Concomitant factors leading to an atypical osteonecrosis of the jaw in a patient with multiple myeloma

Abstract

Osteonecrosis of the jaw (ONJ) is a site specific osseous pathology, characterized by chronic exposed bone in the mouth, which needs to be reinforced periodically within the medical literature. ONJ is a clinical entity with many possible aetiologies and its pathogenesis is not well understood. The risk factors for ONJ include bisphosphonates treatments, head and neck radiotherapy, dental procedures involving bone surgery, and trauma. Management of ONJ has centred on efforts to eliminate or reduce severity of symptoms, to slow or prevent the progression of disease, and to eradicate diseased bone. This case describes a rare case of ONJ in a 64-year-old Caucasian male diagnosed with multiple myeloma stage III. The lesion was related to a traumatic injury during mastication. Eighteen months ago in the same area the molar 37 was extracted, achieving a complete satisfactory healing, when only 2 doses of zoledronic acid had been administered. Actinomyces bacterial aggregates were also identified in the microscopic analysis. The management of this osteonecrotic lesion included antibiotic treatment and chlorhexidine topical gel administration. The evolution was monitored every two weeks until patient's death. The authors provide a discussion of the etiology, pathogenesis, diagnosis, and management. This case report may shed light on the controversies about concomitant factors and mechanisms inducing ONJ.

Figure 1

(a) Clinical image. Chronic suppurated apical periodontitis of tooth 37. Notice the fistula in the buccal area of this molar. (b) Radiological image. Notice the periapical radiolucent lesion in tooth 37.

Figure 2

(a) Panoramic radiograph. Notice the correct healing of the socket after 6 months of the molar 37 extraction. (b) Periapical radiograph. Observe the satisfactory bone density in the socket after 6 months of extraction.

Figure 3

Clinical image. Progression of the lesion. (a) Notice the incipient mucositis and light tumefaction on the affected area. (b) Six weeks later, notice the bone exposure and how the lesion is expanding in mesial direction. ((c) and (d)) Eight weeks later, notice the increase of bone exposure and a characteristic sinus tract with its active exudation.

Figure 4

(a) Panoramic radiograph. Notice in the affected area a high bone density image. (b) CT image. Notice a lingual thin fissure line in the affected area.

Figure 5

Microscopic appearance. (a) Necrotic bone fragment with acute inflammatory reaction with polymorphonuclear. H&E. Original magnification 20x. (b) Notice also the large bacterial aggregate consistent with Actinomyces. H&E. Original magnification 20x.