Radiologic and Pathologic Insights into Medication-Related Osteonecrosis of the Jaw in Myeloma Patients: A Report of 3 Cases

Medication-related osteonecrosis of the jaw (MRONJ) is a rare side-effect of certain drugs, mainly those used in regimens treating specific cancers and in the initial treatment for non-neoplastic conditions. The first cases of jaw osteonecrosis were reported over 2 decades ago in patients taking bisphosphonates (BPs). Since its identification, the nomenclature has changed from bisphosphonate-related osteonecrosis of the jaw (BRONJ) to MRONJ, as other drugs can elicit the same reaction. Invasive dental treatments, such as extractions, are known risk factors. Therefore, the importance of routine dental care before and during such drug therapy cannot be overemphasized. MRONJ is a challenging condition to diagnose early as the radiographic features are subtle and easily overlooked. This case report presents 3 female patients with multiple myeloma, emphasizing the chronological radiologic evolution of MRONJ. Notably, 1 case illustrates a transition from Stage 0 to Stage 2 over a 17-month period, documented through serial panoramic radiographs and a positron emission tomography (PET) scan. Another case highlights the role of cone beam computed tomography (CBCT) in identifying sequestra and pathological fractures. An additional noteworthy case illustrates that conservative dental management avoided the potential development of MRONJ. While histopathology confirmed necrotic bone in 2 cases, early radiologic indicators such as sclerosis and nonhealing sockets provided key diagnostic insights. This case report underscores the importance of regular dental monitoring and interdisciplinary care in at-risk patients and contributes to the growing discourse on the critical role of radiologic evaluation in the early detection and management of MRONJ.