Treatment of Osteonecrosis of the Jaw

The definition of bisphosphonate-related osteonecrosis of the jaw (BRONJ) was recently broadened and it is now known as medication-related osteonecrosis of the jaw (MRONJ). To date, the management of MRONJ is controversial. Conservative treatment is recommended, but it is difficult to successfully treat stage 3 MRONJ. Administration of teriparatide for the MRONJ treatment has only been documented in independent case reports and there are few reports on men with MRONJ treated with teriparatide. An 81-year-old man was referred in May 2014 for treatment of an unhealed tooth extraction wound in the mandible. He took minodronic acid hydrate (1 mg/d orally) for 2 years because of osteoporosis cure. On clinical examination, soft tissue swelling in the left mandibular first molar region extended to the inferior border of the mandible with extraoral fistula. Computed tomography (CT) revealed osteolysis extending to the inferior border resulting in pathologic fracture of mandibular bone. Based on these findings, a diagnosis of stage 3 MRONJ was made. We performed conservative treatment, including amoxicillin, but his symptoms did not improve. He was then treated with once-weekly subcutaneous injection of teriparatide. Although teriparatide injections were started without antibiotics, after 1 week, swelling, erythema, and purulent discharge from the extraoral fistula increased rapidly. Therefore, we combined the once-weekly teriparatide injection with amoxicillin administration. Three months later, the osteonecrosis had healed and CT showed significant bone regeneration and healing of the mandibular pathologic fracture. In addition, the mandibular fistula showed healing and the intraoral fistula was covered with normal mucosa.