Osteonecrosis of the Jaws Unrelated to Bisphosphonate Exposure: A Series of 4 Cases

Dale A Bauer, DDS, MD, Jill M Weber, DDS, David C Collette, DMD, MD, Hardeep Dhaliwal, DMD, MD and Faisal Queresby, DDS, MD, FACS

ONJ and bisphosphonate exposure ONJ definition: death of bone without implying specific causation In the past year (2011-2012) at Case Western, 4 patients with:

Exposed bone that have been refractory to conservative treatment Persisted for at least 8 weeks Have never been exposed to radiation treatment or BP

Introduction

69-year-old female referred for eval of a pathologic fracture of the mandible Medical history: type 2 diabete mellitus, hypothyroidism, hypertension, urinary retention, rheumatoid arthritis, dysthymic disorder, cataracts, and a colostomy as a complication of diverticulitis Medications: metformin, Synthroid, Cymbalta, Vesicare, and Flomax HPI:

Pain in mandible over previous 8 weeks, along with an area of exposed bone in the anterior mandible in the setting of severe dental caries and periodontal disease Treated with oral antibiotics and chlorhexidine until time of pathologic fracture Draining cutaneous fistula subsequently developed. She reported persistent pain and submental swelling in anterior mandible

Case 1

Initial exam:

Grossly carious teeth with areas of exposed, necrotic bone (50 x 6 mm) Purulent drainage expressed from fistula in submental region, tender indurated area (~30mm) Pan: pathologic fracture of mandible with a moth-eaten appearance of the surrounding bone consistent with osteomyelitis CT: hypodense areas of the mandible extending to the mental foramina bilaterally

Case 1

Case 1

Treatment:
Aggressive debridement of the mandible
Resection from 1st PM to 1st PM Debridement carried out until bleeding bone was obtained

Reconstruction plate was placed All remaining teeth extracted

Case 1

Pathologic evaluation:
Soft tissue: acute and chronic inflammation, granulation tissue formation Bony fragment: acute and chronic osteomyelitis with abscess formation

Case 1

Antibiotic suggestions:
Piperacillin and tazobactam while in hospital Administered amoxacillin/clavulanic acid

Reconstruction:
With an anterior iliac crest bone graft

Case 1

50-year-old female Referred for an area of nonhealing, exposed bone arising after a single tooth extraction Medical history:
Paroxysmal atrial fibrillation, hypertension, congestive hear failure, internal defibrillator placement, hypertension, hypothyroidism, COPD, and anxiety disorder 3 previous Mis 35-pack-year history of smoking Medications: Synthroid, lisinopril, Coumadin, carvedilol, Pravachol, Topamax, Xanax, Lasix, Restoril, and Klor-con

Case 2

HPI:
Tooth extracted 2 months prior Area of exposed bone had developed immediately adjacent to extraction side Conservative treatment with chlorhexidine Area of exposed, necrotic bone continued to increase in size Worsening paresthesia had developed along the left distribution of cranial nerve V3 Severe pain over her left face

Case 2

Initial exam:

Pan:

Tenderness on left mandible Necrotic bone from canine to 1st molar Tissues surrounding exposed bone were erythematous and edematous with friable margins

Treatment:

Poorly healing extraction site Subtle radiolucent areas along the distal portion of the root of the canine and in the furcation of the 1st molar
Patient refused treatment

Case 2

58-year-old female referred for eval of an area of exposed necrotic bone in the left mandible
Medical history: diffuse large B-cell lymphoma, type 2 diabetes, hypertension,hyperlipidemia, bronchitis, and dilated cardiomyopathy Medications: Tiazac, Lipitor, Mobic, lisinopril, hydrochlorothiazide, insulin, Metformin and aspirin HPI: His initial oral biopsy was 1 year earlier, and he had had persistent pain since then. He also reported an area of exposed bone that had been progressively worsening over the last year. The patient denied any BP exposure or radiation treatment.

Case 3

Initial exam: The patient exhibited a large area of exposed bone involving the majority of the left mandible. There was purulent drainage present. The area of necrotic bone extended from the area of the left lower canine posteriorly to the area of the left lower third molar
The patient had paresthesia involving both the left lingual and left inferior alveolar nerves.

Imaging indicated that the area of necrotic bone extended from the alveolar crest superiorly to below the level of the nerve canal inferiorly, anteriorly to the area of tooth 22 and posteriorly to the area of the left mandibular canine and posteriorly to the area of the third molar

Case 3

Case 3

Case 3

Treatment: Treatment for this patient consisted of resection of the left mandible from an area just anterior to the canine extending posteriorly to the anterior border of the ramus.
Since the surgery, he has recovered well without signs of recurrence. All remaining portions of the mandible are covered with mucosa at this time, and the patient is asymptomatic.

Case 3

54-year-old female--Referred for an area of evaluation of pain in her right mandible

Medical history: renal failure, obesity, hyperlipidemia, anemia, peripheral neuropathies, chronic venous insufficiency, chronic obstructive pulmonary disease, and hypertension

She denied any tooth pain or recent dental work in that area. She had had mild swelling of her right cheek.

The patients medical history was positive for 4 episodes of deep vein thrombosis and 2 episodes of pulmonary emboli. She reported a history of illicit drug use and ongoing tobacco use. She denied any history of BP exposure.

Medications: Coumadin, morphine,Singulair, Flonase, cyclobenzaprine, Percocet, Neurontin, amitriptyline, Lasix, hydrocortisone (topical), Zocor, albuterol, diltiazem, Nexium, hydrochlorothiazide, and docusate.

Case 4

Initial exam: On examination, the patient had a fluctuant area in the buccal area adjacent to the right mandible. The patient was edentulous in the posterior mandible. The remaining teeth were in good repair. No obvious trauma to the gingiva was noted. The buccal swelling was exquisitely tender on palpation. A panoramic radiograph was taken at this time

Case 4

Treatment: Treatment for this patient consisted of incision and drainage of the area. Poor healing occurred, leaving an area of exposed bone along the edentulous portion of the alveolar crest in the right mandible. Over the course of the next several months, the patient underwent multiple debridement procedures, both in the office and in the operating room. During this time, she continued to use chlorhexidine mouth rinse and take oral antibiotics.

Case 4

After 8 months, she presented to the clinic with signs of pathologic fracture of the right mandible sustained while chewing. The diagnosis was confirmed by panoramic radiograph. She was again taken to the operating room, this time for a resection of her mandible and reconstruction. At the time of the papers writing, the patient was doing well without evidence of exposed bone.

Case 4