2010

iMedPub Journals TRANSLATIONAL BIOMEDICINE Vol.1

No. 1:7
doi: 10:3823/406

Phosphate buffer-stabilized 0.1% chlorine dioxide-containing mouth

wash facilitated sequestration of Bishphosphonate Related Osteonecrosis
of jaw (BRONJ) lesion from a patient who presented with Osteonecrosis of
the jaw and a history of intravenous bisphosphonate use: a case report

Ehsan Soolari1, Amin Soolari 2 and Ahmad Soolari3

1 College of Chemical and Life Sciences, University of Maryland, USA, 2 Churchill High School, Potomac, MD, USA, 3 Private periodontal practice
in Silver Spring and Potomac, Maryland, USA, Diplomate, American Board of Periodontology.

Abstract

Background: Inconclusive protocol and consensus exist at present time regarding treatment of patients who have de-
veloped Osteonecrosis of the Jaw (ONJ) following administration of intravenous Bisphosphonates. Most clinicians are
avoiding treatment for patients presenting with BRONJ due to lack of predictable treatment outcome.

Findings: In this case report, patient was suffering from a non healing lesion on anterior mandible, which was not re-
sponsive to any conventional treatment. Patient was recommended to rinse with the PBSCD for treatment of BRONJ
(Bisphosphonate Related Osteonecrosis of the Jaw) lesion seen on some patients who were on intravenous Bisphos-
phonate medications for multiple myeloma. Patient was recommended to rinse three times a day with PBSCD. After 4
month use of the solution patient presented with soft tissue healing on previously exposed necrotic bone on mandibu-
lar anterior region.

Conclusion: The benefit of Phosphate buffer-stabilized 0.1% chlorine dioxide-containing mouth wash (PBSCD) is dis-
cussed. This is a non invasive protocol that has proved to be effective in closing of an open wound.

Introduction potential adverse effects of dental treatment in patients taking

Multiple myeloma patients with a history of long term use of
IV Bisphosphonates are at risk for complications of ONJ. One
of the major precipitating factors for ONJ is tooth extraction,
which is reported to be the cause of the ONJ lesions.7 Other
factors such as radiation therapy and invasive surgical procedu-
res have been noted as predisposing factors as well.2 Multiple
factors likely contributed to the initial and continued expan-
sion of the necrotic bone from a stable and small lesion (4 x 2
x 2 mm), into a symptomatic and large lesion (6 x 12x 4 mm),
which, in turn, has remained outsized and active. At the pre-
sent time there is considerable confusion among patients and
practitioners about the prevention and treatment of osteone-
crosis of the jaw. To this day, there is no solid treatment plan or
option that has been agreed upon universally in the medical
and dental fields as to how to combat ONJ and the complica-
tions it brings forth. A recently published article in the January
of 2008 by Glick states “some studies do not help clarify the
bisphosphonates.” 15
The progressive and aggressive nature of the disease presented
in this case report demand attention. However, it is important
to keep in mind such important factors like the potency of the
BP used to treat the patient, the duration of treatment with BPs,
and the types of surgical procedures recommended for the pa-
tient at risk for ONJ due to previous intravenous bisphosphona-
te use. In order to alleviate the risk of ONJ in these patients, our
jobs as practitioners should be to identify those individuals at
risk, and do everything we can in order to strive for the preven-
tion of this condition. By continued correspondence between
healthcare providers, dental surveillance and prophylactic care,
and most importantly, early diagnosis and management, mor-
bidity resulting from ONJ due to bisphosphonate use may be
reduced greatly.1

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 2010
iMedPub Journals TRANSLATIONAL BIOMEDICINE Vol.1
No. 1:7
doi: 10:3823/406

Also, through continued research and reports on the subject chief complained remained unresolved as how to close the open
matter, more successful treatment plans will arise. wound, which was easy for patient to see it on a daily basis.

In this report, we present a BRONG case of a patient on IV Bis-

phosphonate with a chief complaint of a “sticky, paint-like
smell”, and a “salty/sour tasting material” in the mouth. There
is no predictable treatment option for resolution of non hea-
ling lesion in anterior mandible. However, The PBSCD rinse was
able to speed up the sequestration of necrotic bone and com-
plete closure of the lesion.

