The use of bisphosphonates seems to be associated with the development of ONJ. Length of exposure seems to be the most important risk factor for this complication. The type of bisphosphonate may play a role and previous dental procedures may be a precipitating factor.

In conclusion, the risk of developing ONJ after treatment of zoledronic acid is reduced (but not deleted) by the implementation of preventive measures.

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IntroductionTumors can metastasize to the oral cavity and affect the jaws, soft tissue and salivary glands. Oral cavity metastases are considered rare and represent approximately 1% of all oral malignancies. Because of their rarity and atypical clinical and radiographic appearance, metastatic lesions are considered a diagnostic challenge. The purpose of this report is to present a rare case of a metastatic breast carcinoma mimicking a periodontal abscess in the mandible.Case presentationA 55-year-old Caucasian woman was referred to our clinic for evaluation of bisphosphonate-induced jaw osteonecrosis. She had undergone modified radical mastectomy with axillary lymph node dissection for invasive ductal carcinoma of the left breast. Her clinical examination showed diffuse swelling and a periodontal pocket of 6 mm exhibiting suppuration in the posterior right mandible. Moreover, paresthesia of the lower right lip and chin was noted. There were no significant radiographic findings other than alveolar bone loss due to her periodontal disease. Although the lesion resembled a periodontal abscess, metastatic carcinoma of the breast was suspected on the basis of the patient's medical history. The area was biopsied, and histological analysis confirmed the final diagnosis of metastatic breast carcinoma.ConclusionThe general dentist or dental specialist should maintain a high level of suspicion while evaluating patients with a history of cancer. Paresthesias of the lower lip and the chin should be considered ominous signs of metastatic disease. This case highlights the importance of the value of a detailed medical history and thorough clinical examination for the early detection of metastatic tumors in the oral cavity.

Purpose: Biphosphonates have been approved for the treatment of bone lesions in patients with multiple myeloma. Although these agents are usually well tolerated, osteonecrosis of the jaw (ONJ) has been recently associated with the use of pamidronate and zoledronic acid. Nevertheless, the true incidence of this complication is not clearly defined. Therefore, we studied the incidence, characteristics and risk factors for the development of ONJ among patients with multiple myeloma treated with biphosphonates in our institution. Patients and Methods: One hundred and thirty-seven patients who received biphosphonates (zoledronic acid: 50 pts, pamidronate: 29 patients, bondronate: 2 pts, pamidronate and zoledronic acid: 50 pts, zoledronic acid and bondronate: 5 pts) since January 1995 and had a minimum exposure of 6 months to the drug were included in this analysis. Since the first reports, which associated ONJ with biphosphonate treatment, we prospectively evaluated this complication (first patient diagnosed in July 2003): all patients complaining of symptoms suggestive of ONJ were referred to a maxillofascial surgeon who confirmed the diagnosis and managed the patients for this complication. The medical records of all patients who were included in the analysis were reviewed in order to exclude symptoms and signs of ONJ, which might have not been formally diagnosed. From this retrospective review, no patient with a highly probable diagnosis of ONJ was identified. Results: Ten patients (6.7%) developed ONJ. The median number of treatment cycles and time of exposure to biphosphonates were 26 infusions and 42 months for patients with ONJ compared to19 infusions (p=0.2) and 27 months (p=0.05) for patients with no ONJ. The cumulative hazard of ONJ increased with time to exposure from 0% for exposure 6–12 months to 13% (95% CI: 3–23) for exposure of 5 years. The use of thalidomide was not associated with the development of ONJ. No case of ONJ was observed among patients treated with pamidronate or pamidronate and ibandronate. In patients who received sequential pamidronate and zoledronic acid, all cases of ONJ occurred during the use of zoledronic acid. The cumulative hazard was significantly higher with zoledronic acid compared to pamidronate alone or sequential administration of pamidronate and zoledronic acid (p=0.022). Among the 10 patients, who developed ONJ, 7 had had dental extraction prior to the development of the complication, 2 had dentures and only one had not had either. In spite of the discontinuation of biphosphonate treatment, only one patient experienced improvement of osteonecrosis, in 7 cases it remained stable and in 2 cases osteonecrosis progressed. Conclusions: The use of biphosphonates in patients with multiple myeloma seems to be associated with the development of ONJ. Our cohort study is the first one which provides a fairly accurate estimate of the incidence of documented ONJ after treatment with biphosphonates. Length of exposure and the type of biphosphonate used appear to be the most important risk factor for this complication. The risk of developing osteonecrosis appears to be higher with zoledronic acid than with pamidronate and may be precipitated by dental extraction.