Alendronic acid
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Osteonecrosis of jaw: case report A 75-year-old woman developed bisphosphonate-related osteonecrosis of jaw (BRONJ) following treatment with alendronic-acid [indication not stated]. The woman presented to the undergraduate periodontology clinic for periodontal evaluation. She mentioned that two dental implants had been placed in the right side of her upper jaw approximately one and a half years ago by a private practitioner. She also reported that over the last few months she had been experiencing soreness in the gums around the implants. She had been receiving oral alendronic-acid [Fosamax] 70mg every week for over 10 years. She had been also taking atorvastatin [Lipitor], valsartan [Diovan], calcium, aspirin, vitamin-D and vitamin E. Her medical history was significant for penicillin allergy. On examination, probing depths around natural teeth were within normal limits. However, those around dental implants in areas of teeth 16 and 17 were 7 to 8mm. Intraoral periapical radiographs showed horizontal bone loss around both the implants. The percentage of sites that showed bleeding on probing was 6 % and her plaque score was 10%. She reported brushing twice a day and flossing daily. She received oral prophylaxis in the undergraduate clinic and the implants were instrumented with plastic curettes. She was also prescribed clindamycin for 7 days. She was re-evaluated 4 weeks later with no improvement in the area of dental implants. She was suggested to undergo further therapy at the graduate periodontology clinic. She presented to the graduate periodontology clinic a few months later due to pain and bleeding associated with the dental implants. She also reported bleeding from the nose on the right side. These nasal pathologic findings were a consequence of her implant related BRONJ. Examination revealed probing depths of 8–10mm around the implants with suppuration. The implant at number 2 was felt to be mobile. A periapical radiograph revealed further bone loss around the implants. A periapical radiolucency was noted in relation to the implant at 16. Also, a horizontal radiolucent area was noted extending between the two implants a few millimeters apical to the crestal bone. Widening of the periodontal ligament space was noted on tooth 15. Based on these findings, she was diagnosed with BRONJ. It was decided to remove the implants due to the severity of bone loss. Since she had been receiving alendronic-acid for a prolonged period of time, she was referred for evaluation of C-terminal cross-linking telopeptide (CTX) values. Her CTX value was 86 pg/mL (values
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