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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 5  |  Issue : 1  |  Page : 41-43

Bisphosphonate related osteonecrosis of jaw: A case report


Department of Oral and Maxillofacial Surgery, Sri Aurobindo College of Dentistry, Indore, Madhya Pradesh, India

Date of Web Publication27-Jul-2017

Correspondence Address:
Waquar Ahmed
Ahmed Hospital, Bnp Road, Dewas - 455 001, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jhnps.jhnps_7_17

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  Abstract 

Bisphonates are used widely to treat osteoporosis, hyperglycemia of malignancy, bone metastasis of solid tumors. However a relationship has been reported between the use of bisphosphonates and osteonecrosis of jaw. Clinical presentation of bisphosphonates related osteonecrosis of jaw (BRONJ) includes gingival ulceration with exposed necrotic bone in the oral cavity involving either maxilla or mandible that has persisted for 6-8 weeks. And in severe cases it may cause spontaneous pain, tooth mobility, pathological fracture. Though treatment recommendation's exists, no definitive standard of care has been established for BRONJ and surgery was previously reported as capable of exacerbating bone exposure. The present study shows a case report of patient of BRONJ treated as conservatively as possible. Patient was managed with observation, oral antibacterial rinse, analgesics for pain control. After follow up of 18 months, healing of the lesion was achieved and patient became symptom free.

Keywords: Bisphonates, jaw, osteonecrosis


How to cite this article:
Ahmed W, Mitra GV, Rajmohan S, Motiwale T, Andhare V. Bisphosphonate related osteonecrosis of jaw: A case report. J Head Neck Physicians Surg 2017;5:41-3

How to cite this URL:
Ahmed W, Mitra GV, Rajmohan S, Motiwale T, Andhare V. Bisphosphonate related osteonecrosis of jaw: A case report. J Head Neck Physicians Surg [serial online] 2017 [cited 2021 Mar 2];5:41-3. Available from: https://www.jhnps.org/text.asp?2017/5/1/41/211732


  Introduction Top


Bisphosphonates are used to treat malignant hypercalcemia and prevent bone complications in patients with multiple myeloma or bone metastases from breast and prostate cancers.[1]

Osteonecrosis, death of bone, can occur as a result of impaired blood supply.[2] Both cancer and its treatment have been associated with an increase in the risk of osteonecrosis, with the most common site being the femoral head.[2] Osteonecrosis of the jaws is well documented in the patients who have radiation therapy of the head and neck and is termed osteoradionecrosis.

Bisphosphonates have been used since 1960 for the treatment of conditions such as bone metastases, multiple myeloma, lung cancer, calcium metabolism disorders, and Paget's disease.[3],[4] Their therapeutic use has increased for the treatment and prevention of osteoporosis and osteopenia.

In 2003, bisphosphonate-related osteonecrosis of the jaw was first reported, with the demonstration of 36 bone lesions of the mandible and/or maxilla in patients on pamidronate or zoledronate, the lesions being attributed to a severe unknown side effect.[5] The variety of clinical signs and symptoms of bisphosphonate-related osteonecrosis of the jaw, its etiology, preventive measures, effects of bisphosphonates discontinuation, and indicators of prognosis remain undefined. The effectiveness and efficacy of the treatment for bisphosphonate-related osteonecrosis of the jaw have not been properly characterized.


  Case Report Top


A 65-year-old male [Figure 1] patient reported to the department with a complaint of exposed bone and pain in lower jaw since past 3 months.
Figure 1: Profile image

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Patient was diagnosed with non-Hodgkin's lymphoma 2 years back. Positron emission tomography-computed tomography revealed active nodes in D10, D11, and L1 level in spinal cord, acetabulum, and right axilla.

Patient underwent palliative radiotherapy for the same targeting disease only spinal level (15 cycles with the last cycle completed on 13/1/14).

Patient also took chemotherapy along with injection intravenous (i.v.) zoledronic acid 4 mg (26 dose total) once a week. Chemotherapy was completed on September 2015.

On examination, no gross facial asymmetry was seen. Right submandibular solitary lymph node palpable which was mobile, nontender and approximately 1 cm in diameter.

Exposed buccal and lingual cortical plate was present in relation to 36, 37 [Figure 2] and exposed lingual cortical plate in relation to 46 [Figure 3].
Figure 2: Exposed alveolus lower right side

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Figure 3: Exposed alveolus lower left side

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Cone beam computed tomography revealed an irregular area of hypodensity resembling moth-eaten appearance extending from the distal aspect of 44 and 34 to retromolar region with loss of buccal and lingual cortical plate. Based on clinical and radiological findings, a diagnosis of bisphosphonate-related osteonecrosis of mandible was made.

Patient was then referred to the department of radiotherapy regarding fitness to undergo sequestrectomy and saucerization of mandible under general anesthesia.

