A review of the patient’s past medical history was significant for osteoporosis and arthritis. She had been treated for osteoporosis with alendronate (Fosamax) at a dosage of 70 mg per week for three years.
Upon examination, the right posterior mandibular alveolar ridge appeared to be covered by intact mucosa (Figure 1). On closer inspection, however, a small ulcer with an adjacent small fistula was discovered hidden beneath the mucosal fold covering the superficial part of the right posterior alveolar ridge close to the retromolar pad area (not apparent in this photograph).
Panoramic and CT-scan radiographs were performed. The panoramic radiograph revealed large pieces of bony sequestra in the right posterior mandible surrounded by an irregular radiolucency and what appeared to be a pathologic fracture (Figure 3).
Incisional Biopsy Findings
Under local anesthesia the biopsy specimens were obtained using simple local curettage of the area (Figures 5 and 6). Histologic examination of the curetted material revealed multiple pieces of decalcified hard and soft tissue. The latter was made up of granulation tissue covered by stratified squamous epithelium (Figure 5) and infiltrated by many neutrophils, lymphocytes, and plasma cells. The bony fragments comprised a significant portion of the specimen (Figure 6) and were mostly lamellar in type with Haversian systems devoid of viable osteocytes. The bony fragments showed evidence of external resorption covered by bacterial colonies of mixed oral flora.