Bisphosphonate-Related Osteonecrosis of the Jaw Workup

Updated: Mar 11, 2019
  • Author: Remy H Blanchaert, Jr, DDS, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
  • Print
Workup

Laboratory Studies

Rule out a primary malignancy, benign bone lesion, osteomyelitis, or metastatic lesion by biopsy when indicated.

A recent study suggests an increase in serum C-terminal telopeptide (CTX) after a “drug holiday” from oral bisphosphonates may help guide surgical treatment. [13] These data have not been corroborated and have not been shown to be reliable. The value of this test is uncertain.

Next:

Imaging Studies

In patients with bisphosphonate-related osteonecrosis of the jaw (BRONJ), panoramic and plain radiography of the mandible reveal areas of sclerosis, destruction, sequestration, or pathologic fractures. Delayed or persistent tooth sockets after extraction may also be revealed in these patients.

A recent study evaluating the computed tomography (CT) and magnetic resonance imaging (MRI) features of bisphosphonate-related osteonecrosis of the jaw (BRONJ) demonstrated characteristic findings with these studies. The CT scans revealed increased medullary density, periosteal reaction, and bone sequestration. MRI revealed a low signal in T1 and T2 images with exposed bone. This is likely due to a decrease in water content. Unexposed, diseased bone showed hypointensity in T1 images and hyperintensity in T2 images. These findings suggest an increase in water content. [14, 15]

A retrospective study by Wasserzug et al indicated that bisphosphonate-related osteonecrosis of the jaw affects the maxillary sinus. The investigators found that among 50 patients in whom bisphosphonate-related osteonecrosis involved the maxilla, CT scan studies in 36 of them (72%) revealed evidence of maxillary sinus opacification (with such opacification reportedly being found incidentally in just 19% of the general population). [16]

Previous
Next:

Diagnostic Procedures

The following diagnostic procedures may be beneficial in the diagnosis of bisphosphonate-related osteonecrosis of the jaw (BRONJ):

  • Panoramic or plain-film imaging

  • CT scanning

  • MRI

  • Area biopsy (if indicated)

Previous
Next:

Histologic Findings

Histologically, nonvital bone that is devoid of osteoblasts and osteoclasts are noted. Fungal contamination of exposed bone has been noted. In affected but unexposed bone, inflammatory infiltrates, fibrous tissue, and a combination of lamellar and woven bone is noted. Viable osteocytes are seen within this bone.

Previous
Next:

Staging

A staging system has been proposed by the American Association of Oral and Maxillofacial Surgeons (AAOMS).

Stage I is as follows:

  • Exposed, necrotic bone

  • Asymptomatic patient

  • No infection

Stage II is as follows:

  • Exposed, necrotic bone

  • Symptomatic patient (ie, patient experiencing pain)

  • Infection

Stage III is as follows:

  • Exposed, necrotic bone

  • Symptomatic patient (ie, patient experiencing pain)

  • Infection

  • One of the following: Pathologic fracture, oral cutaneous fistula, osteolysis extending to the inferior border of the mandible

Previous