A Case of Osteonecrosis of the Jaw in a Patient with Crohn’s Disease Treated with Infliximab

Abstract

Patient: Female, 49Final Diagnosis: Medication related osteonecrosis of the jawSymptoms: Painful bone exposure • pus dischargeMedication: InfliximabClinical Procedure: Surgical removal of necrotic boneSpecialty: SurgeryObjective:Unusual clinical courseBackground:Medication-related osteonecrosis of the jaw (MRONJ) is a severe adverse drug reaction, occurring in patients undergoing treatments with antiresorptive or antiangiogenic agents, such as bisphosphonates, denosumab, or bevacizumab, for different oncologic and non-oncologic diseases. The aim of this study was to report a case of MRONJ in a patient taking infliximab, an anti-TNF-α antibody used to treat Crohn’s disease, rheumatoid arthritis, ulcerative colitis, ankylosing spondylitis, psoriatic arthritis, and plaque psoriasis.Case Report:A 49-year-old female patient affected by Crohn’s disease, who had been undergoing 250 mg intravenous infliximab every six weeks for 12 years, with no history of antiresorptive or antiangiogenic agent administration, came to our attention for post-surgical MRONJ, associated with a wide cutaneous necrotic area of her anterior mandible. Following antibiotic cycles, the patient underwent surgical treatment with wide bone resection and debridement of necrotic tissues; after prolonged follow-up (16 months), the patient completely healed without signs of recurrence.Conclusions:Prevention of MRONJ by dental check-up before and during treatments with antiresorptive treatments (bisphosphonates or denosumab) is a well-established procedure. Although further studies are required to confirm the role of infliximab in MRONJ, based on the results of this study, we propose that patients who are going to be treated with infliximab should also undergo dental check-up before starting therapy, to possibly avoid MRONJ onset.

A Case of Intra-Oral Bone Exposure of the Hard Palate: A Clinical Diagnostic Dilemma

“…ONJ may be related to adalimumab and/or infliximab therapy, 2 anti TNF-α antibody used to treat Crohn's disease and other autoimmune diseases. Few authors reported a relationship between infliximab and/or adalimumab therapy and appearance of ONJ [2][3][4]. In this particular case the area of exposed bone didn't appear after a surgical odontostomatological procedure, but the patient showed a severe generalized periodontitis, a well known ONJ risk factor.…”

Osteonecrosis and osteomyelitis of the jaw associated with tumour necrosis factor-alpha (TNF-α) inhibitors: a systematic review

“…There were five case reports and one case series (Table 3). [29][30][31][32][33][34] Results were expressed as descriptive statistics because of the heterogeneity of the data.…”

“…43 The purpose of this systematic review was to analyse the current evidence and assess the associated risk of the development of ONJ or OM, or both, in patients treated with TNF-␣ inhibitors. [29][30][31][32][33][34] Our findings suggest that some who take these drugs will develop ONJ even if they do not have the conventional risk factors for MRONJ. Despite the low quality and high risk of bias in the studies, ONJ/OM resolved completely in five cases, and in some, TNF-␣ inhibitors were discontinued and then restarted after complete resolution.…”

“…No. of patients Ciantar 2007 29 Case report 1 Cassoni 2016 30 Case report 1 Tsuchiya 2016 31 Case report 1 Aghaloo 2017 32 Case study 1* Favia 2017 33 Case report 1 Cillo 2019 34 Case report 1 * 6 patients but only 1 fitted the criteria for this review.…”

Review and update on drugs related to the development of osteonecrosis of the jaw

“…The mechanism by which these drugs could increase the risk of ONJ has not yet been established. In the case of the anti-TNFα, their use could produce the inhibition of the bone remodeling at the cost of an inhibition of RANKL, with apoptosis induced by activated monocytes, or they could facilitate bone colonization by certain micro-organisms as a result of local immunosuppression (58)(59)(60)63). Table 4 lists the biologic immunomodulators for which cases of ONJ have been described, their brand name and the names of biosimilar products currently on the market.…”