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Low-dose methotrexate in rheumatoid arthritis: a potential risk factor for bisphosphonate-induced osteonecrosis of the jaw

Abstract

Bisphosphonate-induced osteonecrosis of the jaw [BIONJ] is a relatively new pathological condition which was first described in the year 2003. The prevalence of BIONJ in patients on oral formulations is around 0.05% within the first 3 years and increases up to 0.2% after 4 years of consumption. Proven systemic risk factors like anemia, uncontrolled diabetes, corticosteroid therapy, and chemotherapy in neoplastic diseases [e.g., high doses of methotrexate up to 30 mg daily] significantly increase the chances of acquiring BIONJ. We present three patients with osteoporosis and rheumatoid arthritis [RA] who consumed oral bisphosphonates [alendronate] for less than 1 year and developed BIONJ within 2 to 5 months of undergoing a traumatic dental procedure. The patients also gave a history of consuming low doses of methotrexate [disease-modifying anti-rheumatic drugs] up to 20 mg weekly for 4 to 10 years. No history of steroid consumption was given by any of the patients. This case series highlights the possibility of rheumatoid arthritis and low-dose methotrexate being potential risk factors for BIONJ. This may be on account of the synergistic effect of methotrexate and bisphosphonates and the pro-inflammatory state created by RA which increased the risk of acquiring BIONJ.

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Correspondence to Neelam N. Andrade.

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An informed consent was obtained from the patient. This article does not contain any studies with human participants or animals performed by any of the authors, and hence ethics approval was not required.

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Mathai, P.C., Andrade, N.N., Aggarwal, N. et al. Low-dose methotrexate in rheumatoid arthritis: a potential risk factor for bisphosphonate-induced osteonecrosis of the jaw. Oral Maxillofac Surg 22, 235–240 (2018). https://doi.org/10.1007/s10006-018-0688-8

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  • DOI: https://doi.org/10.1007/s10006-018-0688-8

Keywords

  • Rheumatoid arthritis
  • Bisphosphonate
  • Alendronate
  • Osteonecrosis
  • Jaw
  • DMARD