Treatment of bisphosphonate related osteonecrosis following root canal therapy at the 1-year follow-up: report of two cases
A 64-year-old female patient was referred to the Yeditepe University, Faculty of Dentistry with a complaint of severe pain in the right mandible. Her medical history revealed that she was diagnosed with breast cancer 4 years previously, originating from the right breast. Her treatment consisted of nine sessions of chemotherapy, followed by intravenous (IV) zoledronic acid (Zometa®, Novartis, Surrey, UK) once a month for 4 years. The patient’s current medications included IV Zometa® and fulvestrant (Faslodex®, AstraZeneca, London, UK). During the clinical and radiographical examination, decayed dentine was detected distal to the crown of tooth #46 (). The bridge restoration using teeth #44 and #46 as abutments was removed. During removal of the carious dentine, pulp tissue was exposed. Rubber dam was applied following endodontic cavity preparation. The root canal orifices were located with an endodontic explorer (DG 16, Sybron Endo, Orange, CA, USA). The working lengths were measured with an apex locator (Apexit, Micro Mega, Besancon, France) in addition to periapical radiographs. The root canals were shaped with rotary instruments (Revo-S, Micro Mega) until an apical diameter of #30 (Revo-S, AS30, Micro Mega) and a taper of 0.06 were achieved. The root canal irrigation was performed with 2 mL of 5% NaOCl following each instrument. The final irrigation was performed with 10 mL of 5% NaOCl followed by 10 mL ethylenediaminetetraacetic acid (EDTA) and 10 mL deionized water. Irrigation was delivered with 0.19 inch capillary tips (Ultradent, South Jordan, UT, USA) at 2 to 4 mm from the root tip. The root canals were obturated with gutta percha (Diadent; Diadent Group, International, Burnaby, BC, Canada) and a resin based sealer (Ah-Plus; Dentsply, Maillefer, Switzerland) by lateral condensation. Endodontic treatment was completed in the same session (). Following root canal therapy, the related teeth were restored with fixed bridge restoration (). All dental procedures were performed under antibiotic prophylaxis (2 g amoxicillin, 1 hour before the procedure) upon a consultation with the patient’s oncologist.\nThe patient presented with pain and purulent drainage in the mandibular right jaw 2 months after the initial treatment. A bone scintigraphy taken a few days prior was available at the time of the dental visit. A radiolucent area corresponding to the painful area was detected on the scintigraphy and had already been marked by the radiologist (). Upon clinical examination, none of the teeth were tender to percussion and palpation, an insufficient amount of keratinized gingival tissue due to recession was found, as well as a 6 mm pocket depth measured on the buccal side of the mesial root surface of tooth #46. Scaling and root planning were gently performed to not cause any trauma in the related area. The fixed prosthetic restoration was removed to check any irritation and recemented. The patient was also prescribed 1 g of amoxicillin three times a day for 1 week to control the infection. At the second appointment, no change was observed in terms of pocket depth, purulent drainage, of pain level compared to the first session. Topical gaseous ozone was applied using an Omega Probe (Biozonix, Munich, Germany) at the highest level (level 5). This application was made extraorally through the gel (provided with probe) applied onto skin through the buccal side, three times a week for 10 minutes and a total of 12 sessions as an adjunct to an antibiotic regimen with clindamycin (150 mg Cleocin®, Eczacıbaşı Holding, Istanbul, Turkey), four times a day for 1 week. At the end of the 4 weeks, the pain and drainage had disappeared, the pocket depth was reduced to 5 mm and the infection was eliminated; although a complete reversal was not achieved.\nThe patient was educated on all symptoms of BRONJ and was recommended to return to the dental clinic in case of any of the BRONJ symptoms recurred. The patient was free of any clinical symptoms, periodontal status and radiolucent lesions and was stable at a 1-year recall ( and ).