Case Report

Osteonecrosis of the Jaw in a Patient with Multiple Myeloma: A Case Report

by Girão T1*, Noronha S1, Girão MC2

1Dentistry Department, CUF, Hospitais e Clínicas, Portugal

2General Surgery, Unidade Local de Saúde do Baixo Alentejo, Portugal

*Corresponding author: Girão T, Girão T, Dentistry Department, CUF, Hospitais e Clínicas, Portugal.

Received Date: 06 April 2024

Accepted Date: 10 April 2024

Published Date: 12 April 2024

Citation: Girão T, Noronha S, Girão MC (2024) Osteonecrosis of the Jaw in a Patient with Multiple Myeloma: A Case Report. Ann Case Report 9: 1761.


This clinical case describes a 60-year-old man diagnosed with multiple myeloma (MM), treated with chemotherapy and bisphosphonates that later developed osteonecrosis of the mandible. Histopathological examination of the lesion made it possible to associate bisphosphonate therapy as the cause of the pathology, thus ruling out neoplastic involvement.

Keywords: Bisphosphonates; Multiple Myeloma; Osteonecrosis of The Jaw; Oncology; Metastasis


Multiple myeloma is a haematological neoplasm that can manifest with unique involvement of the mandible [1]. One of the therapies used to prevent the occurrence of skeletal lesions in MM is bisphosphonates, due to their role in inhibiting osteoclasts [2]. but it is known that they can cause osteonecrosis. This clinical case reports the occurrence of osteonecrosis of the mandible in a patient with multiple myeloma undergoing treatment with bisphosphonates. The challenge in this case was to identify the etiology of the osteonecrosis, which could be a bone metastasis from the MM or an adverse effect of the associated therapy. Histological examination is the key to the diagnosis.

Clinical Case Presentation

We present the case of a 60-year-old man, diagnosed with MM in May 2022, who underwent 4 cycles of chemotherapy (Velcade (bortezomib) + Revlimid (lenalidomide) + dexamethasone (VRd))from May to September 2022 - combined with bisphosphonates (Zolendronic Acid) - from June to August 2022.

In October 2022, he came to the dental clinic referring intense and continuous pain in the right posterior mandibular region.

Objective examination through the vestibular area revealed gingival edema, suppuration involving teeth 45 to 48 and grade 3 mobility, according to Miller’s classification, on teeth 46, 47 and 48 [3]. On the lingual side, it was possible to evaluate, moderate gingival inflammation and approximately 2.5mm of necrotic bone exposed on the external cortex (figure 1).

Figure 1: Lingual view of the necrotic bone.

Orthopantomography (figure 2) and periapical radiography (figure 3) were requested as complementary diagnostic exams. As neither revealed any findings, a cone beam computed tomography (CBCT) scan was requested (figure 3,4,6).

Figure 2: Initial panoramic x-ray

Figure 3: Periapical x-ray

Figure 4: CBCT (buccal view)

Figure 5: CBCT (lingual view)