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Exposed bone in oral cavities.

Ms. N is a 54-year-old woman initially diagnosed in 2002 with stage IIIB non-small cell lung cancer, for which she received radical pneumonectomy followed by chemotherapy with carboplatin and gemcitabine. After a period of stability (i.e., approximately nine months) in which no further lesions were discovered, in a follow-up visit, she complained of lower abdominal pain, leading to the discovery of several large sclerotic lesions in her pelvis. Ms. N was diagnosed with metastatic lung cancer to the bone and began monthly therapy with zoledronic acid, a bisphosphonate approved for the treatment of metastatic lesions from lung cancer. In 2003, the patient presented with a complex ovarian mass and elevated cancer antigen 125 and began therapy for presumed ovarian cancer. Ms. N received liposomal doxorubicin and continued the monthly infusions of zoledronic acid. Her quality of life was good, and she was able to participate in her usual activities. In 2004, Ms. N began to complain of diffuse jaw pain. The pain was unresponsive to analgesics administered over several months. On examination, the gum looked edematous with mild erythema, and the initial differential diagnosis included oral abscess. After consultation with a dentist, a full panoramic radiologic study was taken of the affected area of her jaw. The patient then presented to the clinic with a complaint of exposed bone in her jaw and gum line (see Figure 1). Ms. N was started on oral clindamycin and oral chlorhexidine 0.12% mouth rinses three times a day. She was referred to an oral surgeon for further evaluation, where avascular necrosis or osteonecrosis of the jaw (ONJ) was diagnosed.