Exposed bone after extraction in a patient on bisphosphonates

§Chief complaint

Socket not healed 3 months after a tooth extraction; bad taste

§Medical & dental history

• 01Osteoporosis on oral alendronate for 7 years
• 02No radiotherapy to the head and neck
• 0337 extracted 12 weeks ago by her dentist

§Clinical examination

• 01Exposed yellowish necrotic bone 10 mm in the 37 socket
• 02Mild surrounding redness, small amount of pus; pain controlled with paracetamol
• 03No lip numbness or skin fistula

§Figures

§Differential diagnosis

§Final diagnosis

MRONJ stage 2 of the left mandible related to oral bisphosphonate

Exposed bone for more than 8 weeks in a patient taking an antiresorptive drug, with no jaw radiotherapy, meets the definition; infection and pain make it stage 2.

§Investigations

• 01OPG and CBCT
• 02Discussion with the prescribing doctor about the drug

§Radiology

• 01CBCT — sclerotic bone with a small sequestrum in the socket; no fracture

§Treatment plan

• 01Chlorhexidine rinses and antibiotics for the infection
• 02Removal of loose sequestrum and smoothing of sharp bone edges
• 03Surgical resection if the disease progresses

§Surgical procedure

• 01Loose sequestrum removed under local anaesthesia; sharp bone smoothed; mucosa closed over healthy bleeding bone

§Histopathology report

Necrotic bone with empty lacunae and bacterial colonies including Actinomyces-like organisms. No malignancy.

§Follow-up & outcome

• 01Month 1 — less pain, no pus
• 02Month 4 — mucosa fully healed

Outcome: Complete mucosal healing after conservative surgery.

§Discussion

• 01Risk is much higher with intravenous drugs used for cancer than with oral osteoporosis treatment.
• 02Prevention matters most: dental check-up before starting the drug and gentle technique if teeth must be removed.

§Clinical pearls / learning points

• 01Always ask about osteoporosis and cancer drugs before extracting teeth.

§Viva questions

§MCQs

§Related diseases

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