Osteonecrosis of the Jaw in the Absence of Antiresorptive or Antiangiogenic Exposure: A Series of 6 Cases

Abstract

Purpose: Medication-related osteonecrosis of the jaws (MRONJ) is a well-described complication of antiresorptive and antiangiogenic medications. Although osteonecrosis can be associated with other inciting events and medications, such as trauma, infection, steroids, chemotherapy, and coagulation disorders, these are rarely reported in the literature.

Materials and methods: This is a six case series of MRONJ associated with medications other than antiresorptive or antiangiogenic drugs.

Results: Patient demographics, inciting event, location, stage, imaging findings, and outcome are reported.

Conclusion: With the continued development and clinical use of new biologic medications for diseases such as cancer and rheumatoid arthritis, it is important to continue to evaluate their effects on the oral cavity. The degree of risk for osteonecrosis in patients taking these new classes of drugs is uncertain but warrants awareness and monitoring.

FIGURE 1

A, Exposed buccal bone between the upper right second molar and upper right first molar. B, Exposed palatal bone of the upper first third molar with surrounding plaque and erythema (black arrows). C, Cone-beam computed tomogram displays serious bone loss (red arrow). D, Cone-beam computed tomogram shows sclerotic bone (yellow arrow) in the right posterior maxilla. E, Substantial improvement is seen, without exposed bone, after endodontic therapy performed on the upper right second molar and upper right first molar and the teeth are sectioned at the gingival level.

FIGURE 2

A, B, Exposed bone is visible on the buccal and alveolar crest of the upper right second premolar extraction site (black arrows). C, Cone-beam computed tomogram depicts bony sequestra (white arrow) and residual bone graft material. D, E, After sequestra exfoliation, the area has healed. F, Healed area but with a large bony defect.

FIGURE 3

Bone that can be probed through the gingiva is seen from the A, buccal and B, palatal views (black arrows). C, Cone-beam computed tomogram shows a large bony defect between the upper left first molar and upper left second molar (red arrow). D, Cone-beam computed tomogram shows sclerotic trabecular bone (yellow arrow). E, F, After 2 years, the exposed bone has progressed clinically (black arrows). G, H, Radiographically, there is maxillary sinusitis (blue arrow) and an increased bony defect (red arrow) with trabecular sclerosis (yellow arrow).

FIGURE 3

Bone that can be probed through the gingiva is seen from the A, buccal and B, palatal views (black arrows). C, Cone-beam computed tomogram shows a large bony defect between the upper left first molar and upper left second molar (red arrow). D, Cone-beam computed tomogram shows sclerotic trabecular bone (yellow arrow). E, F, After 2 years, the exposed bone has progressed clinically (black arrows). G, H, Radiographically, there is maxillary sinusitis (blue arrow) and an increased bony defect (red arrow) with trabecular sclerosis (yellow arrow).

FIGURE 3

Bone that can be probed through the gingiva is seen from the A, buccal and B, palatal views (black arrows). C, Cone-beam computed tomogram shows a large bony defect between the upper left first molar and upper left second molar (red arrow). D, Cone-beam computed tomogram shows sclerotic trabecular bone (yellow arrow). E, F, After 2 years, the exposed bone has progressed clinically (black arrows). G, H, Radiographically, there is maxillary sinusitis (blue arrow) and an increased bony defect (red arrow) with trabecular sclerosis (yellow arrow).

FIGURE 4

A, A small erythematous lesion where bone can be probed through the mucosa is seen on the left maxillary alveolar ridge (black arrow). B, Panoramic radiograph visualizes some possible bony sequestra (white arrow). C, D, Cone-beam computed tomograms clearly display the bony sequestra (white arrows). A large osteolytic lesion, trabecular sclerosis, and substantial thickening of the sinus membrane (blue arrows) also are visualized. E, After exfoliation of the bony sequestrum, the area appears healed, but a large bony defect remains.

FIGURE 5

A, An extraoral fistula (black arrow) is seen in the left submental area that represents sclerotic bone and a possible pathologic fracture. B, Cone-beam computed tomogram depicts the possible fracture (blue arrow). C, Extraction socket of the lower left second molar exhibits exposed bone (black arrow). D, E, Cone-beam computed tomograms also depict severe trabecular sclerosis (yellow arrow). F, After conservative therapy, the fistula has closed but has scarred. G, Exposed bone is still evident, but without signs of infection (black arrow).

FIGURE 5

A, An extraoral fistula (black arrow) is seen in the left submental area that represents sclerotic bone and a possible pathologic fracture. B, Cone-beam computed tomogram depicts the possible fracture (blue arrow). C, Extraction socket of the lower left second molar exhibits exposed bone (black arrow). D, E, Cone-beam computed tomograms also depict severe trabecular sclerosis (yellow arrow). F, After conservative therapy, the fistula has closed but has scarred. G, Exposed bone is still evident, but without signs of infection (black arrow).

FIGURE 5

A, An extraoral fistula (black arrow) is seen in the left submental area that represents sclerotic bone and a possible pathologic fracture. B, Cone-beam computed tomogram depicts the possible fracture (blue arrow). C, Extraction socket of the lower left second molar exhibits exposed bone (black arrow). D, E, Cone-beam computed tomograms also depict severe trabecular sclerosis (yellow arrow). F, After conservative therapy, the fistula has closed but has scarred. G, Exposed bone is still evident, but without signs of infection (black arrow).

FIGURE 6

A, B, Exposed bone is seen on the left buccal alveolar ridge. Cone-beam tomograms visualize bone sequestra from C, coronal, D, axial, and E, sagittal views (yellow arrows). F, Exfoliation of the sequestra and extraction of the root.