Phossy Jaw

April 1, 2009
Imagine working 16 hours a day in the year 1880, without lunch or rest periods, in a matchmaking factory with lousy working conditions.

by Lynne H. Slim, RDH, BSDH, MSDH
[email protected]

Imagine working 16 hours a day in the year 1880, without lunch or rest periods, in a matchmaking factory with lousy working conditions. To make matters worse, the matches are made from white or yellow phosphorus, a poisonous compound with fumes that can cause osteonecrosis or “phossy jaw.” In severe cases, the mandible or even part of the maxilla has to be removed.

Now fast forward to 2009, and picture yourself performing full-mouth debridement on a 72-year-old female with tenacious subgingival calculus. You're frustrated because it's a blind procedure with profuse bleeding and swelling around teeth Nos. 2, 3, and 4. The patient grabs your arm and asks if the bleeding might be due to her “chemo” medicine, and your mouth drops open. You remove your gloves, click on the patient's medical history on the computer, and read that she has been treated with Aredia® (pamidronate) and Zometa® (zoledronate) IV infusions for about six years. You remember that high-dose IV bisphosphonate drugs put some oncology patients at risk of developing bisphosphonate-induced osteonecrosis of the jaw (BON, ONJ, or BIONJ). You stop what you're doing and excuse yourself from the operatory.

The first reports about BIONJ were published in 2003.1 BIONJ occurs more frequently in patients receiving IV bisphosphonates (94.2%) compared to patients taking oral bisphosphonates (5.8%).2 Oncologists often use IV bisphosphonates to reduce the risks of skeletal complications of malignancy such as fractures or high blood calcium levels. Multiple myeloma is the most common cancer treated with bisphosphonates, followed by metastatic breast, prostate, and lung cancers. In about two thirds of patients who receive a diagnosis of BIONJ, a tooth extraction or other invasive procedure preceded the diagnosis, and about 21% of patients develop BIONJ spontaneously. 2

Let's go back to the full-mouth debridement patient with a history of IV bisphosphonates. What should the RDH have done before treating this patient, and how should the debridement protocol have been modified? In the U.S., guidelines for managing IV bisphosphonate users have been developed by the American Dental Association (ADA) and are updated as new information becomes available.3 ADA general recommendations are vague concerning nonsurgical periodontal therapy, but general recommendations include two important points:

  • Informing the patient that there is a low risk of developing BON
  • Documenting your discussion and obtaining written consent for treatment. (Consent forms are available at the ADA Web site.)

A brief discussion with the patient's oncologist is also advisable to confirm current medical status.4 In this instance, the RDH was not prepared to treat this patient, which highlights the importance of taking time to perform a thorough medical history and a comprehensive oral exam, including updated radiographs. The medical history form should include information about bisphosphonate use. Consent forms for bisphosphonate users give the practitioner and patient an opportunity to talk about the drug and its side effects, such as BIONJ. 5

The most beneficial way to manage patients who are IV bisphosphonate users who present with periodontal disease is a team approach that includes a periodontist. For those who are at high risk for developing BIONJ, it's important to emphasize the importance of good oral hygiene, and limiting dental procedures to those that are essential.1


  1. Khan AA et al. Canadian consensus practice guidelines for bisphosphonate-associated osteonecrosis of the jaw. J Rheumatol 2008 Jun; 35: 1391-1397.
  2. King AE, Umland EM. Osteonecrosis of the jaw in patients receiving intravenous or oral bisphosphonates. Pharmacotherapy 2008 May; 28(5): 667-677.
  4. Migliorati CA, HSU CJ, Chopra S, Kaltman SS. Dental management of patients with a history of bisphosphonate therapy: clinical dilemma. CDA Journal 2008; 36(10): 769-774.
  5. Stadeker WJ. Bisphosphonates 101: an update for the general dentist. Inside Dentistry 2008 Oct: 2-9.
  6. Marx RE. Uncovering the cause of “Phossy jaw” Circa 1858 to 1906: oral and maxillofacial surgery closed case files–case closed. J Oral Maxillofac Surg. 2008 Nov;66 (11):2356-63 Marx RE, Sawatari Y, Fortin M, Broumand V. Bisphosphonate-Induced Exposed Bone (Osteonecrosis/Osteopetrosis) of the Jaw: Risk Factors, Recognition, Prevention, and Treatment, J Oral Maxillofac Surg Nov.. 63:1567-1575, 2005