Skip to main content

Advertisement

SpringerLink
Log in

Radiographic findings of bisphosphonate-related osteomyelitis of the jaw: investigation of the diagnostic points by comparison with radiation osteomyelitis, suppurative osteomyelitis, and diffuse sclerosing osteomyelitis

  • Original Article
  • Published:
Oral Radiology Aims and scope Submit manuscript

Abstract

Objectives

To investigate the possibility of radiographic examination as a tool for differential diagnosis of bisphosphonate-related osteomyelitis of the jaw (BROMJ).

Methods

The radiographic findings of the mandibular lesions in 25 BROMJ patients were compared with those in 36 radiation osteomyelitis, 92 suppurative osteomyelitis, and 34 diffuse sclerosing osteomyelitis patients. The diagnostic criterion for BROMJ was osteomyelitis in patients with experience of bisphosphonate therapy. The amount and duration of bisphosphonate administration and presence and term of bone exposure were not considered for diagnosis.

Results

BROMJ revealed characteristic radiographic findings. Osteolytic change that started at the superficial layer of bone (cortical bone), followed by extension between the cortical and cancellous bone, large cancellous bone sequestrum formation often accompanied by extensive osteolytic change of the cortical bone or fairly large cortical bone sequestrum formation, and solid-type periosteal reaction formed at a site related to the margin of the remaining cortical bone were found to be pathognomonic, and were observed not only in cases with bone exposure but also in cases without bone exposure. A relationship between lamina dura thickening and the lesion was doubtful. Osteosclerotic change was frequent and remarkable, but not specific.

Conclusions

Radiographic examination was considered to be useful for differential diagnosis of BROMJ. Inclusion of the pathognomonic radiographic findings into the definition of BROMJ will make it possible to achieve earlier and more accurate diagnoses. In addition, the active bone remodeling in the lesions confirmed by radiography suggested that osteonecrosis was not the cause, but the result of infection.

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

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8
Fig. 9
Fig. 10
Fig. 11
Fig. 12
Fig. 13
Fig. 14
Fig. 15
Fig. 16

Similar content being viewed by others

References

  1. Ruggiero SL, Mehrotra B, Rosenberg TJ, Engroff SL. Osteonecrosis of the jaws associated with the use of bisphosphonates: a review of 63 cases. J Oral Maxillofac Surg. 2004;62:527–34.

    Article  PubMed  Google Scholar 

  2. Hansen T, Kunkel M, Springer E, Walter C, Weber A, Siegel E, et al. Actinomycosis of the jaws—histopathological study of 45 patients shows significant involvement in bisphosphonate-associated osteonecrosis and infected osteoradionecrosis. Virchows Arch. 2007;451:1009–17.

    Article  PubMed  Google Scholar 

  3. Kumar SK, Gorur A, Schaudinn C, Shuler CF, Costerton JW, Sedghizadeh PP. The role of microbial biofilms in osteonecrosis of the jaw associated with bisphosphonate therapy. Curr Osteoporos Rep. 2010;8:40–8.

    Article  PubMed  Google Scholar 

  4. Aspenberg P. Osteonecrosis of the jaw: what do bisphosphonates do? Expert Opin Drug Saf. 2006;5:743–5.

    Article  PubMed  Google Scholar 

  5. Marx RE. Reconstruction of defects caused by bisphosphonate-induced osteonecrosis of the jaws. J Oral Maxillofac Surg. 2009;67:107–19.

    Article  PubMed  Google Scholar 

  6. Suei Y, Taguchi A, Tanimoto K. Diagnosis and classification of mandibular osteomyelitis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005;100:207–14.

    Article  PubMed  Google Scholar 

  7. Ruggiero SL, Dodson TB, Assael LA, Landesberg R, Marx RE, Mehrotra B. American Association of Oral and Maxillofacial Surgeons position paper on bisphosphonate-related osteonecrosis of the jaws—2009 update. J Oral Maxillofac Surg. 2009;67:2–12.

    PubMed  Google Scholar 

  8. Fedele S, Porter SR, D’Aiuto F, Aljohani S, Vescovi P, Manfredi M, et al. Nonexposed variant of bisphosphonate-associated osteonecrosis of the jaw: a case series. Am J Med. 2010;123:1060–4.

    Article  PubMed  Google Scholar 

  9. Junquera L, Gallego L. Nonexposed bisphosphonate-related osteonecrosis of the jaws: another clinical variant? J Oral Maxillofac Surg. 2008;66:1516–7.

    Article  PubMed  Google Scholar 

  10. Pozzi S, Marcheselli R, Sacchi S, Baldini L, Angrilli F, Pennese E, et al. Bisphosphonate-associated osteonecrosis of the jaw: a review of 35 cases and an evaluation of its frequency in multiple myeloma patients. Leuk Lymphoma. 2007;48:56–64.

