Burning Questions: Oral Ulceration Secondary to Improper Bisphosphonate Administration in Advanced Dementia

Abstract

Background: Oral bisphosphonates are first-line osteoporosis therapy but can cause mucosal chemical injury when tablets are retained rather than swallowed correctly. This risk is heightened in cognitively impaired older adults with dysphagia or difficulty complying with medication administration guidelines. Case Presentation: A 73-year-old female nursing home resident with advanced vascular dementia presented with 24 h of oral pain, reduced intake, lethargy and new facial swelling. She had received monthly ibandronic acid 150 mg for two years, with documented difficulty swallowing tablets but no formal swallowing assessment. Examination showed ulceration of the left lower lip and anterior tongue with mild vestibular swelling. Clinical investigations excluded haematinic deficiency and osteonecrosis; traumatic, lichenoid, vesiculobullous and neoplastic causes were considered unlikely based on distribution, clinical features and temporal association with the recent dose. Bisphosphonate-associated chemical mucosal injury was diagnosed by hospital dental services. Ibandronic acid was discontinued, topical treatment initiated, and ulcers resolved by three weeks. Denosumab was substituted in view of the patient’s dysphagia and cognitive status. Discussion: This case supports the existing literature identifying inappropriate administration—often linked to dysphagia or physical impairment—as a leading cause of oral bisphosphonate-associated ulceration, typically affecting the tongue and lower lip. Ibandronate-related cases are rarely reported, likely reflecting prescribing frequency rather than lower risk. Current guidelines lack explicit recommendations addressing dysphagia or cognition in prescribing decisions. Conclusions: Presence of dysphagia and cognitive status should be assessed before and during oral bisphosphonate therapy. New oral pain, ulceration or facial swelling should prompt oral examination and medication review, with alternative antiresorptive agents considered when oral administration is impaired.