Non-Invasive Laser Management of Stage 3 MRONJ (Medication- Related Osteonecrosis of the Jaws) in a Patient Undergoing Multidrug Therapy for Renal Metastatic Cell Carcinoma: A Literary Review and a Case Report

Background: This case report presents an instance of osteonecrosis of the jaw (ONJ) triggered by tooth extraction in a patient with metastatic renal cell carcinoma (RCC) undergoing multidrug treatment therapy. This was a 68-year-old man who presented in September 2023 to a private dental office complaining of severe pain that he had exposed bone in the alveolus of his left maxillary third molar 11 months following the extraction of the tooth root. Methods: The patient was treated for 4 months with various antibiotics and curettage to remove exposed bone with no improvement. The patient had received several courses of tyrosine kinase (TK) inhibitors, the Sunitinib® and Cabometix®, which were discontinued due to drug-related toxic effects and then Everolimus®, which was also discontinued due to pulmonary complications. A year earlier he had undergone antiresorptive therapy with the bisphosphonate Zolendronic® acid and then the human monoclonal antibody Denosumab®. A chronic non-healing extraction cavity's clinical and radiological picture was consistent with ONJ. Results: The CT scan showed a picture suggesting a focus on osteonecrosis. In contrast, the magnetic resonance imaging (MRI) scan showed evidence of ethmoidal-maxillary sinusopathy with the left maxillary sinus almost completely occupied by material fluid with fibrotic sprouts. The patient was treated for 4 months with various antibiotics and curettage to remove the exposed bone without improvement. After several oncology consultations, re- treatment with Sunitinib® was started. A few months later, the patient was referred to another dentist who suggested photobiostimulation therapy with a 980-nanometer diode laser and an ozone-based gel, which resulted in total healing. Conclusions: Mucosal lesions resolved with complete reconstitution of the oral tissue, accompanied by a progressive spontaneous expulsion of a bone sequestrum after topical ozone gel applications and photobiostimulation laser therapy. No toxicity was reported.