Medication Related Osteonecrosis of the Jaw: A Case Report and Review of Literature

Abstract

Medication-related osteonecrosis of the jaw is an adverse reaction caused by the use of antiresorptive antiangiogenic medication. The most commonly affected areas are posterior regions of mandible and maxilla. However, a simultaneous occurrence in both jaws is rarely observed. We present an interesting case of MRONJ affecting both jaws. A 47-year old female presented with pain and swelling in the left posterior region of the mandible. The patient’s medical history was significant for breast cancer with ongoing bisphosphonate therapy. Cone-beam CT (CBCT) confirmed the presence of an extraction socket at the site of complaint. There was evidence of a diffuse sclerotic bone reaction in the maxillary posterior region bilaterally. The mandible showed presence of diffuse sclerotic bone only in the left para-symphysis and posterior region in addition to association with a periosteal bone reaction in the left para-symphysis region. Considering these findings and a history of exposure to bisphosphonate medication, the final diagnosis was conclusive of MRONJ. Management was aimed at suppressing the symptoms of pain and infection. The present case study reinforces the importance of correlating clinical and radiographic findings. Early diagnosis of MRONJ may lead to a more conservative treatment approach, greatly improving the patient’s prognosis. Keywords: MRONJ, Cone-beam CT, breast cancer, bisphosphonate

Keywords

• MRONJ
• Cone-beam CT
• Breast cancer
• Bisphosphonates

References

1. 1 Nicolatou-GalitisO,SchiodtM,MendesRA,RipamontiC,Hope S, Drudge-Coates L, et al. Medication-related osteonecrosis of the jaw: definition and best practice for prevention, diagnosis, and treatment. Oral Surg Oral Med Oral Pathol Oral Radiol. 2019;127(2):117–135. doi:10.1016/j.oooo.2018.09.008.
2. 2. AlDhalaan NA, BaQais A, Al-Omar A. Medication-related Os- teonecrosis of the Jaw: A Review. Cureus. 2020;12(2):e6944. doi:10.7759/cureus.6944.
3. 3. Drake MT, Clarke BL, Khosla S. Bisphosphonates: mecha- nism of action and role in clinical practice. Mayo Clin Proc. 2008;83(9):1032–45. doi:10.4065/83.9.1032.
4. 4. Luckman SP, Hughes DE, Coxon FP, Graham R, Russell G, Rogers MJ. Nitrogen-containing bisphosphonates inhibit the mevalonate pathway and prevent post-translational prenyla- tion of GTP-binding proteins, including Ras. J Bone Miner Res. 1998;13(4):581–9. doi:10.1359/jbmr.1998.13.4.581.
5. 5. Nogueira D, Caldas IM, Dinis-Oliveira RJ. Bisphos- phonates and osteonecrosis of the jaws: Clinical and forensic aspects. Arch Oral Biol. 2023;155:105792. doi:10.1016/j.archoralbio.2023.105792.
6. 6. Ruggiero SL, Dodson TB, Fantasia J, Goodday R, Aghaloo T, Mehrotra B, et al. American Association of Oral and Max- illofacial Surgeons position paper on medication-related os-teonecrosis of the jaw–2014 update. J Oral Maxillofac Surg. 2014;72(10):1938–56. doi:10.1016/j.joms.2014.04.031.
7. 7. De Bruyn L, Coropciuc R, Coucke W, Politis C. Microbial population changes in patients with medication-related os- teonecrosis of the jaw treated with systemic antibiotics. Oral Surg Oral Med Oral Pathol Oral Radiol. 2018;125(3):268–275. doi:10.1016/j.oooo.2017.11.022.
8. 8. Ruggiero SL, Dodson TB, Aghaloo T, Carlson ER, Ward BB, Kade- mani D. American Association of Oral and Maxillofacial Sur- geons’ Position Paper on Medication-Related Osteonecrosis of the Jaws-2022 Update. J Oral Maxillofac Surg. 2022;80(5):920– 943. doi:10.1016/j.joms.2022.02.008.

