Late‐onset medication‐related osteonecrosis of the jaw 11 years after IV bisphosphonates following implant placement

BACKGROUND: Medication-related osteonecrosis of the jaw (MRONJ) is a recognized complication of intravenous (IV) bisphosphonate therapy, particularly following invasive dental procedures such as extractions or implant placement. Although the risk of MRONJ decreases after discontinuation of therapy, prolonged skeletal retention of bisphosphonates necessitates careful long-term evaluation and surgical planning. METHODS: An American Society of Anesthesiologists (ASA) (II 72-year-old male with history of high-dose IV pamidronate therapy for multiple myeloma (last dose 11 years prior) presented for implant placement at tooth #18. Clinical and radiographic examination revealed a vertical root fracture with associated periapical pathology. The tooth was extracted, and ridge preservation was performed. Three and half months later, implant placement followed with the use of preoperative antibiotic prophylaxis. RESULTS: Five months post-implant placement, the patient developed a lesion on the lingual vestibular aspect of site #18, characterized by purulence, bleeding, and exposed necrotic bone measuring approximately 10 × 2 mm, without radiographic appearance. Histopathologic evaluation confirmed MRONJ. The lesion was treated with conservative surgical debridement, followed by 0.12% chlorhexidine gluconate rinses twice daily for 2 weeks. Healing was allowed by secondary intention without sutures, and postoperative systemic antibiotic therapy was prescribed. Follow-up examinations at 2 and 4 weeks demonstrated complete clinical healing, with no recurrence observed at 6 months. CONCLUSIONS: The risk of MRONJ may persist for more than 11 years after cessation of high-dose IV bisphosphonate therapy. The development of MRONJ, despite a C-terminal telopeptide (CTX) value traditionally considered favorable, underscores the limited predictive utility of CTX testing. Accordingly, management decisions should be guided by comprehensive clinical assessment and interdisciplinary communication rather than reliance on biochemical markers alone. KEY POINTS/HIGHLIGHTS: Why is this case new information This case reports stage 2 medication-related osteonecrosis of the jaw (MRONJ) occurring 11 years after high-dose intravenous (IV) pamidronate cessation following extraction, ridge preservation, and implant placement, illustrating very late-onset disease that can arise adjacent to the surgical site, highlighting the limitations of serum C-terminal telopeptide testing, and emphasizing the need for long-term clinical vigilance and cautious surgical planning in patients with a remote history of bisphosphonate therapy. What are the keys to successful management of this case? Successful management relied on thorough risk assessment, informed consent, atraumatic surgery with antibiotic prophylaxis, early detection and conservative stage 2 MRONJ treatment, histopathologic confirmation, healing by secondary intention with antiseptics and short-term antibiotics, and coordinated interdisciplinary care. What are the primary limitations to the success of this case? Limitations stem from the patient's history of high-dose IV bisphosphonate therapy, the unpredictable long-term risk of MRONJ, the lack of reliable biomarkers or imaging for risk prediction, multifactorial pathogenesis including local and systemic factors, and the potential for late recurrence despite initial successful management. PLAIN LANGUAGE SUMMARY: This report describes a patient who developed a rare complication of long-term bisphosphonate therapy, a medication commonly used to treat bone diseases such as multiple myeloma. Eleven years after receiving high-dose intravenous bisphosphonates, the patient underwent tooth extraction and dental implant placement, initially healing without problems. Several months later, a small area of exposed, infected bone appeared near the implant, which was diagnosed as medication-related osteonecrosis of the jaw (MRONJ). The condition was successfully treated with careful surgical cleaning, local antiseptic rinses, short-term antibiotics, and close monitoring, without the need to remove the implant. This case is important because it shows that MRONJ can occur more than a decade after stopping bisphosphonate therapy, even when routine blood tests suggest low risk. It also demonstrates that the disease can appear near, rather than exactly at, the surgical site. The report emphasizes the need for thorough risk assessment, careful surgical planning, prompt recognition of complications, and collaboration among dental and medical specialists. Overall, it highlights that patients with a remote history of high-dose bisphosphonates require long-term vigilance and individualized care when undergoing dental procedures.