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“Introduction Nitrogen-containing bisphosphonates (N-BP) are prescribed for the treatment of bone diseases such as osteoporosis, multiple myeloma, cancer metastases, and Paget’s disease. However, bisphosphonate-related osteonecrosis of the jaws (BRONJ) has been reported as a rare complication. BRONJ occurs at a much higher rate in patients selleck screening library receiving intravenous N-BPs for cancer treatment

versus oral N-BPs. The incidence of BRONJ in patients treated for osteoporosis is low at 0.1 %, but the incidence of BRONJ in cancer patients treated with high doses of intravenous N-BP is higher at 3 to 10 % [1]. Currently, conservative treatment is recommended for BRONJ, in accordance with the American Association of Oral and Maxillofacial Surgeons (AAOMS) Position Paper [2]. Recently, however, it has been reported that daily parathyroid hormone treatment is effective for BRONJ. Weekly teriparatide (TPTD; human parathyroid hormone peptide 1–34) injections have been used to treat osteoporosis in Japan [3], but there are no reports describing the effectiveness

of weekly TPTD injections for the treatment of BRONJ. Management of BRONJ is challenging and controversial, and there is currently no established drug treatment selleck compound for this condition. We report two patients with stage 3 BRONJ. One patient was p38 MAPK signaling successfully treated with weekly PTD injections, and the other with daily TPTD injections. Changes in the levels of serum N-telopeptide of type I collagen (s-NTX) and serum N-terminal propeptide of type I collagen (P1NP) were studied. Case reports Case 1 An O-methylated flavonoid 87-year-old Japanese woman with a 4-year history of alendronate therapy

(35 mg/week orally) was referred for the treatment of multiple fistulas with purulent discharge over the left maxillary ridge. She was diagnosed with stage 3 BRONJ according to the AAOMS guidelines (2009). She initially received conservative treatment, including instruction on oral hygiene, administration of antibiotics, antimicrobial mouth gargles, and local irrigation. N-BP therapy was discontinued at the time of her first visit. Three months later, she underwent sequestrectomy and extraction of the maxillary left first and second molars because of high tooth mobility (Fig. 1a, d, g). We continued conservative therapy and debridement for 1 year. However, her disease was persistent and progressive (Fig. 1b, e, h). She was then treated with TPTD by subcutaneous injection (56.5 μg weekly). After 3 months of TPTD treatment, there was complete coverage of the necrotic tissue and exposed bone with normal mucosa. Computed tomography showed that her maxillary sinusitis attributed to stage 3 BRONJ had resolved (Fig. 1c, f, i).