Sir, in May 2007 a 62-year-old female presented with pain and a bad taste from her lower right jaw. Her previous history included the extraction of the 46 some eight months previously. Her medical history included osteoporosis, type 2 diabetes and a smoking habit of 100 rollups a week. Her drug history included alendronic acid since July 2004. Examination revealed suppuration from the site of the previous extraction with non-vital bone present within the wound. Radiographic evidence of sequestra formation supported a diagnosis of osteonecrosis. Treatment included chlorhexidine M/W, surgical debridement, and culture and sensitivity guided antibiotic Rx (metronidazole). The alendronic acid was discontinued in June 2007 (circa 3-year administration). Following removal of a bony sequestrum symptoms continued episodically but were controlled with regular irrigations and C&S guided systemic antibiotics.

A bone mineral density scan was performed in March 2008 and return to medicated skeletal protection was not indicated. In July 2008 the patient presented with increased pain and dysaesthesia affecting the right side of the lower lip. A radiograph (Fig. 1) demonstrated osteolysis approaching the ID canal with osteosclerotic thickening of the lamina dura of 45, 44 and 43 and a widening of the periodontal space – all signs of progression of the disease. Further antibiotics and surgical debridement gave some relief and in September 2008 resolution of the dysaesthesia was reported and the patient announced that she 'felt best for two years'. Placed on long-term review, a radiograph taken in December 2011 (Fig. 2) demonstrated evidence of bone regeneration and reduced osteosclerosis with return of near normal thickness of the lamina dura and periodontal space of previously affected teeth. The patient was still smoking 100 rollups a week. In December 2014 (age 70) a further bone density scan continued to show an improved bone density when compared to the original diagnostic scan taken in 2004 and no further skeletal protection was recommended.

Figure 1
figure 1

Radiograph taken in July 2008

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Figure 2
figure 2

Radiograph taken in December 2011

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Discontinuation of alendronate in cases of BRONJ can allow recovery of the physiological function of the jaw bone with time while still leaving a positive residual impact on general skeletal protection. Is the higher turnover bone of the jaw showing preferential recovery from the effects of the bisphosphonates?