Diagnosis and Treatment of the BRONJ Case

Click to enlarge

Revisit the Case Presentation and Clinical Evaluation

This case is presented by: 

• Dr. Eric T. Stoopler, D.M.D., FDS RCSEd, FDS RCSEng
• Dr. Juan M. Bugueno, D.D.S.
• Dr. Kevin Sweeney, D.D.S.
• Dr. David C. Stanton, D.M.D., M.D., F.A.C.S 

We would like to thank all our dentists who submitted their responses to the diagnosis and treatment challenge.

Case Diagnosis

The Clinical diagnosis was bisphosphonate-related osteonecrosis of the maxilla.

Treatment

• The patient’s oncologist discontinued the ZA therapy.
• The patient was evaluated by an oral and maxillofacial surgeon who recommended surgical debridement of the affected areas and the patient underwent the procedure five months after cessation of ZA therapy.
• A subperiosteal dissection was completed through a modified Lefort I incision to expose the bone of the anterior maxilla. Extensive necrotic bone was found along the anterior maxilla, involving the nasal floor and piriform rim (Fig 4).

Fig 4. Intra-operative view of extensive maxillary
necrosis

• The nasal mucosa was separated from the necrotic bone without perforation and a 6cm segment of the anterior maxilla, including retained implants, was removed in its entirety (Fig 5).

Fig 5. Resected bone from anterior maxilla

• Following the debridement of all the necrotic bone, the mucosa of the nasal floor bilaterally was clearly visualized and ~ 2 cm2 diameter communications were noted into the maxillary sinuses bilaterally (Fig 6). 

Fig 6. Bilateral communications with the maxillary sinuses

• Large inflammatory polyps and infectious mucosa were noted within the maxillary sinuses and removed with a sinus curette. 
• Bilateral pedicled buccal fat pad flaps were developed and utilized to provide an initial layer of closure over the sinus communications. 
• The labial and buccal mucosa was undermined widely to develop a large advancement flap to allow tension-free, watertight closure. 
• The patient’s final tissue cultures grew anaerobic gram negative rods and few anaerobic gram positive rods (speciation not performed). Fungal, mycobacterial, and acid fast bacilli cultures were negative. 
• The bone pathology specimen revealed necrotic bone with acute and chronic inflammation with cell debris, bacteria and actinomyces. 
• The histopathologic examination of the sinus contents revealed fragments of necrotic bone and sinonasal mucosa with acute and chronic inflammation without evidence of carcinoma.
• The patient completed a four week course of oral levofloxacin and metronidazole, followed by a four week course of penicillin.
• Two months post-operatively, the patient was noted to have persistent bilateral oral-nasal communications. Under local anesthesia, another flap closure was performed, but a small oral-nasal communication persisted and an obturator was fabricated to restore function.
• The patient’s infection resolved (Fig 7) and she resumed chemotherapy for her metastatic disease. One year later, she developed bisphosphonate-related osteonecrosis in her left maxilla and mandible and is currently being monitored by an oral and maxillofacial surgeon.

Fig 7. Maxillary arch two months status-post surgical procedures

Additional Resources

American Association of Oral and Maxillofacial Surgeons’ Position Paper: Medication-Related Osteonecrosis of the Jaw—2014 Update (PDF)

What some dentists are saying about this case…

Bisphosponate-associated osseous necrosis IV bisphosphonates have a higher incidence of osseous necrosis, and in a medically compromised individual also showing evidence of significant alveolar bone loss in the remaining mandibular teeth, this likely indicates past or present history of chronic periodontitis and their associated pathogens. Management would likely involve resection of the compromised necrotic maxillary bone and likely the four dental implants. There may be some benefit to the use of hyperbaric oxygen for healing.

Bisphosphonate-related osteonecrosis of the maxillae. I do not think that it is appropriate to blame the placement of implants since the extractions probably would have been a greater risk factor in the development of BRONJ. There are reports of successful immediate implant placement in patients who have had systemic bisphosphonates. J Periodontol. 2010 Apr;81(4):479-84. doi: 10.1902/jop.2009.090587.

I obviously don’t know the circumstances of why the dentist chose to do an implant supported CUD as opposed to a standard CUD, but with a patient having had IV bisphosphonates (known to be a contraindication for implant placement), I’m thinking he regrets his decision…

Likely osteochemonecrosis as a result of bone exposure after having been treated with Zometa (za) a high potency bisphosphonate. How do I know? I wrote an article during my perio graduate studies and have recently been involved in a case between a patient and Novartis pharmacy in the USA regarding a patient treated almost 10 years ago who recently died (his family sued the drug company). He had multiple myeloma and Zometa and Aridia were used to reduce metastasis of the cancer.

The zoledronic acid in endovenous subministration often give this side effect when extractions and oral surgeries are close. Not to exclude a metastatic lactation of breast adenocarcinoma

This appears to be an unfortunate case of osteonecrosis related to high dosages of bisphosphanse intraoral venous ZA. Had a similar case last December, a 78-year old on oral bisphosphanse treating osteoporosis. She had abnormally large mandibular tori. The tissue covering them was very thin and stripped off from trauma during mastication. The exposed yellowish bone refuses to heal over, even after a tori reduction. Very frustrating but at least she is asymptomatic, has no discomfort.

I suspect there are multiple factors involved in this case that would need addressing, with the medical history being a complicating factor. I presume from the extractions that sharp spikes were left that helped to prevent soft tissue coverage (have seen it before in non-medically compromised patients).

If I see correctly, there is a perforation of the implant in the 1.4 area, exposed threading on a couple implants. 

I suspect artificial bone was placed around the implants to fill in voids and it did not take in all areas, leaving sharper bits of bone.

As a result of all of the above, soft tissue retracted from site rather than healing over, resulting in the exposed bone and chronic inflammation.

In order to treat, I would further research her past medical treatment for potential assistance with tissue management techniques to ensure healing. Provided nothing out of the ordinary, I would look at likely removing the implants, smoothing down all the bone to remove necrotic tissue and providing a more ideal surface for the tissue to adhere to and work towards primary closure if possible. And when I say “I”, I would actually be referring this patient to a specialist, as this is more extensive than cases I have treated with similar issues (2-3 socket sites is very different than a full arch). Very unfortunate turnout overall and would love to hear other people’s ideas, especially on the cause from sources other than “operator error”.

Almost certainly this is osteonecrosis of the jaw (ONJ).

The question is how to treat it…

Resection of the dead bone is likely the only option and the use of doxycycline with a fluorescent light during surgery (e.g. Velscope) to identify live and dead bone during surgical resection. Primary closure of a flap after resection is important. Recurrence is handled in the same way until it ‘burns’ out…

Zoledronic acid is in a class of medications called bisphosphonates. This 64-year-old Caucasian female patient has Bisphosphonate-associated osteonecrosis of the jaw. However, this patient also has “moth-eaten” appearance to the maxillary alveolar ridge which is typical of metastatic cancer.

Osteonecrosis, resulting from cancer and bisphosphonates… almost always cancer is involved. Meanwhile, I’m almost shocked at the number of patients who advise me at their recall appointment, that they’ve started taking these medications. Bisphosphonates are a new therapy. It can take many years before the varieties and dosages are perfected. There’s lots we don’t know. Necrosis of bone in people on a therapy that’s supposed to be good for bone density?  Pretty scary, if you ask me.

• What Am I supposed to do with this new factor?
• How does this alter my “expert” oral health advice?
• What can I tell my patients?
• How do I answer: “My M.D. told me to tell you that I’m taking…..

Would love some info/direction here!