Febrile illness in a toddler: DIAGNOSIS

DIAGNOSIS

The ‘reactivation’ of a BCG site in this patient is characteristic of Kawasaki disease (KD). The diagnosis was ultimately confirmed when the patient fulfilled the usual criteria for KD: fever for more than five days, bilateral conjunctivitis, cervical lymphadenopathy, generalized rash, erythema of the palms and soles, and subsequent development of erythematous oral mucosa. The patient received both intravenous immunoglobulin (2 g/kg) and acetylsalicylic acid. As well, his neck swelling and irritability improved markedly. He was evaluated by a cardiologist and underwent an echocardiogram, which was normal. He was discharged on acetylsalicylic acid (5 mg/kg/day).

Read the rest of this entry »

Febrile illness in a toddler

Clinical aspects of bisphosphonate-associated oral osteonecrosis: Discussion

The observation of the clinical cases described above could suggest that the origin of osteonecrosis has to be associated to pamidronate and zolendronate-induced insufficient vascularity. Hence, the onset of the lesions could be considered as a com­plication of bisphosphonate treatment as it has been shown by the literature.

In 2003 Marx and Stern were the first to describe osteonecrosis in patients suffering from multiple myeloma and treated with bisphosphonates, even though this medication had been used for more than thirty years.

No osteonecrotic lesions had been observed in the clinical tri­als for these drugs and this leads us to infer that other factors could contribute to the onset of lesions. The selective onset of maxillary lesions could be associated with an ecosystem of the oral cavity that can highly colonize any open wound (post-avul­sion sites).

Maxillary osteonecrosis is probably due to the inability of an hypodynamic and hypovascular bone to support an increased healing demand with bone remodelling following physiological distress (chewing), iatrogenic traumas (tooth avulsions, implant surgery, periodontal operations) and tooth infections in an envi­ronment such as the oral cavity that is continuously exposed to traumas and to a strong bacterial action. Other factors could be concomitant medications with anti-angiogenic properties (such as glucocorticoids, talidomide, chemotherapeutic drugs), dia­betes mellitus, maxillary irradiation, peripheral vascular disor­ders and clinical conditions associated with the development of osteonecrosis in any points.

Read the rest of this entry »

Clinical aspects of bisphosphonate-associated oral osteonecrosis: Treatment

Treatment of patients with bisphosphonates-associated os- teonecrosis was difficult and was based on the different clinical situations. Even tough we do not have any scientific data to sup­port a protocol for the treatment of patients with osteonecrosis treated with bisphosphonates, we are following the recommen­dations issued by the Expert Committee in June 2004. Our study showed a high variability of responses. Despite discontinu­ation of bisphosphonate treatment at the osteonecrosis diagno­sis, none patient showed any improvement. The most common therapeutical approach consisted in the ad­ministration of systemic antibiotics (metronidazole 250×3 mg and moxifloxacine 400 mg/die) combined to a local clorexidine therapy followed by surgical toilette of the necrotic area or re­moval of the bone sequestrum.

Aggressive bone surgery was performed on three patients to remove necrotic bone tissue and to enhance healing starting from the vital bone edges.

Read the rest of this entry »

Clinical aspects of bisphosphonate-associated oral osteonecrosis: Results

Clinical aspects

The most common clinical aspect of the lesions was mucosal ulceration with a non-vital bone exposure (Figs. 1, 2 and 3). In 1 case, we observed a mucosal fistula with a mild serosan- guineous exudation. The exposed bone was yellowish/whitish whereas the surrounding mucosa was often irritated and painful if touched (Fig. 4). On the other hand, the exposed bone did not cause any pain and did not bleed. The clinical situation showed all the features of avascular bone necrosis. Bone lesions showed a quite regular surface that in the fol­lowing became irregular as a consequence of bone micro- traumatisms during chewing. In 1 case, the above mentioned irregularity produced ulcerations of the tongue edge touching the bone surface (Fig. 5). In 4 cases, bone exposed areas in­volved the upper maxillary at the crest and on the palate and in 5 cases the mandible on the postero-lingual and crest ar­eas. When bone necrosis was close to the teeth, a deteriora­tion of the local hygiene conditions was observed, with initial damage to the soft tissue with subsequent increased tooth mobility and loss. Case history revealed a previous interven­tion of the oral cavity, in particular tooth avulsions, insertion or removal of implants with subsequent incomplete healing of the surgical site and osteonecrosis of the post-avulsion fault.

Read the rest of this entry »

Clinical aspects of bisphosphonate-associated oral osteonecrosis: Patients and methods

We analysed the clinical data of 9 patients demanding treat­ment for maxillary bone necrosis of unknown origin, sent to us by the Haematology department of the “San Giacomo” Hospital of Rome. The 9 patients belong to a group of 54 patients (41F, 13M) who were under bisphosphonate treatment for multiple myeloma, osteoporosis, hyperparathyroidism and Paget’s dis­ease (Table I).

Table I – Group of analysed patients.

Read the rest of this entry »

Clinical aspects of bisphosphonate-associated oral osteonecrosis