Figure 1: Orthopantogram (cone beam computed tomography) of a partially edentulous maxilla and mandible. Right posterior edentulous body and proximal ramus of the mandible showing 3x2 cm non-viable bony sequestrum surrounded by necrotic tissue. The lesion is noted to extend from the oral cavity superiorly and to the inferior alveolar canal inferiorly. The inferior alveolar canal is a linear hypodensity traveling through the ramus and body of the mandible.
Figure 2: A. Acellular necrotic bone (sequestrum) from edentulous part of mandible. Note lack of viable marrow elements, rimming osteoblasts, osteoclasts, bony remodeling, or metastatic carcinoma (hematoxylin-eosin, original magnification x 40). B. Absence of osteocytes in lacunar spaces (hematoxylin-eosin, original magnification x 40). C. Chronic inflammation of periosteal soft tissue. Note reactive (polyclonal) increase in CD138 positive plasma cells (CD138 immunohistochemical stain, original magnification x 40).
condition is seldom curable. Before commencement of BP therapy, patients should undergo a clinical and radiographic dental examination. Any necessary dental procedures should be completed before onset of BP therapy. On detec- tion of BRONJ, BP therapy should be discontinued and the jaw stabilized to reduce symptoms. 4,12 Treatment for Stage 1 and 2 BRONJ is typicallymedical. A recent prospective clinical trial byMoretti et al. used anti- biotic therapy (Augmentin/Flagyl or Ciprofloxacin/Flagyl) for the acute phase of infection, in addition to antiseptic oral rinses, (Chlorhexidine digluconate 0.12% and essential oils) and achieved control of pain with statistically significant
reduction in the diameter of the initial lesion. 13 It should be noted, however, that with the minimally invasive protocol described, many patients remained with exposed bone, despite reduction in size. Surgical treatment is reserved for Stage 3 or higher as aggressive surgery may result in larger areas of exposed bone and worsening BRONJ. Hyperbaric oxygen (HBO) is effective when used in conjunction with other therapies and may neutralize the antiangiogenic ef- fects of aminobisphosphonates. While hyperbaric oxygen therapy is not indicated as the primarymethod of treatment for BRONJ, a recent randomized controlled trial by Frie- berger et al. showed a decreasedmean time to improvement
J La State Med Soc VOL 166 September/October 2014 201
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