I appreciated the December JADA cover story by Dr. Cesar Migliorati and colleagues, "Managing the Care of Patients With Bisphosphonate-Associated Osteonecrosis: An American Academy of Oral Medicine Position Paper" (
JADA 2005;136:1658–68
), I’d like to share my experience with a 61-year-old, bisphosphonate-taking woman with osteoporosis who had undergone extraction of four mandibular incisors, and socket grafting, by a periodontist.
I initially saw her when she was referred to me by the periodontist. She had an acute submental space abscess and, intraorally, an anteriorly denuded mandibular alveolus and symphasis from canine to canine. She was hospitalized, the abcess was drained, she received intravenous antibiotics and, ultimately, she underwent a complete hyperbaric oxygen therapy course, as well as an arteriogram.
She was treated conservatively over an 18-month period with weekly periodontal packings and a chlorhexidine mouthwash, with little evidence of granulation and epithelialization over the exposed bone. There was no recurrence of the submental infection.
Through her physicians, she continued to receive her bisphosphonate therapy for her osteoporosis throughout the entire 18 months. She was then taken off the bisphosphonate therapy. Within three weeks, a noted increase in granulation and epithelial coverage had begun. Over the next several months, she had a complete mucosal coverage of the denuded mandible. In this case, there appeared to be a direct link with the cessation of the bisphosphonate therapy and the beginning of granulation and epithialization.
It is also of interest that the arteriogram failed to reveal any central vasculature of the mandible, and it appears that all vascularity was derived periosteally.
Since this case, I have seen three additional cases of limited osteonecrosis secondary to bisphosphonate therapy. Unfortunately, we will likely see many more of these in the future. This may be worthy of a case study article. Thanks for bringing it to the profession’s attention.
