Posterior Mandibular Bisphosphonate-Related Osteonecrosis Mimicking Periodontal Disease in a Patient with Multiple Myeloma: A Case Report

Abstract

Aim and Background: Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is an adverse effect of antiresorptive therapy, commonly observed in oncology patients. The condition may clinically resemble periodontal or suppurative infection and therefore requires careful clinical and radiographic correlation. This report aims to outline the clinical, radiographic, and histopathological findings of BRONJ involving the posterior mandible. Case Description: A 61-year-old man with a history of multiple myeloma and prior bisphosphonate therapy presented with pain and tooth mobility in the right posterior mandibular region for two months. Intraoral examination revealed exposed necrotic bone with surrounding mucosal inflammation in the region of teeth 46–48. Investigations and Diagnosis: Panoramic radiography demonstrated an ill-defined mixed radiolucent–radiopaque lesion extending across the right posterior mandible, with sequestrum formation, cortical irregularity, and indistinct visualisation of the inferior alveolar canal. Histopathological examination revealed necrotic bone with chronic inflammatory cell infiltration. The clinical, radiographic, and histopathological findings, together with the history of bisphosphonate exposure, supported the diagnosis of BRONJ. Management and Outcome: Surgical management involved extraction of teeth 44–48, removal of necrotic bone, and placement of platelet-rich plasma (PRP) in the surgical defect. At the six-month follow-up, clinical examination demonstrated complete mucosal healing without exposed bone, while panoramic radiography showed improvement in bone architecture without evidence of lesion progression. Conclusion: This case highlights the diagnostic challenge of BRONJ presenting with features resembling periodontal disease in a patient with multiple myeloma. Careful assessment of medication history and integration of clinical, radiographic, and histopathological findings are essential for diagnosis. Surgical management with adjunctive PRP was followed by favourable clinical and radiographic healing in this case.