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).