Jaw uptake of technetium-99 methylene diphosphonate in patients on biphosphonates: a word of caution.

ing biphosphonates are a group of medications that are increasingly used in the management of Paget's disease, fibrous dysplasia, osteoporosis, multiple myeloma and metastatic prostate or breast cancer bone disease. On 2004 it was established that nitrogen-containing biphos- phonates may induce jaw osteonecrosis and since then, a substantial number of publications has sup- ported this finding. Jaw osteonecrosis may be asymptomatic, lasting for about a year or symptomatic, accompanied with mild or severe pain. Jaw osteonecrosis usually results in patients with poor den- tal hygiene, or subjected to invasive dental procedures. Its incidence increases with the length of ni- trogen-containing biphosphonates treatment and appears to be higher for the Zometai users. It is important to early recognize this entity, since early intervention can make a significant difference to the outcome of this debilitating side effect. We here report three patients who had a positive tech- netium-99m methylene diphosphonate ( 99m Tc-MDP) bone scan. One of these patients also had os- teomyelitis and was treated aggressively. The other two were treated in a more conservative manner. Detailed dental examination supported the scintigraphic findings. Biopsy was performed only in one patient and also offered specimens for antibiotic cultures. In discussion, jaw biopsy is a debatable procedure in the setting of jaw osteonecrosis and many consider that it should be avoided in most cas- es, except if it is necessary to establish the diagnosis and suggest antibiotic treatment by obtaining samples for bacterial cultures. Although axial tomography and magnetic resonance imaging are use- ful in defining the extent of the disease, 3-phase 99m