Bisphosphonate-induced osteoradionecrosis
A 62-year-old, average built, male with average nutrition status of middle income group reported to Oral and Maxillofacial Surgery Clinic with complaint of swelling over left lower jaw since 4 months []. He suffered from orofacial pain and reduced oral opening. The symptoms were acute which subsequently became chronic with foul smelling discharge with a cutaneous fistula and numbness over left lower lip for last 3 months.\nHis past medical history was significant for multiple myeloma diagnosed 3 years back for which he underwent chemotherapy (26 cycles) and was on monthly doses of Zometa. He also underwent radiotherapy of knee and spine a year back. He was being treated for hypertension and diabetes which was being efficiently treated.\nPast dental history revealed that he underwent sequestrectomy on the left alveolus 1 year back.\nThe local examination revealed he was partially edentulous with dehiscence in the alveolar mucosa in left body of mandible and exposure of bone looking yellowish-white in the posterior mandibular region []. Sensory testing of the left lower lip revealed parasthesia of V3. There was mild purulent discharge from the intraoral wound and cutaneous fistula, which was sent for culture sensitivity test. The cultures revealed presence of Staphylococcus aureus, moderate growth of Streptococcus viridans, gram-negative rods and gram-positive cocci.\nOrthopantogram showed diffuse osteolytic lesions and erosion of left side body of mandible involving both buccal and lingual cortical plates []. The routine hemogram was not very significant except raised erythrocyte sedimentation rate (ESR) which was- 86 mm first hour. The scintigraphy which is a definite diagnostic tool for osteomyelitis could not be done because of nonavailability.\nFine needle aspiration (FNA) was performed and pieces of bone were sent for histopathology to rule out multiple myeloma lesions. The FNA revealed inflammatory cells-predominantly atypical lymphocytes and neutrophils-and also was positive for actinomyces. Histopathologically there was anastomizing lamellar bony trabeculae and inflammatory cell infiltration comprising of lymphocytes, plasma cells and histiocytes with congested blood vessels suggestive of chronic osteomyelitis [].\nCorrelating history, clinical evaluation and investigations, diagnosis of BRONJ was derived and sequestrectomy with aggressive debridement under antibiotic coverage was done. Six months follow-up showed no recurrence. Patient is currently under regular follow-up.