Medication-related Osteonecrosis of the Jaw: An Emerging Adverse Effect of Rituximab Therapy – A Case Report

Barbara Bruno Fagundes Marques; Raquel Richelieu Lima de Andrade Pontes; Brenda Xavier dos Santos; Renato Liess Krebs; Eduardo Muniz Barretto Tinoco

doi:10.5327/2525-5711.465

Authors

Barbara Bruno Fagundes Marques Department of Periodontology, Rio de Janeiro State University, Rio de Janeiro, Brazil https://orcid.org/0000-0003-0876-8607
Raquel Richelieu Lima de Andrade Pontes Pedro Ernesto University Hospital, Rio de Janeiro State University, Rio de Janeiro, Brazil https://orcid.org/0009-0002-7139-5639
Brenda Xavier dos Santos Department of endodontics, Rio de Janeiro State University, Rio de Janeiro, Brazil https://orcid.org/0000-0003-1132-9509
Renato Liess Krebs Department of endodontics, Rio de Janeiro State University, Rio de Janeiro, Brazil https://orcid.org/0000-0002-6428-4992
Eduardo Muniz Barretto Tinoco Department of Periodontology, Rio de Janeiro State University, Rio de Janeiro, Brazil https://orcid.org/0000-0003-4798-7175

DOI:

https://doi.org/10.5327/2525-5711.465

Keywords:

Medication-related osteonecrosis of the jaw, Rituximab, Lymphoma, Monoclonal Antibody, Non-antiresorptive

Abstract

Medication-related osteonecrosis of the jaw (MRONJ) is traditionally linked to antiresorptive and antiangiogenic therapies. However, recent evidence suggests that biologic agents, including monoclonal antibodies (mAbs), may also be associated with osteonecrosis. This study reports a case of MRONJ following Rituximab therapy in a patient after treating a non-Hodgkin lymphoma, emphasizing the emergence of this adverse effect in non-antiresorptive protocols. A female patient, following R-CHOP therapy, presented with a painless lesion characterized by bone exposure and suppuration in the periapical region of teeth 43 and 44. Initial management combined professional prophylaxis, antiseptic therapy, debridement, and endodontic treatment under antibiotic coverage. However, the lesion proved refractory, resulting in persistent suppuration and spontaneous bone sequestration after 5 months, which was subsequently treated surgically with adjuvant antibiotic therapy and photobiomodulation. Histopathological examination successfully ruled out malignancy. This clinical outcome highlights the increased susceptibility to bone necrosis in patients undergoing this specific immunotherapy regimen. Ultimately, the early identification of this non-antiresorptive-induced bone necrosis pathobiology is essential to facilitate conservative management and minimize the requirement for extensive surgical interventions.

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