    Article  PubMed  Google Scholar 

  11. Suei Y, Taguchi A, Tanimoto K. Radiographic evaluation of possible etiology of diffuse sclerosing osteomyelitis of the mandible. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1997;84:571–7.

    Article  PubMed  Google Scholar 

  12. Suei Y, Taguchi A, Tanimoto K. Diagnostic points and possible origin of osteomyelitis in synovitis, acne, pustulosis, hyperostosis and osteitis (SAPHO) syndrome: a radiographic study of 77 mandibular osteomyelitis cases. Rheumatology. 2003;42:1398–403.

    Article  PubMed  Google Scholar 

  13. Arce K, Assael LA, Weissman JL, Markiewicz MR. Imaging findings in bisphosphonate-related osteonecrosis of jaws. J Oral Maxillofac Surg. 2009;67:75–84.

    Article  PubMed  Google Scholar 

  14. Yoneda T, Hagino H, Sugimoto T, Ohta H, Takahashi S, Soen S, et al. Bisphosphonate-related osteonecrosis of the jaw: position paper from the Allied Task Force Committee of Japanese Society for Bone and Mineral Research, Japan Osteoporosis Society, Japanese Society of Periodontology, Japanese Society for Oral and Maxillofacial Radiology, and Japanese Society of Oral and Maxillofacial Surgeons. J Bone Miner Metab. 2010;28:365–83.

    Article  PubMed  Google Scholar 

  15. Bisdas S, Chambron Pinho N, Smolarz A, Sader R, Vogl TJ, Mack MG. Bisphosphonate-induced osteonecrosis of the jaws: CT and MRI spectrum of findings in 32 patients. Clin Radiol. 2008;63:71–7.

    Google Scholar 

  16. Krishnan A, Arslanoglu A, Yildirm N, Silbergleit R, Aygun N. Imaging findings of bisphosphonate-related osteonecrosis of the jaw with emphasis on early magnetic resonance imaging findings. J Comput Assist Tomogr. 2009;33:298–304.

    Article  PubMed  Google Scholar 

  17. Reid IR, Cundy T. Osteonecrosis of the jaw. Skeletal Radiol. 2009;38:5–9.

    Article  PubMed  Google Scholar 

  18. Fatterpekar GM, Emmrich JV, Eloy JA, Aggarwal A. Bone-within-bone appearance: a red flag for bisphosphonate-associated osteonecrosis of the jaw. J Comput Assist Tomogr. 2011;35:553–6.

    Article  PubMed  Google Scholar 

  19. Phal PM, Myall RW, Assael LA, Weissman JL. Imaging findings of bisphosphonate-associated osteonecrosis of the jaws. Am J Neuroradiol. 2007;28:1139–45.

    Article  PubMed  Google Scholar 

  20. Store G, Larheim TA. Mandibular osteoradionecrosis: a comparison of computed tomography with panoramic radiography. Dentomaxillofac Radiol. 1999;28:295–300.

    Article  PubMed  Google Scholar 

  21. Hermans R, Fossion E, Ioannides C, Van den Bogaert W, Ghekiere J, Baert AL. CT findings in osteoradionecrosis of the mandible. Skeletal Radiol. 1996;25:31–6.

    Article  PubMed  Google Scholar 

  22. Bianchi SD, Scoletta M, Cassione FB, Migliaretti G, Mozzati M. Computerized tomographic findings in bisphosphonate-associated osteonecrosis of the jaw in patients with cancer. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007;104:249–58.

    Article  PubMed  Google Scholar 

  23. Chiandussi S, Biasotto M, Dore F, Cavalli F, Cova MA, Di Lenarda R. Clinical and diagnostic imaging of bisphosphonate-associated osteonecrosis of the jaws. Dentomaxillofac Radiol. 2006;35:236–43.

    Article  PubMed  Google Scholar 

  24. Mawardi H, Treister N, Richardson P, Anderson K, Munshi N, Faiella RA, et al. Sinus tracts—an early sign of bisphosphonate-associated osteonecrosis of the jaws? J Oral Maxillofac Surg. 2009;67:593–601.

    Article  PubMed  Google Scholar 

  25. Raje N, Woo SB, Hande K, Yap JT, Richardson PG, Vallet S, et al. Clinical, radiographic, and biochemical characterization of multiple myeloma patients with osteonecrosis of the jaw. Clin Cancer Res. 2008;14:2387–95.

    Article  PubMed  Google Scholar 

  26. Treister NS, Friedland B, Woo SB. Use of cone-beam computerized tomography for evaluation of bisphosphonate-associated osteonecrosis of the jaws. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010;109:753–64.

    Article  PubMed  Google Scholar 

  27. Landesberg R, Woo V, Cremers S, Cozin M, Marolt D, Vunjak-Novakovic G, et al. Potential pathophysiological mechanisms in osteonecrosis of the jaw. Ann N Y Acad Sci. 2011;1218:62–79.

