An otherwise well 66-year-old woman was referred with pain, swelling and numbness of the left mandible with pus discharging from around a dental implant. Her problems had developed over the previous six months.
The patient had undergone dental reconstruction 15—20 years previously. This involved eight titanium implants in both jaws with extensive crown and bridge work. (This work involved a personal cost of approximately $25 000 above insurance benefits.)
The woman had been diagnosed with 'borderline osteoporosis'. Her bone mineral density was —2.42 standard deviations below normal (consistent with a diagnosis of osteopenia). She was prescribed 70 mg alendronate weekly but later developed stress fractures. Over three years she took a total dose of 11.2 g.
A clinical diagnosis of bisphosphonate-associated osteonecrosis of the left mandible was made. A CT scan showed extensive involvement around the infected implant. The right mandible and maxilla were not involved.
Alendronate was ceased and non-surgical treatment commenced with 0.12% chlorhexidine mouth washes, intermittent short courses of cephalosporins for the soft tissue infection, and tramadol or paracetamol with codeine for the pain. This controlled the acute symptoms.
One year after stopping alendronate the symptoms recurred. A repeat CT scan showed extension of the necrosis without bone reformation. The involved implant and soft tissue were curetted under general anaesthesia. The wound healed slowly (see Fig. 1).
Clinicians who treat osteoporosis with bisphosphonates need to balance the known beneficial effects of treatment with the small risk of osteonecrosis of the jaws. This risk can be minimised by ensuring that the patient is dentally fit and, in particular, does not require dental extractions or other jawbone surgery, including dental implants.
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