CC
A 65-year-old female is referred for evaluation because “the right side of my face aches, and I feel it is swollen.”
Oral drug–induced osteonecrosis of the jaws
Patients who take oral bisphosphonates must be treated differently from other patients and must also be treated differently from patients receiving intravenous (IV) bisphosphonates. Although drug-induced osteonecrosis of the jaws (DIONJ) caused by oral bisphosphonates can result in a severe and extensive exposure of bone and may also require extensive surgery, it generally is less common, less severe, and more amenable to office-based debridement surgeries than IV DIONJ.
HPI
The patient is a 65-year-old female who was referred by her periodontist after she developed exposed bone as a complication of periodontal surgery to graft vertical defects in the #3 and #4 areas. The referring periodontist did not realize that this female patient had been taking alendronate (Fosamax) 70 mg/week for the past 7 years. The bone exposure apparently developed soon after the surgery, about 10 months ago. The patient states that the initial area of exposed bone has increased in size since that time despite attempts to advance local tissue to cover the bone, various courses of antibiotics, and even hyperbaric oxygen treatment. She reports episodes of increased pain accompanied by swelling of her cheek and some drainage. She also complains that her nose “feels stuffy.”
PMHX/PDHX/medications/allergies/SH/FH
This patient has a history of hypertension and age-related hypothyroidism, in addition to the osteopenia, for which she was started on Fosamax to “prevent osteoporosis.” However, she relates that her dual x-ray absorptiometry scan–generated T scores last year went beyond the −2.5 benchmark for osteoporosis. She currently takes Norvasc and hydrochlorothiazide for her hypertension and Synthroid for her hypothyroidism. She stopped taking Fosamax 6 months ago. She relates an allergy to penicillin, manifested as a rash. She is currently taking clindamycin 300 mg three times daily for her facial swelling and pain.
Examination
The right side of the patient’s face is mildly edematous and tender to the touch. Vital signs indicate that the patient’s hypertension is under control (126/76 mm Hg). She has a heart rate of 80 bpm and respirations of 14 per minute.
Oral and Maxillofacial. The oral examination identified exposed necrotic bone and loss of gingiva and oral mucosa on the facial aspect of the bicuspid and molar teeth in the right side of the maxilla ( Fig. 11.1 ). There is a slight suppurative exudate, and the edge of the retracted mucosa is mildly inflamed. The roots of the teeth within the exposed bone are discolored, and the teeth have 1+ to 2+ mobility.
Imaging
Cone-beam computed tomography scan shows a disrupted and irregular trabecular bone pattern in the alveolar bone in the right side of the maxilla. The right maxillary sinus has a complete opacification with what appears to be a swollen sinus mucous membrane ( Fig. 11.2 ).
Labs
The routine laboratory studies of a complete blood count and basic metabolic panel were within normal ranges. In particular, the white blood cell count was normal at 5000/μL with a normal differential. A morning fasting C-terminal telopeptide (CTX) test was returned as 101 pg/mL.
Assessment
Stage III drug-induced osteonecrosis of the maxilla secondary to alendronate therapy.
What was once referred to as bisphosphonate-induced, related, or associated osteonecrosis of the jaws (ONJ) has now been clearly defined as DIONJ. This is because denosumab, which also works by an antiresorptive effect via osteoclast impairment and death but is not a bisphosphonate, also causes ONJ. The misleading and ill-defined terms “associated” and “related” have been dropped by the American Medical Association; this was originally reflected in version of the International Classification of Diseases, Ninth Revision coding manual and has persisted since, which lists DIONJ, M87.10.
In the current patient, the stage III designation follows the simplified staging system by Marx. That is, extension into the maxillary sinus indicates an advanced presentation and therefore stage III disease. The failure of other staging systems is their reliance on pain. Because the dead bone is not painful by itself and only becomes painful if colonized or infected by microorganisms, pain does not relate to the extensiveness or severity of the disease. Additionally, the use of antibiotics or analgesics changes the pain (but not the severity or extension of the disease) and therefore also changes the stage.
Treatment
This patient was placed on doxycycline 100 mg/day to palliate the secondary infection and pain. She was told to take the doxycycline without milk products or yogurt, which are known to bind doxycycline and reduce its absorption. Doxycycline is the best choice after phenoxymethyl penicillin or amoxicillin for long-term use in patients with DIONJ. Clindamycin, which this patient was taking at the time of presentation, is not a good choice. In DIONJ, most exposed bone is colonized by Actinomyces species, which are not very sensitive to clindamycin. The patient was also placed on a drug holiday, with the approval of her prescribing physician. In addition, the prescribing physician was advised to obtain radiographs of the patient’s femur and was informed of the increased reports of spontaneous subtrochanteric femur fractures in women taking alendronate for 6 years or longer.
After an additional 3-month drug holiday, for a total drug holiday of 9 months, a repeat morning fasting serum CTX test was obtained, and its result was 180 pg/mL. This value was 30 pg/mL above the benchmark at which debridement surgery can be accomplished in an otherwise normal postmenopausal female patient without cancer so that normal healing can be anticipated. In such uncomplicated postmenopausal women who took a bisphosphonate, it was found that after a 9-month drug holiday, all morning fasting serum CTX values were about 150 pg/mL. Therefore, the CTX test is no longer used, and an arbitrary 9-month drug holiday before an alveolar bone procedure followed by a 3-month drug holiday after the procedure is used.
The patient was subsequently treated in the operating room, where the necrotic bone was removed; this amounted to the entire floor of the right maxillary sinus and the teeth within the alveolar bone ( Fig. 11.3 A). The sinus was entered, and multiple mucoceles (often also called sinus polyps ) and the entire edematous sinus membrane were removed with vigorous curettage ( Fig. 11.3 B). An incision was then made through the periosteum in the posterior superior area of the vestibule to expose the buccal fat pad. A pericapsular dissection around the buccal fat pad and gentle traction were used to bring the vascular buccal fat pad forward to completely fill the floor of the sinus ( Fig. 11.3 C). The fat pad was sutured to bur holes placed into the buccal cortex of the remaining sinus wall and to the periosteum of the palatal soft tissue ( Fig. 11.3 D). The buccal mucosa was then undermined so as to advance it sufficiently to gain a primary closure by suturing it to the palatal soft tissue ( Fig. 11.3 E).
