Springer Nature is making SARS-CoV-2 and COVID-19 research free. View research | View latest news | Sign up for updates

Comparative evaluation of SPECT/CT and CBCT in patients with mandibular osteomyelitis and osteonecrosis

  • 214 Accesses



Therapy of osteomyelitis and osteonecrosis very often requires surgery. Proper preoperative radiological evaluation of a lesion’s localization and extent is a key in planning surgical bone resection. This study aims to assess the differences between single-photon emission computed tomography and cone beam computed tomography when detecting an osteomyelitis/osteonecrosis lesion as well as the lesion’s qualitative parameters, extent, and localization.

Material and methods

Identification of candidates was performed retrospectively following a search for patients with histologically or clinically confirmed osteomyelitis or osteonecrosis. They were matched with a list of patients whose disease extent and localization had been evaluated using single-photon emission computed tomography and cone beam computed tomography in the context of clinical investigations. Subsequently, two experienced examiners for each imaging technique separately performed de novo readings. Detection rate, localization, extent, and qualitative parameters of a lesion were then compared.


Twenty-one patients with mandibular osteomyelitis and osteonecrotic lesions were included. Cone beam computed tomography detected more lesions than single-photon emission computed tomography (25 vs. 23; 100% vs. 92%). Cone beam computed tomography showed significantly greater depth, area, and volume, whereas length and width did not differ statistically between the two groups.


Both single-photon emission computed tomography and cone beam computed tomography could sensitively detect osteomyelitis/osteonecrosis lesions. Only single-photon emission computed tomography showed metabolic changes, whereas cone beam computed tomography seemed to display anatomic morphological reactions more accurately. The selection of the most adequate three-dimensional imaging and the correct interpretation of preoperative imaging remains challenging for clinicians.

Clinical relevance

In daily clinical practice, three-dimensional imaging is an important tool for evaluation of osteomyelitis/osteonecrosis lesions. In this context, clinicians should be aware of differences between single-photon emission computed tomography and cone beam computed tomography when detecting and assessing an osteomyelitis/osteonecrosis lesion, especially if a surgical bone resection is planned.

This is a preview of subscription content, log in to check access.

Fig. 1
Fig. 2
Fig. 3
Fig. 4


  1. 1.

    Khalid M, Bora T, Ghaithi AA, Thukral S, Dutta J (2018) Raman spectroscopy detects changes in bone mineral quality and collagen cross-linkage in staphylococcus infected human bone. Sci Rep 8:9417. https://doi.org/10.1038/s41598-018-27752-z

  2. 2.

    Fleisher KE, Pham S, Raad RA, Friedman KP, Ghesani M, Chan KC, Amintavakoli N, Janal M, Levine JP, Glickman RS (2016) Does fluorodeoxyglucose positron emission tomography with computed tomography facilitate treatment of medication-related osteonecrosis of the jaw? J Oral Maxillofac Surg 74:945–958. https://doi.org/10.1016/j.joms.2015.10.025

  3. 3.

    Fleisher KE, Raad RA, Rakheja R, Gupta V, Chan KC, Friedman KP, Mourtzikos KA, Janal M, Glickman RS (2014) Fluorodeoxyglucose positron emission tomography with computed tomography detects greater metabolic changes that are not represented by plain radiography for patients with osteonecrosis of the jaw. J Oral Maxillofac Surg 72:1957–1965. https://doi.org/10.1016/j.joms.2014.04.017

  4. 4.

    Miksad RA, Lai KC, Dodson TB, Woo SB, Treister NS, Akinyemi O, Bihrle M, Maytal G, August M, Gazelle GS, Swan JS (2011) Quality of life implications of bisphosphonate-associated osteonecrosis of the jaw. Oncologist 16:121–132. https://doi.org/10.1634/theoncologist.2010-0183

  5. 5.

