PMC4819088_01
Orthopantomography (OPT) performed on 2009 (a), on May, 2010 (b), on September, 2010 (c), on May, 2011 (d), on August, 2011 (e), and on August, 2014 (f). The last one revealed osteosclerosis, osteolysis, and subperiosteal bone deposition and persistence of extraction socket.
CRID2016-2856926.001.jpg
PMC4819088_01_CRID2016-2856926.001.jpg
fig1
An orthopantomography (OPT) performed on 2009, before starting treatment with Humira, did not show bone alterations (Figure 1(a)). On May, 2010, two titanium fixtures were positioned in the maxilla (1.5 and 2.5) (Figure 1(b)) and, on September-October, 2010, four titanium fixtures were put in the mandible by her dentist (3.6, 3.7, 4.6, and 4.7) (Figure 1(c)). On May, 2011, the fixture positioned in the region of 3.6 was lost too (Figure 1(d)), and, moreover, one month later, after appearance of pain in the right mandible, the fixture in the region of 4.7 was removed (Figure 1(e)). Patient referred persistence of pain, partially resolved after systemic antibiotic therapy (amoxicillin + clavulanic acid 1 gr twice a day) (Figure 1(e)). Orthopantomography revealed osteosclerosis, osteolysis, and subperiosteal bone deposition and persistence of extraction socket (Figure 1(f)).
CT Dentascan scan performed on July, 2011, showing sequestrum.
CRID2016-2856926.002.jpg
PMC4819088_01_CRID2016-2856926.002.jpg
fig2
A CT scan was performed (Figure 2); because of difficult healing, patient underwent curettage medications with local antibiotics (Rifocin) for about 2-3 months.
Static whole body bone scintigraphy performed on October, 2013, revealed an intensive trace uptake at the right mandible.
CRID2016-2856926.003.jpg
PMC4819088_01_CRID2016-2856926.003.jpg
fig3
A static whole body bone scintigraphy revealed an intensive trace uptake at the right mandible (Figure 3).
Schematic view of disease progression.
CRID2016-2856926.004.jpg
PMC4819088_01_CRID2016-2856926.004.jpg
fig4
Nevertheless, the patient came to our attention on August 2014 referring recurrence of pain; on the basis of clinical history (Figure 4) and radiological imaging, such as CT scan showing sequestrum, diagnosis of MRONJ with nonexposed necrotic bone was suspected (Figure 5).
Postoperative control in 2015 showing the healing of the mucosa after extraction of tooth 4.5 and curettage of the bone.
CRID2016-2856926.005.jpg
PMC4819088_01_CRID2016-2856926.005.jpg
fig5
Nevertheless, the patient came to our attention on August 2014 referring recurrence of pain; on the basis of clinical history (Figure 4) and radiological imaging, such as CT scan showing sequestrum, diagnosis of MRONJ with nonexposed necrotic bone was suspected (Figure 5).
CT scan performed on April, 2015. (a) Panorex view showing sequestrum, (b) axial view, and (c) 3D reconstruction.
CRID2016-2856926.006.jpg
PMC4819088_01_CRID2016-2856926.006.jpg
fig6
We considered the patient to be at Stage 0 (nonexposed bone variant) because she presented with no clinical evidence of necrotic bone but presented with nonspecific symptoms and clinical and radiographic findings (odontalgia not explained by an odontogenic cause and aching bone pain in the body of the mandible, loosening of teeth not explained by chronic periodontal disease, alveolar bone loss or resorption not attributable to chronic periodontal disease, changes to trabecular pattern dense woven bone, and persistence of unremodeled bone in extraction sockets and regions of osteosclerosis involving the alveolar bone and/or the surrounding basilar bone) (Figure 6).