Restoring skeletal remodeling in antiresorptive-treated patients: clinical outcomes of teriparatide in medication-related osteonecrosis of the jaw.

Abstract

Medication-related osteonecrosis of the jaw (MRONJ) is a challenging complication associated with antiresorptive and antiangiogenic therapies. Prolonged suppression of bone remodeling has been implicated as a key mechanism in its pathophysiology. Teriparatide, an osteoanabolic agent that restores coupled bone remodeling, has been proposed as a potential therapeutic strategy. This review aimed to synthesize reported clinical outcomes of teriparatide use in MRONJ within a systemic remodeling-based framework. We conducted a structured descriptive review based on a systematic literature search and reported in accordance with PRISMA 2020. Studies reporting therapeutic use of teriparatide in established MRONJ were included regardless of the triggering medication. Data were extracted on patient characteristics, MRONJ stage, lesion site, antiresorptive exposure, teriparatide regimen, antiresorptive interruption, antiresorptive type, and clinical outcomes. Because of substantial heterogeneity in study design, patient populations, co-interventions, and outcome reporting, evidence was synthesized qualitatively. Thirty-four publications including 207 patients were included. Clinical outcomes were available for 201 patients: complete coverage/healing was reported in 163, partial improvement in 24, no change in 12, and worsening in 2. Teriparatide discontinuation or dropout after treatment initiation was reported in 13 patients. Stage 2 disease predominated among stageable cases, mandibular involvement was the most frequent anatomical site, and daily teriparatide dosing was more commonly reported than weekly regimens. Bisphosphonate exposure predominated, whereas denosumab-associated cases were fewer; therefore, differential effectiveness by antiresorptive class could not be determined. Published reports describe frequent clinical improvement after teriparatide use in MRONJ. However, the evidence remains descriptive, heterogeneous, and commonly confounded by concomitant therapies. These findings support a biologically plausible remodeling-based interpretation but do not establish efficacy or define teriparatide as standard therapy.