    Pautke C, Bauer F, Otto S, Tischer T, Steiner T, Weitz J, Kreutzer K, Hohlweg-Majert B, Wolff KD, Hafner S, Mast G, Ehrenfeld M, Sturzenbaum SR, Kolk A (2011) Fluorescence-guided bone resection in bisphosphonate-related osteonecrosis of the jaws: first clinical results of a prospective pilot study. J Oral Maxillofac Surg 69:84–91. https://doi.org/10.1016/j.joms.2010.07.014

  6. 6.

    Store G, Larheim TA (1999) Mandibular osteoradionecrosis: a comparison of computed tomography with panoramic radiography. Dentomaxillofac Rad 28:295–300. https://doi.org/10.1038/sj/dmfr/4600461

  7. 7.

    Lapa C, Linz C, Bluemel C, Mottok A, Mueller-Richter U, Kuebler A, Schneider P, Czernin J, Buck AK, Herrmann K (2014) Three-phase bone scintigraphy for imaging osteoradionecrosis of the jaw. Clin Nucl Med 39:21–25. https://doi.org/10.1097/RLU.0000000000000296

  8. 8.

    Stockmann P, Hinkmann FM, Lell MM, Fenner M, Vairaktaris E, Neukam FW, Nkenke E (2010) Panoramic radiograph, computed tomography or magnetic resonance imaging. Which imaging technique should be preferred in bisphosphonate-associated osteonecrosis of the jaw? A prospective clinical study. Clin Oral Investig 14:311–317. https://doi.org/10.1007/s00784-009-0293-1

  9. 9.

    Guggenberger R, Fischer DR, Metzler P, Andreisek G, Nanz D, Jacobsen C, Schmid DT (2013) Bisphosphonate-induced osteonecrosis of the jaw: comparison of disease extent on contrast-enhanced MR imaging, [18F] fluoride PET/CT, and conebeam CT imaging. AJNR Am J Neuroradiol 34:1242–1247. https://doi.org/10.3174/ajnr.A3355

  10. 10.

    Bolouri C, Merwald M, Huellner MW, Veit-Haibach P, Kuttenberger J, Perez-Lago M, Seifert B, Strobel K (2013) Performance of orthopantomography, planar scintigraphy, CT alone and SPECT/CT in patients with suspected osteomyelitis of the jaw. Eur J Nucl Med Mol Imaging 40:411–417. https://doi.org/10.1007/s00259-012-2285-7

  11. 11.

    Dore F, Filippi L, Biasotto M, Chiandussi S, Cavalli F, Di Lenarda R (2009) Bone scintigraphy and SPECT/CT of bisphosphonate-induced osteonecrosis of the jaw. J Nucl Med 50:30–35. https://doi.org/10.2967/jnumed.107.048785

  12. 12.

    Fullmer JM, Scarfe WC, Kushner GM, Alpert B, Farman AG (2007) Cone beam computed tomographic findings in refractory chronic suppurative osteomyelitis of the mandible. Br J Oral Maxillofac Surg 45:364–371. https://doi.org/10.1016/j.bjoms.2006.10.009

  13. 13.

    Wilde F, Heufelder M, Lorenz K, Liese S, Liese J, Helmrich J, Schramm A, Hemprich A, Hirsch E, Winter K (2012) Prevalence of cone beam computed tomography imaging findings according to the clinical stage of bisphosphonate-related osteonecrosis of the jaw. Oral Surg Oral Med Oral Pathol Oral Radiol 114:804–811. https://doi.org/10.1016/j.oooo.2012.08.458

  14. 14.

    Olutayo J, Agbaje JO, Jacobs R, Verhaeghe V, Velde FV, Vinckier F (2010) Bisphosphonate-related osteonecrosis of the jaw bone: radiological pattern and the potential role of CBCT in early diagnosis. J Oral Maxillofac Res 1:e3. https://doi.org/10.5037/jomr.2010.1203

  15. 15.

