title: Bisphosphonate-associated osteonecrosis of jaw reoccurrence after methotrexate therapy: a case report.
abstract: BACKGROUND
  Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is a well-known complication caused by amino-bisphosphonate therapy. We document one case of BRONJ associated with oral administration of methotrexate, a known immunosuppressive drug used to treat rheumatoid arthritis.
  
  
  METHODS
  A 66-year-old woman was referred for evaluation and endodontic surgery of recently re-treated tooth 13. Tooth 14 was extracted 3 months prior, and the extraction site had not completely healed. Her medical history revealed rheumatoid arthritis and osteoporosis. She had been taking Fosamax (alendronate) 70 mg daily. Because of adequate root canal therapy of tooth 13, endodontic surgery was performed. Five months after apicoectomy, her symptoms had not changed. Tooth 13 was extracted, and the socket healed without complications. The socket of extracted tooth 14 was also healing. At the 3-month recall visit, bone exposure and purulent discharge at the site of extracted tooth 14 were noted. The patient had recently received methotrexate. The methotrexate was discontinued, and she was given course of amoxicillin.
  
  
  RESULTS
  At the 18-month follow-up, the healing progressed, and the wound was closed.
  
  
  CONCLUSIONS
  A medication that suppresses the immune system such as methotrexate may complicate the management of BRONJ. Once a diagnosis of BRONJ is made, a closely monitored conservative approach is recommended.
authors.affiliation: Department of Surgical Specialties, College of Dentistry, University of Nebraska Medical Center, Lincoln, Nebraska; Department of Restorative Dental Sciences, College of Dentistry, King Saud University, Riyadh, Saudi Arabia. Electronic address: fahd.alsalleeh@unmc.edu.
authors.forename: Fahd
authors.initials: F
authors.lastname: Alsalleeh
authors.affiliation: Department of Surgical Specialties, College of Dentistry, University of Nebraska Medical Center, Lincoln, Nebraska.
authors.forename: Jeffery
authors.initials: J
authors.lastname: Keippel
authors.affiliation: Department of Surgical Specialties, College of Dentistry, University of Nebraska Medical Center, Lincoln, Nebraska.
authors.forename: Lyde
authors.initials: L
authors.lastname: Adams
authors.affiliation: Department of Surgical Specialties, College of Dentistry, University of Nebraska Medical Center, Lincoln, Nebraska.
authors.forename: Bruce
authors.initials: B
authors.lastname: Bavitz
mesh_terms: D000368:Aged; D019386:Alendronate / Q000009:adverse effects*; D000658:Amoxicillin / Q000627:therapeutic use; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D001047:Apicoectomy / Q000379:methods; D001172:Arthritis, Rheumatoid / Q000188:drug therapy; D059266:Bisphosphonate-Associated Osteonecrosis of the Jaw / Q000188:drug therapy / Q000209:etiology*; D050071:Bone Density Conservation Agents / Q000009:adverse effects*; D004347:Drug Interactions; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007166:Immunosuppressive Agents / Q000009:adverse effects*; D008727:Methotrexate / Q000009:adverse effects*; D010024:Osteoporosis / Q000188:drug therapy; D014081:Tooth Extraction / Q000379:methods; D014945:Wound Healing / Q000187:drug effects
chemical_list: D000900:Anti-Bacterial Agents; D050071:Bone Density Conservation Agents; D007166:Immunosuppressive Agents; D000658:Amoxicillin; D019386:Alendronate; D008727:Methotrexate
keywords: Bone necrosis induced by bisphosphonate; methotrexate; rheumatoid arthritis