Pentoxifylline and Tocopherol (PENTO) in the Treatment of Medication-related Osteonecrosis of the Jaw (MRONJ)
Pentoxifylline and Tocopherol (PENTO) in the Treatment of Medication-related Osteonecrosis of the Jaw (MRONJ)
The overall purpose of this project is to answer the following clinical question: Among
 Medication-Related Osteonecrosis of the Jaw (MRONJ) patients, do those who are treated with
 the Pentoxifylline and Tocopherol (PENTO) regimen and standard of care, when compared to
 those treated with standard of care alone, have decreased areas of exposed bone after one
 year of treatment?
HYPOTHESES

 HA: Among patients with MRONJ, after 12 months of treatment with PENTO, the area of exposed
 bone in the PENTO group will be different than the area of exposed bone in the standard
 therapy group.

 H0: Among patients with MRONJ, after 12 months of treatment with PENTO, the area of exposed
 bone in the PENTO group will equal the area of exposed bone in the standard therapy group.

 SPECIFIC AIMS

 To determine if the PENTO regimen in addition to the standard of care treatment for MRONJ
 significantly reduces the area of exposed bone compared to standard of care alone. Standard
 of care is defined as the clinical guidelines of the 2014 AAOMS Position Paper on
 Medication-Related Osteonecrosis of the Jaw (MRONJ)

 1. Challenges: Identifying patients with Stage 1, 2, 3 MRONJ who will be compliant with
 therapy and available for follow-up. Measuring greatest anterior-posterior and
 superior-inferior dimensions to calculate area. Ensuring patient safety with interim
 analyses and an appropriate stopping protocol.

 2. Approach: The investigators will treat patients with Stage 1, 2, 3 MRONJ with either
 PENTO as an adjunct to the standard of care or standard of care alone with placebo.

 Impact: >6 million patients in the US are at risk for MRONJ. If proven to successfully treat
 MRONJ, the trial would establish a non-operative treatment option for successful management
 of MRONJ with potential for significant decreased morbidity for the patient.

 SAMPLE

 The sample will be derived from the population of patients who present to a participating
 trial site for management of MRONJ during the trial's enrollment period. To be included in
 the trial a patient must meet the criteria listed below. If a patient is excluded from the
 trial the reason will be documented for the study's record as well as basic demographic data,
 MRONJ staging, risk medications, indication for and use of antiresorptive and antiangiogenic
 medications and area of exposed bone will be collected.

 RANDOMIZATION

 A stratified permuted-block randomization will be used to allocate patients to treatment.
 This method ensures balanced allocations to achieve approximately the preset treatment
 allocation ratio of 1:1 and avoids predictability of future assignments. Strata will be
 constructed for the prognostic variables of initial MRONJ stage (1,2,3) and antiresorptive
 therapy (bisphosphonate vs. denosumab/RANK-L inhibitor). Within each strata, block sizes of 2
 and 4 will be used to randomize patients to PENTO + standard of care or to standard of care
 with placebo alone with randomization of treatment sequence to meet the 1:1 allocation ratio
 within each block.

 A computer-generated list of random allocations will be prepared for each strata. The
 allocation sequence will be concealed from the researcher enrolling and assessing
 participants in sequentially numbered, opaque, sealed and stapled envelopes. Corresponding
 envelopes will be opened only after the enrolled participants complete

 DATA MANAGEMENT AND ANALYSIS

 The primary analysis of interest is the association between treatment group and area of
 exposed bone. The primary analysis will be a repeated measures analysis of variance (ANOVA)
 with one within subject (time) factor and one between subject (treatment) factor will be
 completed for A = area based upon Dap and Dsi and geometric shape of the lesion. If outcomes
 do not meet assumptions then non-parametric analogues will be used.

 SAMPLE SIZE ESTIMATE

 alpha = 0.05, beta = 0.10, Anticipated drop-out rate = 30%

 A stratified permuted- block randomization will be used to allocate patients to treatment.
 Intention to treat to include all subjects as randomized to treatment (detailed on page 3 of
 the application). If a patient drops out or is withdrawn prior to 12-month treatment
 endpoint, the last observation carried forward (LOCF) will be included in analysis. In
 addition, patients "as treated" (patient received incorrect treatment) or "as protocol"
 (doesn't include patient dropouts or withdrawals) will be analyzed to evaluate effectiveness
 of the treatment. To detect a relative change in primary outcome ≥20% with the above
 parameters, a minimum sample of 44 patients in each study arm is required (total n=88).