    Article  PubMed  Google Scholar 

  28. Bedogni A, Blandamura S, Lokmic Z, Palumbo C, Ragazzo M, Ferrari F, et al. Bisphosphonate-associated jawbone osteonecrosis: a correlation between imaging techniques and histopathology. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008;105:358–64.

    Article  PubMed  Google Scholar 

  29. Mortensen M, Lawson W, Montazem A. Osteonecrosis of the jaw associated with bisphosphonate use: presentation of seven cases and literature review. Laryngoscope. 2007;117:30–4.

    Article  PubMed  Google Scholar 

  30. Hutchinson M, O’Ryan F, Chavez V, Lathon PV, Sanchez G, Hatcher DC, et al. Radiographic findings in bisphosphonate-treated patients with stage 0 disease in the absence of bone exposure. J Oral Maxillofac Surg. 2010;68:2232–40.

    Article  PubMed  Google Scholar 

  31. Patel S, Choyee S, Uyanne J, Nguyen AL, Lee P, Sedghizadeh PP, et al. Non-exposed bisphosphonate-related osteonecrosis of the jaw: a critical assessment of current definition, staging, and treatment guidelines. Oral Dis. 2012;18:625–32.

    Article  PubMed  Google Scholar 

  32. Bedogni A, Fusco V, Agrillo A, Campisi G. Learning from experience. Proposal of a refined definition and staging system for bisphosphonate-related osteonecrosis of the jaw (BRONJ). Oral Dis. 2012;18:621–3.

    Article  PubMed  Google Scholar 

  33. Marx RE, Tursun R. Suppurative osteomyelitis, bisphosphonate induced osteonecrosis, osteoradionecrosis: a blinded histopathologic comparison and its implications for the mechanism of each disease. Int J Oral Maxillofac Surg. 2012;41:283–9.

    Article  PubMed  Google Scholar 

  34. Lesclous P, Abi Najm S, Carrel JP, Baroukh B, Lombardi T, Willi JP, et al. Bisphosphonate-associated osteonecrosis of the jaw: a key role of inflammation? Bone. 2009;45:843–52.

  35. García-Ferrer L, Bagán JV, Martínez-Sanjuan V, Hernandez-Bazan S, García R, Jiménez-Soriano Y, et al. MRI of mandibular osteonecrosis secondary to bisphosphonates. Am J Roentgenol. 2008;190:949–55.

    Article  Google Scholar 

  36. Treister N, Sheehy N, Bae EH, Friedland B, Lerman M, Woo S. Dental panoramic radiographic evaluation in bisphosphonate-associated osteonecrosis of the jaws. Oral Dis. 2009;15:88–92.

    Article  PubMed  Google Scholar 

  37. Paparella ML, Brandizzi D, Santini-Araujo E, Cabrini RL. Histopathological features of osteonecrosis of the jaw associated with bisphosphonates. Histopathology. 2012;60:514–6.

    Article  PubMed  Google Scholar 

  38. Marx RE, Sawatari Y, Fortin M, Broumand V. Bisphosphonate-induced exposed bone (osteonecrosis/osteopetrosis) of the jaws: risk factors, recognition, prevention, and treatment. J Oral Maxillofac Surg. 2005;63:1567–75.

    Article  PubMed  Google Scholar 

  39. Hellstein JW, Marek CL. Bisphosphonate osteochemonecrosis (bis-phossy jaw): is this phossy jaw of the 21st century? J Oral Maxillofac Surg. 2005;63:682–9.

    Article  PubMed  Google Scholar 

  40. Stockmann P, Hinkmann FM, Lell MM, Fenner M, Vairaktaris E, Neukam FW, et al. 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. 2010;14:311–7.

    Article  PubMed  Google Scholar 

  41. Khosla S, Burr D, Cauley J, Dempster DW, Ebeling PR, Felsenberg D, et al. Bisphosphonate-associated osteonecrosis of the jaw: report of a task force of the American Society for Bone and Mineral Research. J Bone Miner Res. 2007;22:1479–91.

    Article  PubMed  Google Scholar 

Download references

Conflict of interest

There are no financial or other relations that could lead to a conflict of interest.

Author information

Authors and Affiliations

  1. Department of Oral and Maxillofacial Radiology, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, Japan

    Yoshikazu Suei

Authors
  1. Yoshikazu Suei
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Yoshikazu Suei.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Suei, Y. Radiographic findings of bisphosphonate-related osteomyelitis of the jaw: investigation of the diagnostic points by comparison with radiation osteomyelitis, suppurative osteomyelitis, and diffuse sclerosing osteomyelitis. Oral Radiol 29, 121–134 (2013). https://doi.org/10.1007/s11282-013-0135-3

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11282-013-0135-3

Keywords

Search

Navigation