A Case of Osteonecrosis of the Jaw in a Patient with Crohn's Disease Treated with Infliximab

Abstract

Patient: Female, 49

Final Diagnosis: Medication related osteonecrosis of the jaw

Symptoms: Painful bone exposure • pus discharge

Medication: Infliximab

Clinical Procedure: Surgical removal of necrotic bone

Specialty: Surgery

Objective:: Unusual clinical course

Background:: Medication-related osteonecrosis of the jaw (MRONJ) is a severe adverse drug reaction, occurring in patients undergoing treatments with antiresorptive or antiangiogenic agents, such as bisphosphonates, denosumab, or bevacizumab, for different oncologic and non-oncologic diseases. The aim of this study was to report a case of MRONJ in a patient taking infliximab, an anti-TNF-α antibody used to treat Crohn’s disease, rheumatoid arthritis, ulcerative colitis, ankylosing spondylitis, psoriatic arthritis, and plaque psoriasis.

Case Report:: A 49-year-old female patient affected by Crohn’s disease, who had been undergoing 250 mg intravenous infliximab every six weeks for 12 years, with no history of antiresorptive or antiangiogenic agent administration, came to our attention for post-surgical MRONJ, associated with a wide cutaneous necrotic area of her anterior mandible. Following antibiotic cycles, the patient underwent surgical treatment with wide bone resection and debridement of necrotic tissues; after prolonged follow-up (16 months), the patient completely healed without signs of recurrence.

Conclusions:: Prevention of MRONJ by dental check-up before and during treatments with antiresorptive treatments (bisphosphonates or denosumab) is a well-established procedure. Although further studies are required to confirm the role of infliximab in MRONJ, based on the results of this study, we propose that patients who are going to be treated with infliximab should also undergo dental check-up before starting therapy, to possibly avoid MRONJ onset.

Keywords: Bisphosphonate-Associated Osteonecrosis of the Jaw; Bone Density Conservation Agents; Crohn Disease.

Figure 1.

Patient’s clinical features. Wide cutaneous necrotic area (A) with bone exposure and pus discharge, and (B) intraoral necrotic bone exposure on the anterior mandible in a female patient affected by Crohn’s disease, undergoing infliximab therapy. This shows the area were the teeth extractions was performed. The lesion was classified as stage 3 medication-related osteonecrosis of the jaw according to the American Association of Oral and Maxillofacial Surgeons staging system [1].

Figure 2.

Radiological exams, orthopantomography (A) and enhanced multi-slice spiral computed tomography (B) showed severe bone loss and resorption of the anterior mandible, in the region of bone exposure.

Figure 3.

Surgical treatment. Surgical removal of the necrotic alveolar process (A); a iodoform gauze was put into the external infected wound after debridement of the cutaneous necrotic area (B).

Figure 4.

Intra- and extra-oral wound healing. Rehabilitation with a removable prosthesis was chosen to guarantee function and aesthetics (A). Clinical (B) and radiological (C) healing of surgical wound after 12-month follow-up are shown.