Early-onset medication-related osteonecrosis of the jaw in adolescents with Duchenne muscular dystrophy receiving long-term antiresorptive combined with glucocorticoid therapy: Two case reports

Background Youth with Duchenne muscular dystrophy (DMD) are at high risk of osteoporosis due to progressive muscle weakness and chronic glucocorticoid (GC) therapy. Current guidelines recommend routine vertebral fracture screening leading to earlier antiresorptive initiation. Medication-related osteonecrosis of the jaw (MRONJ) is a well-established complication of antiresorptives in adults but is exceedingly rare in youth, with no reported cases in children or adolescents with DMD. Methods We describe two adolescents with DMD who developed MRONJ following dental extraction during antiresorptive therapy for GC-induced osteoporosis. Results Case 1: A 15-year-old on long-term deflazacort began zoledronic acid at age 11.8 years for a vertebral fracture. MRONJ developed at age 15 post dental extraction, seven months after their last infusion. Case 2: An 18-year-old receiving bisphosphonates from age 8 years, was switched to denosumab at age 18 years. MRONJ occurred six months later, following tooth extraction. In both cases, antiresorptives were suspended and conservative management led to complete healing of MRONJ. Antiresorptives were later resumed for pain and fracture prevention, with no recurrence after one year. Review of more than 1000 pediatric patients treated with bisphosphonates or denosumab identified no prior reports of MRONJ in children or adolescents with DMD. Conclusions To our knowledge, these are the two youngest reported cases of MRONJ in patients with DMD. They highlight a potential vulnerability related to prolonged GC exposure combined with long-term antiresorptive therapy. Although pediatric MRONJ risk remains extremely low, clinicians should be aware of this complication, particularly when invasive dental procedures are planned.