Maxfacts

Hard tissue necrosis

As can be seen in the interventions for, and even the natural progress of, hard tissue necrosis (overwhelmingly osteonecrosis of the jaws with rare cases of osteonecrosis of the skull or necrosis of nasal or laryngeal cartilage) is very wide and varied.

Untreated osteonecrosis caused by medication does differ from that caused by radiation [treatment-radiotherapy-preamble] in that discontinuation of some of the drugs (for example, denusomab) and conservative care may allow spontaneous healing to take place whereas osteonecrosis caused by other agents (bisphosphonates) will not. Radiation effects are effectively permanent and spontaneous resolution of osteoradionecrosis only really happens when the bone sequestrates and falls out of the surrounding soft tissue.

To generalise in the case of conservative management for hard tissue necrosis:

• Short term: very little actually happens and it can feel like you are getting nowhere, which is obviously frustrating. Continue with analgesia (this will be very dependent on the underlying conditions and which drugs were being used for their treatment - minor analgesia may be suitable in someone experiencing little discomfort from necrosis secondary to bisphosphonate treatment for osteoporosis, but opioid analgesia may be in use for someone with metastatic cancer) and the conservative regimen you are using.
• Medium term: fragments of bone may detach, become loose and either fall away or be easily picked off (they do no damage if swallowed), the area of exposed bone appears to shrink and this can be encouraging. If the sequestrated bone becomes infected (more likely if it is buried deep in soft tissue; if superficial, it just falls out) the area can become acutely painful and swollen.
• Long term: it may take many months to see mucosa gradually cover over the area of exposed bone, although the associated tenderness and discomfort often improve before complete mucosal coverage.

Interventions have a more predictable sequence of events largely depending on the degree of intervention. In the case of major surgical intervention this is basically along the lines of resection of the necrotic hard and soft tissue, with a margin of apparently normal tissue and its replacement with fresh healthy vascularised tissue. The timelines for these operations follow those for the operations for mouth cancer, facial skin cancer and other major reconstructive surgery. In the case of medical management where regimens such as PENTOCLO are followed:

• Short term: no benefits of treatment will be noticed, although unwanted effects of the drug combination may be noticed in the first 24 to 48 hours.
• Medium term: if no unwanted effects of the drug cocktail are noticed during the first 2 to 4 weeks, then even if no discernible benefit is seen the recommended regimen would suggest continuation as the benefits are noticed in the long term.
• Long term: sequestration of superficial necrotic bone with a gradual vascularisation occurs. You may notice dead bone being shed and underneath it healthy red and sometimes even bleeding bone appear. This is met with a creeping in from the margins of surrounding mucosa. The original wound appears to be gradually shrinking. This whole process may take 6 to 9 months.