Sinus tracts--an early sign of bisphosphonate-associated osteonecrosis of the jaws?
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.
Mawardi
Hani
H
Department of Oral Medicine, Infection and Immunity, Harvard School of Dental Medicine, Boston, MA, USA. hmawardi@partners.org
Treister
Nathaniel
N
Richardson
Paul
P
Anderson
Kenneth
K
Munshi
Nikhil
N
Faiella
Robert A
RA
Woo
Sook-Bin
SB
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
D050071:Bone Density Conservation Agents; D004164:Diphosphonates