    Wilkinson GS, Kuo YF, Freeman JL, Goodwin JS (2007) Intravenous bisphosphonate therapy and inflammatory conditions or surgery of the jaw: a population-based analysis. J Natl Cancer Inst 99:1016–1024. https://doi.org/10.1093/jnci/djm025

  16. 16.

    Cheriex KC, Nijhuis TH, Mureau MA (2013) Osteoradionecrosis of the jaws: a review of conservative and surgical treatment options. J Reconstr Microsurg 29:69–75. https://doi.org/10.1055/s-0032-1329923

  17. 17.

    Assaf AT, Zrnc TA, Remus CC, Adam G, Zustin J, Heiland M, Friedrich RE, Derlin T (2015) Intraindividual comparison of preoperative (99m)Tc-MDP SPECT/CT and intraoperative and histopathological findings in patients with bisphosphonate- or denosumab-related osteonecrosis of the jaw. J Craniomaxillofac Surg 43:1461–1469. https://doi.org/10.1016/j.jcms.2015.06.025

  18. 18.

    Hakim SG, Bruecker CW, Jacobsen H, Hermes D, Lauer I, Eckerle S, Froehlich A, Sieg P (2006) The value of FDG-PET and bone scintigraphy with SPECT in the primary diagnosis and follow-up of patients with chronic osteomyelitis of the mandible. Int J Oral Maxillofac Surg 35:809–816. https://doi.org/10.1016/j.ijom.2006.03.029

  19. 19.

    Guggenberger R, Koral E, Zemann W, Jacobsen C, Andreisek G, Metzler P (2014) Cone beam computed tomography for diagnosis of bisphosphonate-related osteonecrosis of the jaw: evaluation of quantitative and qualitative image parameters. Skelet Radiol 43:1669–1678. https://doi.org/10.1007/s00256-014-1951-1

  20. 20.

    Gonen ZB, Yillmaz Asan C, Zararsiz G, Kilic E, Alkan A (2018) Osseous changes in patients with medication-related osteonecrosis of the jaws. Dentomaxillofac Rad 47:20170172. https://doi.org/10.1259/dmfr.20170172

  21. 21.

    Drubach LA (2017) Nuclear medicine techniques in pediatric bone imaging. Semin Nucl Med 47:190–203. https://doi.org/10.1053/j.semnuclmed.2016.12.006

  22. 22.

    Bailey DL, Willowson KP (2013) An evidence-based review of quantitative SPECT imaging and potential clinical applications. J Nucl Med 54:83–89. https://doi.org/10.2967/jnumed.112.111476

  23. 23.

    Ljungberg M, Pretorius PH (2018) SPECT/CT: an update on technological developments and clinical applications. Br J Radiol 91:20160402. https://doi.org/10.1259/bjr.20160402

  24. 24.

    Al Abduwani J, ZilinSkiene L, Colley S, Ahmed S (2016) Cone beam CT paranasal sinuses versus standard multidetector and low dose multidetector CT studies. Am J Otolaryngol 37:59–64. https://doi.org/10.1016/j.amjoto.2015.08.002

  25. 25.

    Ruggiero SL, Dodson TB, Fantasia J, Goodday R, Aghaloo T, Mehrotra B, O'Ryan F, American Association of O and Maxillofacial S (2014) American Association of Oral and Maxillofacial Surgeons position paper on medication-related osteonecrosis of the jaw--2014 update. J Oral Maxillofac Surg 72:1938–1956. https://doi.org/10.1016/j.joms.2014.04.031

  26. 26.

    Buglione M, Cavagnini R, Di Rosario F, Sottocornola L, Maddalo M, Vassalli L, Grisanti S, Salgarello S, Orlandi E, Paganelli C, Majorana A, Gastaldi G, Bossi P, Berruti A, Pavanato G, Nicolai P, Maroldi R, Barasch A, Russi EG, Raber-Durlacher J, Murphy B, Magrini SM (2016) Oral toxicity management in head and neck cancer patients treated with chemotherapy and radiation: dental pathologies and osteoradionecrosis (part 1) literature review and consensus statement. Crit Rev Oncol Hematol 97:131–142. https://doi.org/10.1016/j.critrevonc.2015.08.010

  27. 27.

