Zoledronic Acid Treatment for Diffuse Sclerosing Osteomyelitis of the Mandible: A Case Report and Literature Review of Antiresorptive Therapy

Diffuse sclerosing osteomyelitis (DSO) is a rare, chronic aseptic osteomyelitis of the mandible characterized by resistance to conventional therapies including nonsteroidal anti-inflammatory drugs (NSAIDs), antibiotics, corticosteroids, and surgery. Diagnosis is often delayed due to nonspecific symptoms and lack of typical infectious signs, sometimes resulting in misdiagnosis. We report a case of a 58-year-old male patient with persistent mandibular pain initially misdiagnosed as trigeminal neuralgia and treated with microvascular decompression surgery without improvement. Subsequent imaging revealed bone sclerosis and resorption consistent with DSO. IV administration of zoledronic acid resulted in rapid and sustained pain relief, improved mouth opening, and radiographic bone regeneration without adverse events. A review of 139 reported cases treated with antiresorptive agents (ARAs) including bisphosphonates (BPs) and denosumab (DMB) demonstrated a high remission rate (95%), though treatment protocols varied widely. BPs appear preferable to DMB due to longer duration of effect and lower risk of medication-related osteonecrosis of the jaw (MRONJ). This case and literature review underscore the efficacy and safety of ARAs in managing DSO but highlight the need for standardized treatment guidelines and further prospective studies to optimize therapy.