From acids to antibiotics

Needless to say, a proper diagnosis begins with history-taking. To confirm BONJ, clinical examination is most important. In addition, we need imaging of the jaw to see through the underlying bone and in extensive cases, to plan surgery. Biopsy is very rarely done as we now know that the disease is associated with bisphosphonates, whereas in early 2000, it was thought to be caused by the spreading of cancer and biopsy was used to exclude metastases.

Managements of phosphorus necrosis/phossy jaw in Victorian times and BONJ nowadays are similar in a way that both consist of medical and surgical treatment. Before the era of antibiotics, poor phossy jaw patients received hydrochloric acid, sulphuric acid and other potions: see abstract of the first case in England in 1846. For BONJ, there are guidelines recommending its treatment although they are not universally agreed. A rule of thumb is that patients need to keep their mouths clean in order to prevent infection and if there were pain and inflammation, pain-killers and antibiotics are required.

In advanced cases, we need surgery. I am not going to post real photos here since they are too graphic. Below is a wax model illustrating a jaw surgery. It could be showing the removal of a tumour, but the approach is similar. The left cheek of the frowning patient is opened and the flying hands of the surgeon are holding a saw, the blade of which has been wrapped around the jaw. Of course nowadays we do surgeries under general anaesthesia instead of chloroform and we have more advanced tools to help us; the theory is still the same as in the past – cut the diseased part, then reconstruct the jaw to restore function and appearance.

Now you think BONJ is curable? With the above symptomatic treatments, disease at one site can heal, but it can come back afterwards, at the same site or another. Therefore, patients are advised to have regular review appointments.

If you are worried, a dentist should be able to help. Seek treatments early. It is important for everyone to have good dental health and have check-up at least once a year.

  • Ruggiero, Salvatore L, Thomas B Dodson, Leon A Assael, Regina Landesberg, Robert E Marx, and Bhoomi Mehrotra. 2009. “American Association of Oral and Maxillofacial Surgeons Position Paper on Bisphosphonate-related Osteonecrosis of the Jaws–2009 Update.” Journal of Oral and Maxillofacial Surgery: Official Journal of the American Association of Oral and Maxillofacial Surgeons 67 (5 Suppl) (May): 2–12.
  • Wright, W.C. 1846. “Case of Salivation and Diseased Jaw from the Fumes of Phosphorus.” The Medical Times 15 (377) (December): 224–225.
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