 The investigators deemed that an improvement of ≥20% by the intervention group compared to
 the control group in decreased bone exposure to be clinically significant. There is no
 consensus in the current literature on a clinically significant difference between the
 control and treatment arms. However, if the study is powered for the outcomes expected based
 on current literature, a difference of 50% between arms would only require 7 patients per
 arm. Therefore the investigators believe the study to be overpowered to ensure the
 statistical analysis would remain significant if the suspected success of the PENTO regimen
 is not true.

 STOPPING RULES

 Because this is an investigational use of pentoxifylline and the benefits of PENTO in MRONJ
 are not presently established, interim analyses (p=.001) will be performed at 3 and 6 months.
 If the trial is stopped after an interim analysis for proven benefit, the trial will be
 converted to an open trial and the patients will be followed for the entire 12-month
 treatment period, or until they achieve complete mucosal coverage.

 Patient withdrawal from study criteria include:

 -  A serious adverse event related to the trial medication.

 -  Patient becomes pregnant.

 -  Any relevant deterioration in the health of the subject (AEs, vital signs, ECG,
 laboratory parameters).

 -  Clinically relevant change in vital signs if technical failure

 OVERSIGHT RESPONSIBILITIES

 Oversight of the trial is provided by the Principal Investigator (PI) Dr. Dillon and Co-
 Investigators (Co-I) Dr. Petrisor, Dr. Ruggiero, Dr. Morlandt, and Dr. Ward.

 MONITORING PROCEDURES

 Drs. Dillon, Ruggiero, Petrisor, Morlandt, and Ward assure that informed consent is obtained
 prior to performing any research procedures, that all subjects meet eligibility criteria, and
 that the study is conducted according to the IRB-approved research plan. Blinded study data
 are accessible at all times for the PI and Co-investigators to review. All five investigators
 will review study conduct including accrual, drop-outs, and protocol deviations on a
 quarterly basis. In addition, the investigators will review adverse events (AEs) individually
 real-time and in aggregate on a monthly basis. Last, the investigators will review serious
 adverse events (SAEs), dose limiting toxicities, and any other specific intervention
 complications in real-time. The PI ensures all protocol deviations, AEs, and SAEs are
 reported to the FDA, DSMB and IRB according to the applicable regulatory requirements.

 COLLECTION AND REPORTING OF SAEs AND AEs

 For this study, the following standard AE definitions are used:

 Adverse event (AE): Any unfavorable and unintended sign (including an abnormal laboratory
 finding), symptom or disease temporally associated with the use of a medical treatment or
 procedure, regardless of whether it is considered related to the medical treatment or
 procedure.

 Serious Adverse Event: Any AE that results in any of the following outcomes:

 -  Death

 -  Life-threatening

 -  Event requiring inpatient hospitalization or prolongation of existing hospitalization

 -  Persistent or significant disability/incapacity

 AEs are graded according to the following scale:

 -  Mild: An experience that is transient & requires no special treatment or intervention.

 -  Moderate: An experience that is alleviated with simple therapeutic treatments.

 -  Severe: An experience that requires therapeutic intervention. The experience interrupts
 usual daily activities.

 The study uses the following AE attribution scale:

 -  Not related: The AE is clearly not related to the study

 -  Possibly related: An event that follows a reasonable temporal sequence from the
 initiation of study procedures, but that could readily have been produced by a number of
 other factors.

 -  Related: The AE is clearly related to the study procedures.

 SAEs and specific procedure-associated AEs are reported to the University of Washington IRB
 and DSMB within 24 hours. In addition, all AEs are reported according to the University of
 Washington IRB AE reporting guidelines.

 MANAGEMENT OF RISKS TO SUBJECTS

 Expected AEs associated with the Pentoxifylline and Tocopherol include: Dizziness, headache,
 nausea, vomiting, indigestion, flushing, angina, palpitations, hypersensitivity, itchiness,
 rash, hives, bleeding, hallucinations, arrhythmias, aseptic meningitis

 AE Management

 If any unanticipated problems related to the research involving risks to subjects or others
 happen during the course of this study (including SAEs) these will be reported to the IRB in
 accordance with University of Washington Human Subjects Division (HSD) protocols and the
 DSMB. AEs that are not serious but that are notable and could involve risks to subjects will
 be summarized in narrative or other format and submitted to the IRB and DSMB at the time of
 continuing review.

