bacteria and inflammation have been demonstrated to stimulate bony resorption via stimulation of osteocl activity, thus producing a favorable context for the evolution toward MRONJ [16; 17; 18].  
The AAOMS proposed in 2014 a classification that differentiates MRONJ into five stages according to disease severity [1]. Although it has been questioned, this classification remains the most commonly used among surgeons and clinicians all over the world. Based on the AAOMS classification, the Multinational Association of Supportive Care in Cancer (MASCC), the International Society of Oral Oncology (ISOO), and the American Society of Clinical Oncology (ASCO) released a joined practice guideline to standardize the management of patients developing MRONJ [19]. As clearly stated by the experts, poor evidence has been reported in the published literature and proposed recommendations are mainly based on authors' formal consensus.  
Focusing on treatment recommendations proposed for stage 2 disease acc. AAOMS classification, MASCC/ISOO/ASCO guidelines advise to carry out a strict follow-up, trying to educate patients on optimal oral hygiene and the use of topical medications (such as antimicrobial oral rinses) to minimize avoidable risk factors and to use systemic antibiotic therapy. However, it has been observed that following necrotic bone exposure, bacterial contamination may produce biofilms and membranes that affect the efficacy of systemic therapies [18; 20].  
The aim of this study is to compare surgical and functional outcomes of patients affected by stage 2 MRONJ acc. AAOMS staging system, receiving surgical debridement or surgical resection and to verify the applicability of treatment guidelines as foreseen by MASC/ISOO/ASCO 2019 in patients refractory to conservative management.