Teriparatide Therapy for Bisphosphonate-Associated Osteonecrosis of the Jaw in an Elderly Japanese Woman with Severe Osteoporosis

Abstract

We report on the case of a severely osteoporotic elderly Japanese woman with bisphosphonate-associated osteonecrosis of the jaw (ONJ), who was treated successfully with teriparatide. A 79-year-old woman with severe osteoporosis and bisphosphonate-associated ONJ was treated with teriparatide after debridement of the necrotic tissue in the jaw bone. Computed tomography (CT) images revealed the bone defect in the mandible after debridement of the necrotic tissue associated with ONJ. According to the attending dentist, the ONJ healed after 2 months of therapy. After 3 months of treatment, a robust increase in the serum level of the bone formation marker, serum intact procollagen type 1 N-terminal propeptide, was noted and a repeat CT revealed improvement of the bone defect of the mandible. These results suggest the beneficial effects of teriparatide therapy in the severely osteoporotic elderly woman with ONJ.

Diagnosis and Management of Osteonecrosis of the Jaw: A Systematic Review and International Consensus

“…Considering the low risk of ONJ in patients with osteoporosis being treated with osteoporosis doses of antiresorptive agents and the absence of evidence that changing to teriparatide would alter the outcome of an invasive dental procedure in someone who does not have ONJ, it is not recommended at this time to switch to teriparatide in those at a low risk of ONJ or fracture. However, in an osteoporotic patient with established ONJ, treatment with teriparatide may be of value as observed in published case reports …”

Strontium ranelate improves delayed healing of osteolytic lesions of the jaw in a man with chronic osteomyelitis. Case report

“…When SAPHO syndrome is suspected, notably in cases of sclerosing osteomyelitis, bisphosphonates as well as corticosteroids have been rarely reported as additional therapy (20). It is also well known that teriparatide has been used in several cases of bisphosphonate-related osteonecrosis of the jaw with positive results (18,19). In the case of our patient, while SAPHO syndrome was also suspected, the precipitating event of a dental procedure that was complicated with infection seemed to provide the most plausible explanation for his condition.…”

“…The patient was then referred to the Bone Metabolic Unit for consultation in order to exclude the co-existence of a bone metabolic disorder, as well as with the question of locally compromised bone strength and possible susceptibility To optimize levels of vitamin D, although clearly they were not indicative of osteomalacia, the patient was prescribed cholecalciferol 800 IU per day along with 1000 mg of Calcium. A bone agent used in the osteoporosis field was then considered in order to promote bone healing; clinical relevant data at the time were not existent with the exception of few case-reports of bisphosponate-related osteonecrosis of the jaw treated with teriparatide (18,19). Since off-label therapy with teriparatide was expensive and would not be re-embursed by the patient's social security, we proposed off-label therapy with Strontium Ranelate, with the hypothesis that SrRan would decrease osteoclastic activity at the site of the lesions as well as possibly enhance osteoblastogenesis locally.…”

Management of bisphosphonate‐related osteonecrosis of the jaw: a literature review

“…Accordingly, another case of successful teriparatide treatment was reported in an 88‐year‐old BRONJ patient (Cheung and Seeman, ). Progressive bone regeneration of the osteonecrotic lesion, oral mucosa healing, and elimination of pain were described in a 78‐year‐old osteoporotic woman with BRONJ after teriparatide therapy (Lee et al , ), while a similar successful response to teriparatide was revealed by the improvement of bone defects in CT of the mandible and the increase in the serum P1NP in an elderly osteoporotic woman with jaw osteonecrosis (Iwamoto et al , ). In six BRONJ patients, short‐term teriparatide therapy was administered from 1 to 3 months depending on the clinical condition of each patient (Kwon et al , ).…”