Successful Treatment of BRONJ in the Palatal Torus with Teriparatide

Introduction: It was first reported by Marx in 2003, an effective treatment for bisphosphonate-associated osteonecrosis of the jaw (BRONJ) has yet to be established. However, in recent years, favorable outcomes have been reported with the administration of teriparatide acetate (teriparatide), a parathyroid hormone (PTH) preparation. The present paper reports and discusses a case of successful teriparatide treatment of stage 2 BRONJ in the palatal torus.

Case report: The patient was a 78-year-old woman with a previous history of osteoporosis, diabetes mellitus, hypertension, colorectal cancer (postoperative), pancreatic cancer (postoperative) and lumbar compression fracture. The patient’s osteoporosis was treated with risedronate sodium hydrate from 2005 to 2012. At the end of August 2012, while eating, she suffered thermal burns and soon after noticed apthous stomatitis on the palatal torus, and on November 7, 2012, she visited our department for further testing because her symptoms had not resolved. Intraoral findings on initial examination comprised ulceration on the palatal torus with exposed bone and swelling, erythema, and purulent discharge of the surrounding mucosa. Plain radiography, computed tomography (CT), and histopathological examination confirmed a diagnosis of BRONJ. Sequestrectomy and resection of the palatal torus were considered, but she refused, and a 72-week course of weekly single-dose (56.5 mg) teriparatide injection administered by her regular orthopedist was initiated on March 8, 2013. After 4 weeks, the sequestrum had spontaneously detached, and mucosal covering was observed. After 42 weeks, ossification was observed on CT. Follow-up is ongoing.

Conclusion: PTH preparations stimulate proliferation and differentiation of osteoblast progenitor cells and promote osteoclast formation and activation. In the present patient, intermittent administration of teriparatide promoted ossification, suggesting the utility of teriparatide for accelerated healing in cases of BRONJ.