Medication Related Osteonecrosis of Jaw (MRONJ): A Case Report of the Synergistic Effect of Pentoxifyllin and Tocopherol (PENTO Protocol) in Treatment of MRONJ Volume 54- Issue 4

Aya Mostafa*

• Department of oral medicine and periodontology, College of dentistry, Ain shams University, Egypt

Received: January 03, 2024; Published: January 22, 2024

*Corresponding author: Aya Mostafa, Department of oral medicine and periodontology, College of dentistry, Ain shams University, Cairo, Egypt

DOI: 10.26717/BJSTR.2024.54.008575

Abstract PDF

Osteonecrosis of jaw is a condition in which bone cells die due to various causes. It has several types one of them is Medication related osteonecrosis of the jaw (MRONJ). MRONJ significantly affects the patient’s quality of life and leads to a significant percentage of mortality. The treatment of osteonecrosis can be conservative, which aims to be beneficial for the patient’s quality of life, and surgical, which involves debridement of the necrotic bone. This article describes a case of a 60 years old female patient with necrotic segment of her mandibular jaw with no pain and a history of taking hormonal drug after stopping chemotherapy for 1 year. We have laid down a new non-surgical well tolerated treatment modality with minimal side effects.

Keywords: Osteonecrosis of Jaw; Pentoxifyllin; Tocopherol; MRONJ

Osteonecrosis of the jaw is a rare condition in which part of your Jawbone exposed through your gum. This area does not receive blood, causing bone cells to die. It is classified as drug-induced jaw osteonecrosis, osteoradionecrosis, traumatic, non-traumatic, and spontaneous osteonecrosis [1]. Medication related osteonecrosis of the jaw (MRONJ) is a severe adverse drug reaction, consisting of progressive bone destruction in the maxillofacial region of patients. ONJ can be caused by two pharmacological agents: Antiresorptive (including bisphosphonates (BPs)) and antiangiogenic [2].

A 60 years old female patient came to department of Oral Medicine and Periodontology with a chief complaint of foul odor and a bad esthetic due to greyish discoloration in the lower left mandibular gum. This condition noticed 3-month ago. The patient gave history of breast cancer and chemotherapy that was stopped 1 year ago and after that she is on Hormonal drug (Arimidex1mg) and a drug for osteoporosis called (bonecare1mcg). Although, she is Hypertensive on Aldomet 250 mg, And diabetic Type II on Amaryl 2mg with last HgA1C test result 8.8%. On Intraoral Examination we found a large Irregular area in lower left mandible covered by necrotic membrane extending from lower left central to the left second premolar and from the free gingival margine to the alveolar mucosa labially and lingually with grade III mobility of all these teeth (Figure 1), and another small greyish area in IDP between upper two centrals with no mobility (Figure 2). All these areas are painless and not surrounded by redness. On Extraoral examination for submental and submandibular lymphnodes We found the submental and left submandibular LNs palpable, soft, tender and mobile.

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A CBCT radiograph was performed and it showed a sequestration of bone under the lower left central and lateral (Figure 3). The first step done in the treatment of this condition was mechanical removal of the necrotic membrane. Then prescribed an H2O2 Mouthwash (10%) (4 times per day), flumox 1g IM Injection (once per day), and flagyl 500(1 tab 2 times per day) for 3 weeks to get rid of anaerobic bacteria. In order to avoid secondary fungal infection a nystatin oral drops 4 times per day were prescriped for one week. then we prescriped Trental 400 1 tab 2 times per day and vitamin E 1g 1 tab per day for 1.5 month to increase blood supply and promote healing. After the size of lesion was regressed and signs of healing showed up (Figures 4 & 5) we decided to extract all teeth with grade III mobility (left central to left second premolar) and the bone sequestrum fall by itself (Figures 6 & 7). The socket left to heal and follow up done after 10 days (Figure 8) and she is still on trental and Vit E even after complete healing approached (Figure 9).

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The mechanism of action of Trental (Pentoxifylline) is decreasing viscosity of blood by decreasing erythrocyte aggregation and stimulating fibrinolysis to reduce plasma fibrinogen concentrations. It also Increase red blood cell flexibility by increasing erythrocyte ATP and cyclic nucleotide levels. In addition it exerts vasodilatation by Inhibiting PDE and Increasing cAMP, it also inhibit platelet aggregation, decrease leukocyte adhesion to endothelial cells and increase prostacyclin production [3]. All these effects enhance the ability of blood to flow through peripheral vessels. Tocopherol (Vit E) produce antioxidant effect to protect cell membranes from lipid peroxidation. In addition it act as anti-inflammatory and inhibits platelet aggregation. Also it has an immune enhancing activity and stimulates bone remodelling. So, the PTX and tocopherol combination (PENTO protocol) has a positive synergistic effect in treating osteoradionecrosis, MRONJ and osteomyelitis [4].

Medication related osteonecrosis of jaw (MRONJ) is described as debilitating condition in which patient experience progressive bone destruction in the maxilla and/or mandible after exposure to certain drugs. This case report draws attention to PENTO protocol as a well-tolerated, non-surgical and non-expensive treatment for MRONJ with minimal side effects.

Written informed consent was obtained from the patient.

There are no conflict of interest.

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3. Gabrielle Delfrate, Tayline Mroczek, Leomar Emanuel Almeida Mecca, Jessica Daniela Andreis, Daniel Fernandes, et al. (2022) Effect of pentoxifylline and α-tocopherol on medication-related osteonecrosis of the jaw in rats: Before and after dental extraction. Archives of Oral Biology 137: 105397.
4. Rafael Correia Cavalcante, Guilherme Tomasetti (2020) Pentoxifylline and tocopherol protocol to treat medication-related osteonecrosis of the jaw: A systematic literature review. Journal of Cranio-Maxillofacial Surgery 48(11): 1080-1086.