title: Sinus tracts--an early sign of bisphosphonate-associated osteonecrosis of the jaws?
abstract: OBJECTIVE
  Bisphosphonate-associated osteonecrosis of the jaw (BONJ) is defined as the presence of exposed bone for at least 8 weeks in patients with exposure to bisphosphonates and no history of radiotherapy to the jaw. We report 5 patients with a history of bisphosphonate use, sinus tracts or deep periodontal pockets and radiographic findings typical for BONJ but with no evidence of exposed necrotic bone at the first evaluation visit.
  
  
  METHODS
  The mean age was 70 years (range 66-77) and all were males. Patients had multiple myeloma (2), multiple myeloma and prostate cancer (1), monoclonal gammopathy of unknown significance (1) and osteoporosis (1). Three cases involved the mandible and 2 the maxilla. Four patients were on intravenous pamidronate and/or zoledonic acid and 1, alendronate. All cases except 1 (with deep periodontal pockets) presented with intraoral draining sinus tracts.
  
  
  RESULTS
  Radiographic findings included persistence of extraction socket (2), mottled radio-opacity and radiolucency (1), presence of sequestrum (1) and no significant findings (1). Subsequently, 4 patients developed exposed bone and 1 patient had necrotic bone removed from the jaws.
  
  
  CONCLUSIONS
  We report 5 patients with a history of bisphosphonate therapy where 4 patients had persistent sinus tracts and a fifth, severe bone loss. Four patients had radiographic findings typical for BONJ, and all subsequently developed necrotic bone. We propose modifying the definition of BONJ to include a category of "suspected BONJ" Stage 0(sa) where patients have persistent sinus tracts or localized deep periodontal pockets and typical radiographic findings for BONJ but are asymptomatic, and Stage 0(ss) for those who are symptomatic.
authors.affiliation: Department of Oral Medicine, Infection and Immunity, Harvard School of Dental Medicine, Boston, MA, USA. hmawardi@partners.org
authors.forename: Hani
authors.initials: H
authors.lastname: Mawardi
authors.forename: Nathaniel
authors.initials: N
authors.lastname: Treister
authors.forename: Paul
authors.initials: P
authors.lastname: Richardson
authors.forename: Kenneth
authors.initials: K
authors.lastname: Anderson
authors.forename: Nikhil
authors.initials: N
authors.lastname: Munshi
authors.forename: Robert A
authors.initials: RA
authors.lastname: Faiella
authors.forename: Sook-Bin
authors.initials: SB
authors.lastname: Woo
mesh_terms: D000368:Aged; D050071:Bone Density Conservation Agents / Q000009:adverse effects*; D003751:Dental Fistula / Q000209:etiology*; D004164:Diphosphonates / Q000009:adverse effects*; D006801:Humans; D007571:Jaw Diseases / Q000139:chemically induced / Q000150:complications*; D008297:Male; D009369:Neoplasms / Q000188:drug therapy; D010020:Osteonecrosis / Q000139:chemically induced / Q000150:complications*; D010514:Periodontal Pocket / Q000209:etiology; D014081:Tooth Extraction / Q000009:adverse effects
chemical_list: D050071:Bone Density Conservation Agents; D004164:Diphosphonates