Denosumab-associated osteonecrosis of the jaw; A case series and literature review

Introduction: Medication-related osteonecrosis of the jaw (MRONJ) is a severely debilitating condition of multifactorial pathogenesis. It primarily involves patients receiving intravenous bisphosphonates (BPs) and most recently the new antiresorptive drug, denosumab, for the treatment of skeletal-related malignancies. There is no curative treatment and no consensus exists regarding the clinical management of such patients. This review aims to share our current clinical experience at Sheffield Teaching Hospitals’ Trust and raise awareness of the increase in severity of ONJ in patients receiving denosumab. Patients and Methods: Four new cases with clinical diagnosis of MRONJ were presented to Sheffield Teaching Hospitals’ Trust. MRONJ was attributed to denosumab therapy, as all patients were treated solely with denosumab for skeletal-related malignancies. Results: All cases appear to have a more aggressive mode of ONJ compared to that seen with IV and/or oral BPs so far. The cause of MRONJ was observed in the presence of periodontal disease alone and following dental extractions. Progression of the disease occurred considerably faster with the development of widespread suppuration and tooth mobility within weeks. Imaging revealed rather extensive areas of bony destruction, sometimes with associated periosteal reaction in keeping with a chronic bony infection. Conclusion: It is imperative for all dental and medical teams involved in treating these patients to understand the side effects of RANKL inhibitors on bone metabolism and how it affects treatment. Helping patients to understand the chronicity and potential progression of the disease is essential to a satisfactory outcome.