Osteonecrosis of the jaw in a patient with rheumatoid artritis treated with an oral aminobisphosphonate: a clinical case report

Abstract

SummaryOsteonecrosis of the jaw (ONJ) has been recently described after intravenous administration of amino-bisphosphonates and -less frequently -in association with the use of oral bisphosphonates. Bisphosphonate-Related Osteonecrosis of the Jaw (BRONJ) may affect mandible bone (65%), maxilla bone (26%) and rarely (9%) both sites simultaneously. Although causality may never be proven, emerging experimental data have established a strong association between monthly intravenous bisphosphonate administration and ONJ. Current level of evidence does not fully support a cause and effect relationship between the use of oral BPs and ONJ. In this paper, we report a clinical case of BRONJ in a 73 years old woman affected by rheumatoid arthritis (RA) and periodontitis, after three years of treatment with alendronate 70 mg one a week, plus daily calcium and vitamin D. The patient developed a tooth abscess at the lower jaw, accompanied by increased inflammatory markers, that never returned to normal range despite antibiotic therapy, inducing deterioration of joint synovium. The worsening of joint status after the onset of ONJ was reflected by the progressive increase in the number of swollen (SJ) and tender (TJ) joints, by the deterioration of the score DAS 28 (which passed from 5.46 to 7.07), pain (with VAS increasing from 60 to 90), and by a progressively impaired quality of life, as reported using the HAQ score (from 1,25 to 2,5). The patient was switched to antifracture therapy with strontium ranelate and the osteonecrosis was successfully treated with antibiotics, surgical curettage and local ultrasounds.

Periodontitis in rheumatoid arthritis patients, abundance and association with disease activity

“…3) Many patients with RA are treated by bisphosphonates (BP) for management of osteoporosis, and potentially they are prone to jaw necrosis even with oral BP ( 17 ) especially in presence of periodontitis ( 18 ),…”

Strontium ranelate treatment in a postmenopausal woman with osteonecrosis of the jaw after long-term oral bisphosphonate administration: a case report

“…They showed that SR has short-term stimulating effect on bone formation, and is associated with a long-term increase in BMD. Longato et al reported a case of BRONJ in a patient with rheumatoid arthritis 7. The patient was switched from BP to SR after the occurrence of BRONJ, but the effect of SR treatment was not reported.…”

“…Also, a 10-year clinical trial finds that SR reduces the risk of vertebral and non-vertebral fractures, and increases bone mineral density (BMD) 6. Yet, few reports detail surgical interventions followed by daily SR for osteoporosis patients suffering BRONJ 7. Here, we present the case of a postmenopausal woman with osteoporosis who suffered from ONJ related to long-term oral BP consumption.…”

“… 6 Yet, few reports detail surgical interventions followed by daily SR for osteoporosis patients suffering BRONJ. 7 Here, we present the case of a postmenopausal woman with osteoporosis who suffered from ONJ related to long-term oral BP consumption. We describe the treatment of BRONJ and report the findings from 3 years of follow-up visits after switching from BP therapy to SR treatment.…”

Osteonecrosis of the jaw associated with everolimus: A case report

“…Cancer patients have been reported to be at a higher risk for ONJ, with a prevalence of 1.5%. In Australia, an average prevalence of 1.15% was reported in cancer patients, reaching 7.8% in those undergoing dental work (11,12). In another study, patients with myeloma had a prevalence nearly double (55.9%) that of patients with BC (33.4%) or prostate cancer (4.6%), despite all three groups being treated for metastatic bone lesions with zoledronate or pamidronate by the same protocol (12).…”