Patient was declared fit from the department of radiotherapy for surgical intervention.

Patient was then referred to Department of Medical Oncology for their opinion for same. Patient was not deemed fit for surgical intervention stating patient will not be benefited from surgery due to global effect of bisphosphonate therapy.

Patient was council regarding limitation of mode of treatment and palliative and symptomatic treatment was advised to continue. Antibiotic therapy, chlorhexidine mouthwash, warm saline gargle, and analgesic (SOS) were prescribed.

Patient was recalled at interval of 7 days, 15 days, 1 month, 6 months, 12 months, and 18 months. Patient was relieved of symptoms, and he discontinued the use of analgesics after 2 months.


  Discussion Top


Bisphosphonate-related osteonecrosis of the jaws presents with a clinical and radiographic appearance similar to that of radiation necrosis. The lack of radiation exposure in these patients, who either shared a history of malignancy or osteoporosis, was initially puzzling until it became clear that all patients with malignancies were receiving an (i.v.) bisphosphonate.[6] According to Hellstein and Marek in their study in 2005 on phossy jaws, they compare the similarity of this condition with the current bis-phossy jaws. Suppuration was not common in osteoradionecrosis, while phossy jaw was inevitably complicated by bacterial infection. Radiographic changes associated with bisphosphonate-related osteonecrosis of the jaws are generally only seen once there is a significant bone involvement.[7] Early on, the condition may not be radiographically detectable or may appear as subtle periodontal ligament widening equal to the findings in periodontal disease. Advanced cases show a moth-eaten, poorly defined radiolucency, with or without radio-opaque sequestra. Zarychanski et al. reported worsening in symptoms by surgical debridement and attempts at wound closure in all cases.[8] On the basis of such results, surgical debridement has been actively discouraged. Surgical intervention is fraught with difficulty since finding viable bone margins is impossible given the global effect bisphosphonates have on the skeleton. Where aggressive osseous surgery has been performed, the development of an enlarged necrotic area has occurred.[9] Equally ineffective is the use of tissue flaps to cover painful exposed bone. In these situations, fistulae tend to develop around the flap edges, with complete dehiscence a secondary complication.[10]

After review of literature, it is concluded that conservative approach is best in treating bisphosphonate-related osteonecrosis of jaw; therefore, the decision was to treat patient conservatively. Patient reported relief of symptom which was main concern after following this regimen.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Mandich P, Cavalli P, Pasini B. Cancer genetic counselling. Ann Oncol 2005;16:171.  Back to cited text no. 1
[PUBMED]    
2.
Marx RE, Sawatari Y, Fortin M, Broumand V. Bisphosphonate-induced exposed bone (osteonecrosis/osteopetrosis) of the jaws: Risk factors, recognition, prevention, and treatment. J Oral Maxillofac Surg 2005;63:1567-75.  Back to cited text no. 2
[PUBMED]    
3.
Fleisch H. Bisphosphonates: Mechanisms of action. Endocr Rev 1998;19:80-100.  Back to cited text no. 3
[PUBMED]    
4.
American Dental Association Council on Scientific Affairs. Dental management of patients receiving oral bisphosphonate therapy: Expert panel recommendations. J Am Dent Assoc 2006;137:1144-50.  Back to cited text no. 4
[PUBMED]    
5.
Marx RE. Pamidronate (Aredia) and zoledronate (Zometa) induced avascular necrosis of the jaws: A growing epidemic. J Oral Maxillofac Surg 2003;61:1115-7.  Back to cited text no. 5
[PUBMED]    
6.
Ruggiero SL, Mehrotra B, Rosenberg TJ, Engroff SL. Osteonecrosis of the jaws associated with the use of bisphosphonates: A review of 63 cases. J Oral Maxillofac Surg 2004;62:527-34.  Back to cited text no. 6
[PUBMED]    
7.
Hellstein JW, Marek CL. Bisphosphonate osteochemonecrosis (bis-phossy jaw): Is this phossy jaw of the 21st century? J Oral Maxillofac Surg 2005;63:682-9.  Back to cited text no. 7
[PUBMED]    
8.
Zarychanski R, Elphee E, Embil J et al. Osteonecrosis of the Jaw Associated with Pamidronate Therapy. Blood 2004;104:4908.  Back to cited text no. 8
    
9.
Migliorati CA, Casiglia J, Epstein J, Jacobsen PL, Siegel MA, Woo SB. Managing the care of patients with bisphosphonate-associated osteonecrosis: An American Academy of Oral Medicine position paper. J Am Dent Assoc 2005;136:1658-68.  Back to cited text no. 9
[PUBMED]    
10.
Carter G, Goss AN, Doecke C. Bisphosphonates and avascular necrosis of the jaw: A possible association. Med J Aust 2005;182:413-5.  Back to cited text no. 10
[PUBMED]    


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  [Figure 1], [Figure 2], [Figure 3]



 

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