 DATA SAFETY AND MONITORING (DSMB) ANALYSIS PLAN

 The Analysis for safety (AEs) will be conducted at a minimum of 3 and 6 months. However,
 depending upon recruitment the analysis of safety will be as follows when:

 10, 20, 30, 40, 60, 80, 100 patients have completed 3 months of follow up.

 Patient withdrawal criteria include:

 -  A serious adverse event related to the trial medication.

 -  Patient becomes pregnant.

 -  Any relevant deterioration in the health of the subject (AEs, vital signs, ECG,
 laboratory parameters).

 -  Clinically relevant change in vital signs if technical failure can be excluded and
 result is confirmed by at least 1 additional measurement.

 PLAN FOR DATA MANAGEMENT

 Compliance of regulatory documents and study data accuracy and completeness will be
 maintained through an internal study team quality assurance process.

 Confidentiality throughout the trial is maintained by the previously described study-specific
 confidentiality procedures. DATA will be stored as de-identified on a REDCap database which
 will be password protected and only accessible by study members.

 INFORMED CONSENT/ETHICAL CONSIDERATIONS

 Quality and integrity of the research will be ensured through data safety monitoring and
 informed patient consent for participation. Enrollment will be done by the study coordinator
 at each site not the participating surgeon. Other than the UW study coordinator the other
 coordinators will be research students participating in the trial. The research will be
 independent and impartial, and key study personnel directly involved in patient care will be
 blinded to the treatment. Informed consents to be obtained from patients will state the
 overall purpose of the study, alternatives to participation, and any direct and indirect
 risks/benefits from participation. All patient literature and consents will be written at an
 8th grade reading level. The confidentiality and anonymity of the research respondents and
 patient health information will be respected. IRB approvals will be obtained at all study
 sites prior to beginning any research activities. The individual study site IRBs will
 determine if it is appropriate to pursue an expanded access Investigational
Inclusion Criteria:

 1. Stage 1, 2, or 3 MRONJ as defined by the AAOMS Position Paper on Medication-Related
 Osteonecrosis of the Jaw-2014 Update (Ruggiero 2014).

 2. History of exposure to antiresorptive medications such as bisphosphonates or RANK-L
 inhibitors

 3. Absence of tumor in the jaw at the time of recruitment

 4. Patients with the capacity to give informed consent

 Exclusion Criteria:

 1. Patients with history of external radiation therapy to the jaws

 2. Patients who underwent any surgical intervention for MRONJ in the past 4 months

 3. Patients with past microvascular reconstruction of the head and neck

 4. Patients with an expected survival less than 1 year

 5. Patients with allergy or hypersensitivity to pentoxifylline, xanthines, or tocopherol

 6. Patients with planned invasive dental procedure in the next year

 7. Patients taking oral anticoagulants

 8. Patients with known hemorrhagic and coagulation disorder

 9. Patients with a vitamin K deficiency due to any cause

 10. Female patients who are pregnant or lactating

 11. Patients with history of serious bleeding or extensive retinal hemorrhage

 12. Patients with ischemic heart diseases, including, but not limiting, recent myocardial
 infarction

 13. Patients with serious cardiac arrhythmia

 14. Patient with history of prostate cancer

 15. Patients with severe liver disease

 16. Patients with severe renal failure (Creatinine clearance <30 mL/min)

 17. Patients with diagnosed hypotension

 18. Patients taking CYP1A2 inhibitors (e.g. ciprofloxacin, fluvoxamine)

 19. Diagnosis of MRONJ with no exposed bone

 20. Patient cannot tolerate impressions of exposed bone in a clinical setting, if needed.

 21. There is a change in the patient's clinical presentation (tooth extraction,
 sequestrectomy) from alginate impression, if impression is indicated.

 22. Any other situation or condition that, in the opinion of the INVESTIGATOR, may
 interfere with optimal PARTICIPATION in the study

 23. A patient who has taken both bisphosphonate and Denosumab