    Landis JR, Koch GG (1977) The measurement of observer agreement for categorical data. Biometrics 33:159–174

  28. 28.

    Bland JM, Altman DG (2007) Agreement between methods of measurement with multiple observations per individual. J Biopharm Stat 17:571–582. https://doi.org/10.1080/10543400701329422

  29. 29.

    Berg BI, Mueller AA, Augello M, Berg S, Jaquiery C (2016) Imaging in patients with bisphosphonate-associated osteonecrosis of the jaws (MRONJ). Dent J 4. https://doi.org/10.3390/dj4030029

  30. 30.

    Hong CM, Ahn BC, Choi SY, Kim DH, Lee SW, Kwon TG, Lee J (2012) Implications of three-phase bone scintigraphy for the diagnosis of bisphosphonate-related osteonecrosis of the jaw. Nucl Med Mol Imaging 46:162–168. https://doi.org/10.1007/s13139-012-0144-x

  31. 31.

    O'Ryan FS, Khoury S, Liao W, Han MM, Hui RL, Baer D, Martin D, Liberty D, Lo JC (2009) Intravenous bisphosphonate-related osteonecrosis of the jaw: bone scintigraphy as an early indicator. J Oral Maxillofac Surg 67:1363–1372. https://doi.org/10.1016/j.joms.2009.03.005

  32. 32.

    Cankaya AB, Erdem MA, Isler SC, Demircan S, Soluk M, Kasapoglu C, Oral CK (2011) Use of cone-beam computerized tomography for evaluation of bisphosphonate-associated osteonecrosis of the jaws in an experimental rat model. Int J Med Sci 8:667–672

  33. 33.

    Assaf AT, Zrnc TA, Riecke B, Wikner J, Zustin J, Friedrich RE, Heiland M, Smeets R, Grobe A (2014) Intraoperative efficiency of fluorescence imaging by Visually Enhanced Lesion Scope (VELscope) in patients with bisphosphonate related osteonecrosis of the jaw (BRONJ). J Craniomaxillofac Surg 42:e157–e164. https://doi.org/10.1016/j.jcms.2013.07.014

  34. 34.

    Otto S, Ristow O, Pache C, Troeltzsch M, Fliefel R, Ehrenfeld M, Pautke C (2016) Fluorescence-guided surgery for the treatment of medication-related osteonecrosis of the jaw: a prospective cohort study. J Craniomaxillofac Surg 44:1073–1080. https://doi.org/10.1016/j.jcms.2016.05.018

  35. 35.

    Hutchinson M, O'Ryan F, Chavez V, Lathon PV, Sanchez G, Hatcher DC, Indresano AT, Lo JC (2010) Radiographic findings in bisphosphonate-treated patients with stage 0 disease in the absence of bone exposure. J Oral Maxillofac Surg 68:2232–2240. https://doi.org/10.1016/j.joms.2010.05.003

Download references


We want to thank the Clinical Trials Unit Bern for their support in data management and statistics.


The work was supported by the Swiss Association of Dentomaxillofacial Radiology (SADMFR; Grant Number 17/02).

Author information

Correspondence to Johann Malina-Altzinger.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.

Informed consent

For this type of study, formal consent is not required.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Malina-Altzinger, J., Klaeser, B., Suter, V.G. et al. Comparative evaluation of SPECT/CT and CBCT in patients with mandibular osteomyelitis and osteonecrosis. Clin Oral Invest 23, 4213–4222 (2019). https://doi.org/10.1007/s00784-019-02862-8

Download citation


  • Single-photon emission computed tomography
  • Cone beam computed tomography
  • Radiography
  • Osteomyelitis
  • Osteonecrosis
  • Mandible