Hyperbaric Oxygen Therapy and Conservative Approach Effectively Manage Severe MRONJ: Case Report

A recent case report published in the Cureus journal highlights the successful management of an advanced case of medication-related osteonecrosis of the jaw (MRONJ) using hyperbaric oxygen (HBO) therapy in combination with conservative treatment.

An 81-year-old male with a history of prostate cancer and bone metastases developed extensive MRONJ after receiving denosumab therapy for nearly three years. The patient, who had been on a standard regimen of 120 mg subcutaneous denosumab every four weeks, presented with significant mandibular bone exposure, an extraoral fistula, and radiographic evidence of sequestration. Given his overall health condition and the preferences of his family, conservative treatment was chosen over extensive surgical intervention.

The treatment strategy involved a combination of antimicrobial therapy, regular oral irrigation, and HBO therapy. The patient was prescribed oral amoxicillin (750 mg/day) for 60 days and underwent 20 HBO therapy sessions on an outpatient basis. Each HBO session included controlled compression, a steady pressure maintenance phase, and gradual decompression using a specialized hyperbaric oxygen chamber. The therapy's goal was to enhance oxygen supply to the affected area, facilitating the healing process.

Following HBO therapy, imaging revealed increased separation of the necrotic bone. To improve oral hygiene and aid sequestrum removal, the patient underwent a minor surgical procedure—saucerization—under local anesthesia. Histopathological analysis confirmed the presence of bacterial colonies and granulation tissue, further supporting the MRONJ diagnosis.

Post-saucerization, the patient continued with antimicrobial therapy and regular oral irrigation at a dental care unit. Nine months later, follow-up imaging showed further sequestrum separation, prompting a sequestrectomy under local anesthesia. Over the next two years, the remaining necrotic bone naturally detached, with no recurrent infections or worsening symptoms. Though an extraoral fistula persisted, there were no signs of active infection.

This case emphasizes the potential benefits of HBO therapy and conservative management in treating advanced MRONJ. The patient maintained his quality of life while managing the condition by avoiding extensive surgery. The findings also suggest that discontinuing denosumab could play a role in MRONJ resolution. Continued collaboration between medical and dental teams further contributed to positive patient outcomes.

This report highlights a non-invasive treatment alternative that may be particularly beneficial for elderly patients or those with significant comorbidities.

"MRONJ is a challenging condition that often necessitates extensive surgical intervention. However, this case report demonstrates the successful management of an elderly patient with advanced MRONJ through conservative treatment and hyperbaric oxygen therapy, avoiding invasive procedures," wrote Tougo Tanabe and colleagues from the Department of Oral Diagnosis and Medicine, Hokkaido University, Sapporo, Japan.

"The findings also suggest that discontinuing denosumab may facilitate recovery. Additionally, continued medical collaboration was crucial in preserving the patient’s ability to use dentures and maintaining overall quality of life," they concluded.

Tanabe T, Kimura T, Sakata K, et al. (February 18, 2025) Medication-Related Osteonecrosis Successfully Treated With Hyperbaric Oxygen Therapy and Conservative Treatment: A Case Report. Cureus 17(2): e79213. DOI 10.7759/cureus.79213