We read with great interest Drs. John Nase and Jon Suzuki’s Clinical Practice case report in August JADA, "Osteonecrosis of the Jaw and Oral Bisphosphonate Treatment" (
JADA 2006;137[8]:1115–9
). The authors are to be commended for their thorough description of osteonecrosis in a patient undergoing periodontal and endodontic treatment and receiving oral bisphosphonates.
However, we believe the findings do not provide any evidence supporting a potential involvement of either the necrotic root canal system of tooth no. 27 or the endodontic treatment on the outcome of this case. Instead, all of the stated findings appear directly related to the use of a radiosurgical device for removal of an exophytic growth of gingival mucosa.
These findings include:
- – a preoperative radiograph of tooth no. 27 with an intact lamina dura without any described apical symptoms, which leads us to assume that the patient presented with a diagnosis of normal periradicular tissue (Figure 1);
- – the clinical presentation of the area of osteonecrosis was completely restricted to the interproximal site of radiosurgery (Figure 2); and
- – the very small size of the bone sequestrum (5 millimeters x 2 mm x 2 mm), which was clearly too small to involve apical tissues (Figure 3).
Taken together, the osteonecrosis appears highly probable to be secondary to the periodontal surgical procedure. There is no evidence presented to support a conclusion that pulpal bacteria or endodontic treatment contributed to this outcome.
In this period of growing recognition of conditions such as bisphosphonate-associated osteonecrosis, it is very important to make careful clinical conclusions about potential etiologic factors. The absence of any bone changes in the periapical tissues of tooth no. 27, combined with the restriction of the bone sequestrum to the localized area receiving radiofrequency periodontal surgery, provides compelling clinical evidence of a localized response to the surgical procedure alone. There is simply no evidence suggestive of a pulpal or endodontic contribution to this outcome.
Additionally, we are concerned, lest there be any misinterpretation by the readers of this Journal, that periodic tissue débridement for three months may well be considered aggressive treatment for osteonecrosis of the jaw. To date, no definitive guidelines exist for the management of oral bisphosphonate-induced osteonecrosis of the jaw.
