Abstract
Although osteonecrosis of the jaw is a well-known adverse reaction of bisphosphonates (BPs), random cases of oral mucosal ulceration after per os administration of BP-aledronate have been attributed to prolonged mucosal irritation. This report, for the first time, describes the mucosal ulceration related to intravenous use of zoledronic acid (ZA). A 52-year-old female patient presented with painful ulcers on both cutaneous/mucosal surfaces of the lower lip and a 2-month history of osteonecrosis of the mandible beside the right lower canine. Her medical record included intravenous administration of ZA for 10 months for primary breast cancer metastatic to bone. Examination of the peripheral blood showed severe anemia and a slightly increased white blood cell count, due to urinary tract infection by E. coli, but no evidence of a viral infection. The treatment of anemia and E. coli infection did not improve the labial ulcers. Biopsy from the mucosal lesion revealed a non-specific ulceration with moderate inflammatory infiltration. There was no evidence of infection or malignancy. ZA administration was discontinued and within 3 months the lesions were resolved after treatment with systemic antibiotics (amoxicillin), vitamins A and E, chlorexidine and H2O2 (hydrogen peroxide) solutions and local pantothenic acid/vitamin A creams. Recurrence was detected a month after ZA re-administration. Nevertheless, after new treatment, the patient was free of oral/skin lesions 18 months later. This case, which is the first report of ulceration associated with intravenous administration of bisphosphonates, suggests that systemic mechanisms may be implicated in BP-induced oral mucosal ulceration. Furthermore, ZA appears to cause the same oral mucosal manifestations as alendronate. This emphasizes the need for oral examination in all cases of BP therapy, whether per os or intravenously administrated.
References
Cremers SC, Pillai G, Papapoulos SE. Pharmacokinetics/pharmacodynamics of bisphosphonates: use for optimisation of intermittent therapy for osteoporosis. Clin Pharmacokinet. 2005;44(6):551–70.
Ezra A, Golomb G. Administration routes and delivery systems of bisphosphonates for the treatment of bone resorption. Adv Drug Deliv Rev. 2000;42:175–95.
Cremers SC, Papapoulos SE. Pharmacology of bisphosphonates. Bone. 2011;49(1):42–9.
Marx RE. Pamidronate (Aredia) and zoledronate (Zometa) induced avascular necrosis of jaws: a growing epidemic. J Oral Maxillofac Surg. 2003;61(9):1115–7.
Ruggiero SL, Mebrotra B, Rosenberg TJ, et al. Osteonecrosis of the jaws associated with the use of biphosphonates. A review of 63 cases. J Oral Maxillofacial Surg. 2004;62:527–34.
de Groen PC, Lubbe DF, Hirsch LJ, et al. Esophagitis associated with the use of aledronate. N Eng J Med. 1996;335:1016–21.
Kharazmi M, Sjoqvist K, Rizk M, et al. Oral ulcers associated with aledronate: a case report. Oral Surg Oral Med Oral Pathol Oral Endod. 2010;110e:11–3.
Aleid W, Sidebottom A. Oral mucosal irritation with incorrect use of aledronate. Br J Oral Maxillofac Surg. 2009;47:166–71.
Garcia-Font M, Curcó N, Prat C, et al. Mouth sores caused by alendronate. Actas Dermosifiliogr. 2009;100:77–83.
Treister NS, Richardson P, Schlossman R, et al. Painful tongue ulcerations in patients with bisphosphonate-associated osteonecrosis of the jaws. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008;105(105):e1–4.
Krasagakis K, Kruger-Kragasakis S, Ioannidou D, et al. Chronic erosive and ulcerative oral lesions caused by incorrect administration of alendronate. J Am Acad Dermatol. 2004;50(4):651–2.
Gonzales-Moles MA, Bagan-Sebastian JV. Aledronate-related oral mucosa ulcerations. J Oral Pathol Med. 2000;29:514–8.
McClung M. Bisphosphonates. Arq Bras Endocrinol Metabol. 2006;50(4):735–44.
Silverman SL. Paget’s disease: therapeutic options. J Clin Rheum. 2008;14(5):299–305.
Vescovi P, Nammour S. Bisphosphonate-related osteonecrosis of the jaw (BRONJ) therapy. A critical review. Minerva Stomatol. 2010;59(4):181–213.
Reid IR, Bolland MJ, Grey AB. Is biphosphonate-associated osteonecrosis of the jaw caused by soft tissue toxicity? Bone. 2007;41(3):318–20.
Scheper MA, Chaisuparat R, Cullen KJ, et al. A novel soft tissue in vitro model for biphosphonate-associated osteonecrosis. Fibrogenesis & Tissue Repair. 2010;3:6–17.
Scheper MA, Badros A, Chaisuparat R, et al. Effects of zoledronic acid on oral fibroblasts and epithelial cells. A potential mechanism of biphosphonate-associated osteonecrosis. Br J Haematol. 2009;144(5):667–76.
Agis H, Blei J, Waltzek G, et al. Is zoledronate toxic to human periodontal fibroblasts? J Dent Res. 2010;89(1):40–5.
Walter C, Klein MO, Pabst A, Al-Nawas B, Duschner H, Ziebart H. Influence of bisphosphonates on endothelial cells, fibroblasts, and osteogenic cells. Clin Oral Invest. 2010;14:35–41.
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Andreadis, D., Mauroudis, S., Poulopoulos, A. et al. Lip Ulceration Associated with Intravenous Administration of Zoledronic Acid: Report of a Case. Head and Neck Pathol 6, 275–278 (2012). https://doi.org/10.1007/s12105-011-0313-8
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DOI: https://doi.org/10.1007/s12105-011-0313-8