Current therapy
Bisphosphonate Osteochemonecrosis (Bis-Phossy Jaw): Is This Phossy Jaw of the 21st Century?

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Purpose

Bisphosphonates are being implicated in a growing number of complications of the jaws. A number of terms are being applied to this phenomenon and perhaps the descriptive term bisphosphonate osteochemonecrosis has the most merit. But the eerie similarity of this 21st century disease process with the 19th century disease known as phossy jaw is striking. As the nomenclature continues to evolve, the term used in this article will be bis-phossy jaw. This article will explore historical and current aspects of these diseases. Although there may be other mitigating factors, such as oral health, chemotherapy history, immune status, Karnofsky performance status, or Kaplan-Feinstein index, bisphosphonates appear to be the necessary component in cases of bis-phossy jaw.

Materials

This is primarily a review article on reported cases of bis-phossy jaw, with historical looks at phossy jaw and osteoradionecrosis. Our laboratory has reviewed 20 suspected cases of bis-phossy jaw and the typical histopathologic features of bis-phossy jaw are presented.

Results

Descriptions of phossy jaw and current bis-phossy jaw cases are remarkably similar. Histopathologic features of bis-phossy jaw showed intact vascular channels, even in areas with acute inflammatory infiltrates and bacterial overgrowth. Non-vital bone fragments with reduced evidence of osteoclastic action were also noted.

Conclusion

Bis-phossy jaw may have more of a bacterial cofactor risk than osteoradionecrosis, and though altered angiogenesis may yet prove to be a factor, avascularity does not appear to be a major cofactor. The historical disease phossy jaw appears to serve as a possible analogous disease for current research and treatment of bis-phossy jaw. Prevention and early identification of patients at risk should be of prime concern.

Section snippets

Historical aspects and nomenclature

History may help us in our endeavors to diagnose and treat bisphosphonate associated effects of the jaws. White phosphorus, the cause of phossy jaw, appears to have had similar skeletal effects as bisphosphonate therapy. Phossy jaw has interesting historical aspects and was known by several nomenclature variations. Phosphorus necrosis was perhaps the most common and proper term used in publication. However, “phossy” jaw was also commonly used and appears to have been the term used most often in

Phossy jaw review

Phossy jaw was first described in the mid portion of the 19th century, when it became apparent that workers in the matchmaking industry were being afflicted with an unusual necrosis of the jaws. Lorinser first reported these cases in 1845.24 The victims were often young and otherwise healthy. Eventually, the workers were diagnosed with what became known as phossy jaw or phosphorus necrosis. The morbidity and mortality associated with phossy jaw were significant. Severe pain and deformity were

Modern bis-phossy jaw findings and further review

In comparing modern cases of bis-phossy jaw with osteoradionecrosis, we are also seeing differences. In the last year, 20 cases of osteomyelitis in patients with a history of breast cancer, prostate cancer, or multiple myeloma have been reviewed at the University of Iowa Surgical Oral Pathology Laboratory (Iowa City, IA). Bisphosphonates were confirmed or suspected as cofactors in these cases. A review showed that bacteria were commonly associated with the non-vital bone fragments. In addition,

Therapy and prevention

First, as related to the above sequence, we as oral health care providers should be able to apply the criteria we currently use in patients before artificial replacement of large joints, head and neck radiation, bone marrow transplant, and organ transplant patients. Second, at least in the case of widespread metastatic disease, nuclear medicine scans of the jaws should be available on most patients being worked up for such metastatic diseases. We must immediately require nuclear medicine

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    Copyright © 2005 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.