9. 9. Stockmann P, Hinkmann FM, Lell MM, Fenner M, Vairaktaris E, Neukam FW, et al. Panoramic radiograph, computed tomogra- phy or magnetic resonance imaging. Which imaging technique should be preferred in bisphosphonate-associated osteonecro- sis of the jaw? A prospective clinical study. Clin Oral Investig. 2010;14(3):311–7. doi:10.1007/s00784-009-0293-1.
10. 10. Mauceri R, Coppini M, Attanasio M, Bedogni A, Bettini G, Fusco V, et al. MRONJ in breast cancer patients under bone modifying agents for cancer treatment-induced bone loss (CTIBL): a multi-hospital-based case series. BMC Oral Health. 2023;23(1):71. doi:10.1186/s12903-023-02732-6.
11. 11. Dhesy-Thind S, Fletcher GG, Blanchette PS, Clemons MJ, Dill- mon MS, Frank ES, et al. Use of Adjuvant Bisphosphonates and Other Bone-Modifying Agents in Breast Cancer: A Cancer Care Ontario and American Society of Clinical Oncology Clin- ical Practice Guideline. J Clin Oncol. 2017;35(18):2062–2081. doi:10.1200/JCO.2016.70.7257.
12. 12. Liu FC, Luk KC, Chen YC. Risk comparison of osteonecrosis of the jaw in osteoporotic patients treated with bisphospho- nates vs. denosumab: a multi-institutional retrospective co- hort study in Taiwan. Osteoporos Int. 2023;34(10):1729–1737. doi:10.1007/s00198-023-06818-3.
13. 13. Aboubacar BH, Jumelle ZNA, Odero-Marah V, Romuald KT, Laetitia O, Tarcissus K. Post biphosphonate mandible osteonecrosis: A case study and literature review. Oral OncolRep. 2023;7. doi:10.1016/j.oor.2023.100081.
14. 14. Otto S, Schreyer C, Hafner S, Mast G, Ehrenfeld M, Sturzen- baum S, et al. Bisphosphonate-related osteonecrosis of the jaws - characteristics, risk factors, clinical features, localiza- tion and impact on oncological treatment. J Craniomaxillofac Surg. 2012;40(4):303–9. doi:10.1016/j.jcms.2011.05.003.
15. 15. Aljohani S, Fliefel R, Ihbe J, Kuhnisch J, Ehrenfeld M, Otto S. What is the effect of anti-resorptive drugs (ARDs) on the development of medication-related osteonecrosis of the jaw (MRONJ) in osteoporosis patients: A systematic review. J Craniomaxillofac Surg. 2017;45(9):1493–1502. doi:10.1016/j.jcms.2017.05.028.
16. 16. Hallmer F, Andersson G, Gotrick B, Warfvinge G, Anderud J, Bjornland T. Prevalence, initiating factor, and treatment out- come of medication-related osteonecrosis of the jaw-a 4-year prospective study. Oral Surg Oral Med Oral Pathol Oral Radiol. 2018;126(6):477–485. doi:10.1016/j.oooo.2018.08.015.
17. 17. KhanAA,MorrisonA,HanleyDA,FelsenbergD,McCauleyLK, O’Ryan F, et al. Diagnosis and management of osteonecrosis of the jaw: a systematic review and international consensus. J Bone Miner Res. 2015;30(1):3–23. doi:10.1002/jbmr.2405.
18. 18. Schiffman E, Ohrbach R, Truelove E, Look J, Anderson G, Goulet JP, et al. Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) for Clinical and Research Applications: recommen- dations of the International RDC/TMD Consortium Network* and Orofacial Pain Special Interest Groupdagger. J Oral Facial Pain Headache. 2014;28(1):6–27. doi:10.11607/jop.1151.
19. 19. Rosella D, Papi P, Giardino R, Cicalini E, Piccoli L, Pompa G. Medication-related osteonecrosis of the jaw: Clinical and prac- tical guidelines. J Int Soc Prev Community Dent. 2016;6(2):97– 104. doi:10.4103/2231-0762.178742.
20. 20. Vanpoecke J, Verstraete L, Smeets M, Ferri J, Nicot R, Politis C. Medication-related osteonecrosis of the jaw (MRONJ) stage III: Conservative and conservative surgical ap- proaches versus an aggressive surgical intervention: A sys- tematic review. J Craniomaxillofac Surg. 2020;48(4):435–443. doi:10.1016/j.jcms.2020.02.017.