Osteochemonecrosis: an overview

Abstract

Osteonecrosis of the jaw to a certain extent has been with us for many years. But recently the advent of various medications such as bisphosphonates, VEGF inhibitors, tyrosine kinase inhibitors and humanized antibodies to osteoclastic action have resulted in thousands of cases. While the bisphosphonates continue to be the most common medication associated with osteochemonecrosis antibodies such as denosumab which irreversibly act on osteoclastic action are also being reported. This narrative review will serve as an update with a focus on some of the histopathologic features discussed and reviewed. Perhaps even more uncommonly seen in past reports a discussion of features possibly observed while grossing specimens will be discussed. At the end of this report is hoped that the pathologist will have a better understanding of the historical features, clinical settings, gross examination features as well as histopathologic features associated with osteochemonecrosis.

Fig. 1

Bisphosphonate osteochemonecrosis in a low bone density patient. Presentation on palate with underlying granulation tissue, sequestrectomy specimen and healing at about 6 weeks post sequestrectomy. New areas of exposed bone are also noted. Arrows indicate the slight chlorhexidine staining

Fig. 2

Example of surface bacteria with relatively fine resorptive bone features compared to the underlying nonexposed bone with a coarser resorptive pattern more likely to represent past osteoclastic action

Fig. 3

Radiographic composite image showing axial, sagittal, coronal and “3-D”reconstruction aspects of a sequestrum in the right mandibular alveolus

Fig. 4

Additional photomicrograph displaying typical Howship lacunae, detached osteoclasts, neutrophils and granulation tissue

Fig. 5

Actinomycotic colonies seen on the nonexposed side near soft tissue, with a thin layer of bacterial colonization on the exposed bone surface