A dentist initiated (December 2012) systemic antibiotherapy (AB) (amoxicillin, 1.5 g/day) and antibacterial mouth rinse with no impact on the symptoms. The patient was referred to us (April 2013).

Clinical examination revealed oral lesions with bone exposure. CT of the right mandible showed an extensive osteolysis, with a sequestrum in the medullary cavity, surrounded by a periosteal thickening, highly suggestive of an osteonecrosis of the jaw (ONJ), subsequent to a mandibular osteomyelitis (Fig. 1). Fig. 1 CT scan of the right mandible revealing JQEZ5 chemical structure osteonecrosis. a Sequestrum in the medullary cavity (white arrow) and b extensive osteolysis of the right mandible (white arrow) RG7420 datasheet Concomitant malignant tumor was excluded. Treatment included AB coverage, removal of necrotic bone, and treatment with a bone anabolic agent (teriparatide, 20 g/day subcutaneously) with the maintenance of a calcium and vitamin D daily supplementation. ONJ is a clinical condition that presents as exposed bone in the mandible, maxilla, or both, that persists for at least 8 weeks, in the absence of previous radiation and of metastases in the jaw. Whereas no epidemiologic

data on the incidence of ONJ in the general population are available, a positive relationship was described between ONJ occurrence and the use of inhibitors of bone resorption (mainly BP) in patients with multiple myeloma, EVP4593 price metastatic breast cancer, Paget’s disease, osteoporosis, or other skeletal disorders [11]. Several pathogenic mechanisms have been proposed. One of them suggests that ONJ can be caused by BP-induced low-bone turnover, which leads to decreased blood flow and bone cell necrosis and apoptosis. In conjunction with chronic oral or dental infection, this leads to the development of exposed, nonhealing bone areas in the mouth [12]. The use of inhibitors of bone resorption prevents

bone remodeling to ensure the replacement of defective bone with an equivalent volume of healthy bone [13]. DMab was previously related to the development of ONJ, during treatment for sacral giant cell tumor [14], metastatic bone disease [15], and prostatic adenocarcinoma [16, 17], the doses of DMab used in metastatic bone diseases being 12 times greater than almost in the management of OP. A recent meta-analysis assessing a total of 8,963 patients of both genders, with a variety of solid tumors, from seven studies (i.e., the majority of these patients had either prostate or breast cancer) revealed an overall incidence of ONJ in cancer patients receiving DMab of 1.7 % (95 % Cl, 0.9–3.1 %). This study concluded that, in such patients, the use of DMab is associated with an increased risk of developing ONJ when compared with BP treatment or placebo, although the increased risk was not statistically significant between DMab and BP treatments [18].