A 68-year-old woman comes to the office due to oral pain. For the last 3 days, she has had mild pain in the left lower jaw associated with swelling of the gums. The patient had a loose molar extracted 3 weeks ago, and the extraction site never completely healed. Medical history is notable for osteoporosis treated with calcium, vitamin D, and zoledronic acid. She has never used tobacco or alcohol. Vital signs are normal. Examination shows gingival edema and erythema surrounding an area of exposed bone at the left lower jaw. Which of the following is the most likely diagnosis?

Question

A 68-year-old woman comes to the office due to oral pain.  For the last 3 days, she has had mild pain in the left lower jaw associated with swelling of the gums.  The patient had a loose molar extracted 3 weeks ago, and the extraction site never completely healed.  Medical history is notable for osteoporosis treated with calcium, vitamin D, and zoledronic acid.  She has never used tobacco or alcohol.  Vital signs are normal.  Examination shows gingival edema and erythema surrounding an area of exposed bone at the left lower jaw.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d860_eb49_bc81_ef9f153208bd_MD0003_00 This patient has a nonhealing dental extraction site associated with local swelling, mild pain, and exposed bone. Given her treatment of osteoporosis with zoledronic acid, these findings most likely represent bisphosphonate-related osteonecrosis of the jaw (ONJ), which is likely caused, at least in part, by impaired bone remodeling. It is most common in patients receiving high-dose parenteral bisphosphonates in the context of cancer therapy, but it can also occur in those taking bisphosphonates for osteoporosis. ONJ classically presents as an area of exposed, necrotic bone following tooth extractions or other dental procedures. It may persist for extended periods (months to years) and is often asymptomatic for much of the course. The mandible is more commonly affected than the maxilla. Treatment is largely supportive, including careful oral hygiene and antibacterial rinses; oral antibiotics and limited debridement are used only when needed. Because the course can be intractable, some experts advise dental consultation and completion of any anticipated dental procedures prior to initiation of bisphosphonate therapy. (Choices A and B) Both aphthous ulcers and herpetic stomatitis present with painful oral ulcers. However, these conditions cause superficial ulcerations without exposed bone that heal spontaneously, usually within 7-10 days. (Choice C) Mucormycosis (acute invasive fungal sinusitis) can present with pain and bone destruction. However, it occurs almost exclusively in immunocompromised patients (eg, those with uncontrolled diabetes mellitus) and presents with rapidly progressive fever, facial pain, nasal congestion, and changes in vision or mentation. (Choice E) Periodontal abscess can cause pain and swelling of tissues surrounding the affected tooth, but symptoms are typically acute. Patients usually have associated fever and lymphadenopathy. (Choice F) Like ONJ, squamous cell carcinoma can present as a nonhealing oral ulceration, and biopsy is often required for definitive diagnosis. However, this patient has no other clinical features (eg, cervical lymphadenopathy) or risk factors (eg, tobacco, heavy alcohol use) for oral cancer. Her history of bisphosphonate use makes ONJ much more likely. Educational objective: Bisphosphonate-related osteonecrosis of the jaw is characterized by chronic swelling, mild pain, and exposed, necrotic bone. It is often triggered by tooth extractions or other invasive dental procedures. The course can be intractable, and treatment is largely supportive with careful oral hygiene and antibacterial rinses. References: Diagnosis and management of osteonecrosis of the jaw: a systematic review and international consensus. (http://www.ncbi.nlm.nih.gov/pubmed/25414052)

A 68-Year-Old Woman Comes to the Office Due to Oral