A 64-year-old woman had been treated with oral BP since 1991 for arthritic pain and osteoporosis. There were no other medical problems, no other medications used, she did not smoke nor drink alcohol.

In 2005, the left maxillary molars had been extracted. The extraction site failed to heal, but she continued to use BP. Eighteen months later she presented with swelling and pain, suppuration and an area of 2 x 1 cm of exposed necrotic bone in the left posterior maxilla and oroantral fistula (OAF).

Panoramic radiograph showed partial opacification of the maxillary sinus, unhealed extraction site, and sclerosis of adjacent maxillary alveolus. Histopathological analysis diagnosed osteomyelitis associated with actinomycosis, consistent with BRONJ.

BP was discontinued, followed by 7 months of PO antibiotics and iodoform gauze packs. The wound seemed to be completely closed but within 2 months signs and symptoms and OAF recurred. Treatment continued with antibiotics daily rinses and weekly irrigation with Chlorhexidine 2%, and several repeated sequesterctomies, however, the patient still had pain. A course of 30 hyperbaric oxygen treatment was administered. Three years from onset symptoms improved, and sequstered bone is no longer visible. However, the OAF is still present, requiring irrigations, and the radiographs still present bony abnormality.

An unusually severe BRONJ of 3 years duration associated with 15 years oral BP use is presented.