In the past, osteomyelitis was frequent and characterized by a prolonged course, treatment response uncertainty, and occasional disfigurement. Today, the disease is less common; it is believed that the decline in prevalence may be attributed to increased availability of antibiotics and improvement of overall health patterns. Currently, more common osteomyelitis variants are seen, namely, osteoradionecrosis (ORN) and bisphosphonate-related osteonecrosis of the jaws (BRONJ). Osteomyelitis, ORN, and BRONJ can present with similar symptoms, signs, and radiographic findings. However, each condition is a separate entity, with different treatment approaches. Thus, accurate diagnosis is essential for adequate management and improved patient prognosis. The aim of this paper is to report three cases of inflammatory lesions of the jaws—osteomyelitis, ORN, and BRONJ—and to discuss their etiology, clinical aspects, radiographic findings, histopathological features, treatment options, and preventive measures.
The osteomyelitis is an inflammatory condition of the bone, which generally begins as an infection of the marrow cavity, rapidly involves the Haversian canals, and eventually extends to the periosteum [
Currently, more common osteomyelitis variants are seen. ORN is one of the most serious complications in the treatment of head and neck malignancies and is defined as the ischemic necrosis of the irradiated bone, which becomes hypovascular, hypocellular, and hypoxic [
Osteomyelitis, ORN, and BRONJ can present with similar symptoms, signs, and radiographic findings. However, each condition is a separate entity, with different management approaches [
A 77-year-old white female was seen at the Oral Medicine Clinic of the Federal University of Alfenas (UNIFAL-MG) with an asymptomatic, smooth surfaced, normal colored tumor on the anterior mandibular alveolar ridge, with two months evolution. A drainage point with purulent material was also present (Figure
((a) and (b)) Initial clinical and radiographic features of osteomyelitis, located in the anterior mandible, consistent with necrotic bone.
Surgical removal of bone sequestration.
((a) and (b)) Clinical and radiographic aspects 30 days after surgery showing almost complete healing of the operated area.
A 46-year-old male was seen at the Oral Medicine Clinic of the UNIFAL-MG with chief complaint of pain in the area of tooth no. 20. Medical history revealed a history of oral squamous cell carcinoma 15 months before. The cancer had been treated with 40 sessions of radiotherapy and 7 cycles of chemotherapy six months before. No surgical treatment and preradiotherapy dental assessment had been performed. A history of tobacco and alcohol use was also reported. Clinical examination showed splinting of anterior teeth due to periodontal disease, absence of teeth, and generalized radiation caries. Radiographic examination showed generalized bone loss. In view of the patient’s unsatisfactory oral condition and due to the short period since the end of radiotherapy, a conservative approach was instituted. Preventive and restorative procedures were executed for oral health establishment. Subsequently, no. 28 and the anterior incisors, presenting extensive carious lesions with periapical involvement, were extracted under antibiotic therapy (500 mg amoxicillin, three times a day, for 10 days). After 15 days, the extraction site in the region of no. 28 failed to heal appropriately. Thus, irrigation with sodium iodide and chlorhexidine, as well as surgical debridement, was instituted. After 7 days, no improvement was noted; clinical examination revealed an ulcer with an erythematous halo and a serofibrinous pseudomembrane (Figure
(a) Clinical aspects of osteoradionecrosis showing bone exposure of the operated area. (b) Panoramic radiograph showing pathological fracture in the mandible.
A 51-year-old female was referred for evaluation of a submental fistula with purulent drainage, with evolution of 7 days (Figure
((a) and (b)) Clinical aspect of BRONJ showing purulent drainage in the submental region and absence of radiographic changes.
Osteomyelitis, ORN, and BRONJ are all, in general, more common in the mandible (angle and body) than in the maxilla. This likely occurs due to the mandible’s increased density and less vascularized cortical plates. Also, in contrast to the maxilla, the mandible has only a single blood supply source, from the inferior alveolar neurovascular bundle [
Local and systemic host factors are key in understanding the pathogenesis of osteomyelitis [
The pathogenesis of ORN has not yet been fully elucidated. It is thought that radiation-generated free radicals and corresponding damage to endothelial cells lead to hypovascularity, tissue hypoxia, destruction of bone-forming cells, and marrow fibrosis [
ORN is typically associated with surgical extractions, which should ideally be performed 21 days before initiation of RT [
Bisphosphonates are primarily effectively employed in neoplasia-related conditions, such as malignant hypercalcemia, bony metastasis, and lytic lesions of multiple myelomas [
Surgical therapy in association with antibiotics and anti-inflammatory drugs has been shown to be beneficial for patients with all three types of disease, with significant improvement in quality of life. Still, exacerbations may occur and regular follow-up is necessary [
Bone inflammatory diseases are important due to high morbidity and mortality rates. Even with a decline in traditional osteomyelitis, ORN and BRONJ have emerged as important secondary consequences of commonly used therapeutics. Osteomyelitis, ORN, and BRONJ may present with similar sign and symptoms; thus, it is crucial for oral health professionals to differentiate between these processes. A correct diagnosis will allow adequate management and improve patients’ prognosis. Dentists also play an important role in preventing damage, by providing pretherapy care aiming to eliminate compromising or infectious foci.
The authors declare that there is no conflict of interests regarding the publication of this paper.
The authors wish to thank FAPEMIG (Fundação de Amparo à Pesquisa do Estado de Minas Gerais) for supporting this study.