Are ministerial recommendations sufficient to avoid bisphosphonate related osteonecrosis of the jaw? A case report

Bisphosphonate related osteonecrosis of the jaw (BRONJ) can occur in patients affected by malignancy associated hypercalcemia, bone metastases of solid tumors or multiple myeloma intaking amino-bisphosphonates or other bone resorption inhibitors. BRONJ occurs initially with alveolar bone radiographic alterations, with peripheral facial neurological symptoms and thereafter with bone exposition and necrosis.Drug related ONJ were also reported in oncologic patients intaking angiogenesis inhibitors or monoclonal antibodies that inhibit bone resorption (e.g. Denosumab).In the present case report, Denosumab has been administered to treat bone lesions related to invasive ductal breast cancer.Before starting therapy with Denosumab, in order to restore oral and periodontal health, dental extractions were performed without any modifications to surgical protocols and waiting the complete healing of extraction sites (6 weeks).Even if ministerial recommendations were followed, even if we waited the biologic healing and even if denosumab therapy started without symptoms, BRONJ occurred in this patient.The mistake made in the management of the present case is that we did not carefully evaluated early radiological signs (alveolar crest thickening, bone sclerosis, persistent alveolar post-extraction socket, periodontal space widening, formation of bone sequestrum) that could bring the clinician to the diagnostic suspect of BRONJ before the onset of clinical signs (fistula, and bone exposure).Identifying early radiological signs could bring the clinician to an early diagnosis and consequently a better prognosis.