The n e w e ng l a n d j o u r na l of m e dic i n e

Images in Clinical Medicine

Stephanie V. Sherman, M.D., Editor

Medication-Related Osteonecrosis of the Jaw

Yu-Feng Chen, D.D.S., M.D.S.

Kaohsiung Medical University Hospital
Kaohsiung, Taiwan

Hong-Po Chang, D.M.D., Ph.D.

Kaohsiung Medical University
Kaohsiung, Taiwan
chang610004@gmail.com

This article was published on May 20,

2023, at NEJM.org.

A
54-year-old woman with metastatic breast cancer presented to the oral surgery clinic
with a 4-month history of right jaw pain. For the past 10 months, she had been receiving denosumab at a dose
of 120 mg every 4 weeks to prevent complications related to bony metastases. Physical examination was notable
for swelling over the right jaw from an oral cutaneous fistula that connected to the mandible (Panel A). An area of
exposed, necrotic bone was seen inside the mouth in an edentulous region of the right mandible (Panel B). She had
several missing teeth and periodontitis. A panoramic radiograph showed an ill-defined radiolucent border with seques-
trum over the right mandible (asterisk, Panel C). A diagnosis of medication-related osteonecrosis of the jaw complicated
by secondary infection with extraoral fistula formation was made. Medication-related osteonecrosis of the jaw is an
uncommon but severe complication of treatment with osteoclast inhibitors, such as denosumab and bisphosphonates.
Risk factors include oral surgery, poor oral hygiene, and dental disease. It does not commonly occur with the use of
antiresorptive medications at lower doses for conditions such as osteoporosis. The patient underwent surgical débride-
ment and sequestrectomy, during which time treatment with denosumab was discontinued, and antimicrobials and oral
rinses were administered. Denosumab therapy was resumed, and at the 1-year follow-up, her symptoms had resolved.
DOI: 10.1056/NEJMicm2209172
Copyright © 2023 Massachusetts Medical Society.

n engl j med 388;21 nejm.org May 25, 2023 e69

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