Figure 2: Orthopantomography (OPT) exhibited from the patient during the first visit, revealing the non-healing alveolus 4 months after tooth extraction.
Her anamnesis was carefully harvested. The patient underwent a surgical resection of a cutaneous melanoma in 2009. Then, in 2015, for lung progression of disease, she was treated with ipilimumab (3mg/kg mg iv, every 3 weeks for 4 cycles) with complete remission of the disease. During the follow up, in 2017 the patient had hepatic progression and so, due to the presence of the BRAF mutation, she started the treatment with dabrafenib+trametinib (300 + 2 mg per os/die). Due to the G. 3 toxicity (fever) experienced by the patient the treatment was stopped and was replaced with vemurafenib + cobimetinib (vemurafenib: 1920 per os/die for 3 months, then 1440 mg per os/die; cobimetinib: 60 mg per os/die for three weeks then 1 week pause), still ongoing. She was then taking 1440 mg vemurafenib + 60 mg cobimetinib per os/die at the moment of her tooth extraction. She had no history of smoking nor Head & Neck Radiotherapy. Among all the medications she had undergone, ipilimumab was the only one which has been related to MRONJ.12,17Staging of the MRONJ was thus performed; being the alveolus completely surrounded by mucosa, it was evaluated to be a “stage 0 MRONJ” showing “no clinical evidence of necrotic bone but nonspecific clinical findings, radiographic changes, and symptoms” 1. She was thus treated accordingly, starting a treatment with amoxicilline + metronidazole (3 + 1.5 g per os/die) and chlorhexidine 0.2% mouth rinse twice a day; paracetamol (1g per os) was prescribed in case of pain. During the two-weeks follow-up visit, the patient showed clinical improvement. She referred the ejection of a 10 x 5 mm bone sequestrum after 6 days of therapy and that her symptoms had therefore disappeared. The clinical examination evidenced still an incomplete alveolar healing. Two additional weeks of therapy were prescribed and, after that, the patient obtained a complete healing of the defect. Treatment for the MRONJ was stopped and the patient was regularly followed-up monthly. After 4 months, a new OPT showed complete healing of the alveolus (figures 3 and 4).