Case:
Patient is a 64 year old African American with a history of long
term use of IV Bisphosphonate. The medical consultation with
the patient’s hematologist/oncologist revealed that the patient
was diagnosed with multiple myeloma in early 2005 and initially
started on Dexamethasone and had received 4 mg zoledronic
acid treatments intravenously, on a monthly basis, until January
2007 (six month post-extraction of tooth # 24 and two years
post treatment with zoledronic acid), when the treating medi-
cal personnel had discovered the emergence of ONJ. However,
the discontinuation of zoledronic acid treatments in January
2007 did not help our patient. This finding is in agreement with
Ruggiero et al, whom stated that “there is no evidence to sug-
gest interrupting bisphosphonate therapy will prevent or lower
the risk of ONJ.”12,13 Clinical (Figure 1) and radiographic (Figure
2) evaluation revealed 2 x 4 x 2 mm size lesion on extraction Figura 2
site, which was asymptomatic and stable in Feb 2008. Three
dimensional image of the area revealed break in cortical plate
and a non healing socket (Figure 3). The lesion became aggres- Patient was instructed to rinse with the PBSCD (CloSYS II-Rowpar
sive and increased in size (Figure 4). Patient called and stated Pharmaceuticals) for 30 second three times a day. Four month
that he has aches and pain on mandibular anterior area. later patient presented to our office with the necrotic bone in
his hand (Figure 5). Patient was happy with the mouth wash
and stated that the rinse helped him getting rides of the loose
bone. Clinical evaluation disclosed complete soft tissue healing
on previously exposed necrotic bone on mandibular anterior
region (Figure 6). We recommend this product. Our results are
in agreement with the previous report by Marder (2009) that
the PBSCD has potential rinsing solution to facilitate release of
necrotic bone and closure of an open wound.

Figura 1

Patient was treated with Augmentin 500 mg 30 tab I. P.O. TID and
Chlorohexidine16oz rinse twice daily. Patient response was po-
sitive and stated that he felt much better. Aches were gone but Figura 3

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Discussion
Osteonecrosis of the jaw (ONJ) refers to necrotic jawbone due
to decrease in blood supply—leading to decay, rotting, and in-
fection in the diseased regions 1-3. The uses of bisphosphona-
tes (BPs), analogs of pyrophosphonates 4, 5, usually prescribed
in response to certain cancer treatments 6-12, have been linked
with ONJ 3,4,7,8 and have been speculated to be a cause of the
condition 14-19. BPs are recommended to prevent bone resorp-
tion by suppressing all activities, and in particular, reducing the
Figura 4
bone resorption activities of the osteoclast—it has been noted
however, that over suppression of osteoclastic activity may lead
to ONJ. The condition most often presented itself following an
invasive dental procedure, such as an extraction3, 5, 7. The majori-
ty of these ONJ patients were also being treated due to multiple
myeloma and breast cancer, which had been metastatic to the
bone 3, 5, 6-12. The oral bisphosphonate impose much smaller risk
in developing BRONG. The 2008 advisory statement of ADA con-
cluded that the risk of developing bisphosphonate –associated
osteonecrosis (BON) of the jaw remains low and current scree-
ning and diagnostic tests are unreliable for predicting patient’s
Figura 5
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2010
TRANSLATIONAL BIOMEDICINE Vol.1
No. 1:7
doi: 10:3823/406
risk of developing the condition. The expert panel recommen-
ded routine general dental care should not be modified solely
because of the patient’s use of oral bisphosphonates. 13Dr.
Marder (2008) has reported successful treatment outcome of
BON with phosphate buffer-stabilized 0.1% chlorine dioxide-
containing mouth wash (CloSYS II-Rowpar Pharmaceuticals).
Authors speculated that this mouthwash has anti inflammatory
/anti fungus activities.
Figura 6
We recommended that patient used PBSCD for 30 seconds 3
times a day. Patient was happy with the mouth wash and stated
that the rinse help getting rid of the loose bone. Clinical and
radiographic evaluation disclosed complete soft tissue healing
on previously exposed necrotic bone on mandibular anterior
region. However, the radiograph revealed the radiolucency ex-
tended to adjacent teeth # 22 and 26. Our main concerns are
loss of # 26 and 27 with subsequent bone exposure. Patient was
instructed to use this mouthwash indefinitely. 14
In conclusion, there is a non invasive treatment option is avai-
lable for patients who are suffering from the BRONJ. The PBSCD
facilitated sequestration of a hard to hide necrotic bone in an-
terior mandible. Complete soft tissue closure of a non healing
lesion made patient very happy.
Acknowledgements: The authors, in reference to this case report,
have no affiliation or financial support from any institution in
the completion of this study.
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