Pictures of Osteonecrosis of the Jaw: Warning Signs

Osteonecrosis of the jaw (ONJ) is a serious condition where bone tissue in the jaw fails to heal properly, leading to deterioration. It is most commonly associated with bisphosphonate medications, radiation therapy, and certain infections or trauma. Early detection is crucial, as timely intervention can prevent severe complications.

Recognizing visual warning signs through clinical examination and imaging plays a key role in diagnosis. Understanding how ONJ presents at different stages allows for better monitoring and treatment planning.

Exterior Appearance in Early Progression

The initial signs of ONJ often manifest subtly, making early identification challenging. Patients may notice minor mucosal changes, such as slight swelling or redness in the gum tissue overlying affected bone. These early signs can resemble common oral conditions like gingivitis or mild periodontal irritation. In some cases, small ulcerations may develop, exposing underlying bone, which appears as a pale or yellowish-white area distinct from the surrounding tissue. Unlike typical oral wounds, these lesions persist longer than expected and may not heal with standard treatments.

As the condition progresses, exposed bone becomes more apparent, often accompanied by mild discomfort or a dull ache. The affected area may feel rough or irregular, and patients sometimes report a sensation of sharp edges where necrotic bone is beginning to protrude. Surrounding soft tissues may show signs of secondary infection, including increased redness, localized warmth, and occasional pus discharge. Mechanical irritation from dentures or oral hygiene practices can exacerbate these symptoms, further delaying healing.

A key early indicator is delayed socket healing after tooth extraction. In individuals predisposed to ONJ, post-extraction sites may fail to close properly, leaving exposed bone visible for weeks or months. This non-healing presentation is often accompanied by mild to moderate pain, though some patients remain asymptomatic despite clear visual evidence of necrotic bone. The absence of expected granulation tissue in these areas distinguishes ONJ from common complications like dry socket.

Radiographic and Imaging Differences

Imaging plays a crucial role in diagnosing ONJ, particularly when clinical examination alone is inconclusive. Different imaging modalities provide varying levels of detail, helping to assess bone integrity, detect structural changes, and monitor disease progression. Each technique has unique advantages, with some better suited for identifying subtle bone density alterations and others for visualizing soft tissue involvement.

X-Ray

Conventional radiographs are often the first imaging tool used when ONJ is suspected. In early stages, X-rays may not reveal significant abnormalities, but as the condition progresses, characteristic findings become more apparent. These include areas of radiolucency and radiopacity, indicating regions of bone resorption and sclerosis. A mottled or “moth-eaten” appearance is commonly observed, reflecting irregular bone destruction. In advanced cases, sequestra—fragments of necrotic bone separated from healthy tissue—appear as well-defined radiopaque structures.

Panoramic radiographs help assess the extent of bone involvement across the mandible and maxilla. However, X-rays have limitations in detecting early-stage ONJ, as subtle changes in bone metabolism may not be visible until significant necrosis has occurred. This underscores the need for more sensitive imaging techniques when clinical suspicion is high but radiographic findings remain inconclusive.

MRI

Magnetic resonance imaging (MRI) provides superior soft tissue contrast and is highly effective in detecting early ONJ changes before they become visible on X-rays. MRI can identify bone marrow edema, an early indicator of reduced blood supply and impending necrosis. T1-weighted images typically show areas of low signal intensity in affected bone, while T2-weighted and short tau inversion recovery (STIR) sequences highlight regions of increased fluid accumulation, suggesting inflammation or infection.

MRI is particularly valuable in differentiating ONJ from conditions like osteomyelitis or malignancies, as it provides detailed visualization of both bone and surrounding soft tissues. Contrast-enhanced MRI can further delineate viable from necrotic bone by highlighting areas with reduced blood flow. This modality is often recommended when clinical symptoms persist despite unremarkable X-ray findings, allowing for earlier intervention and more precise treatment planning.

CT

Computed tomography (CT) offers high-resolution imaging of bony structures, making it essential for evaluating ONJ-related bone destruction. Unlike X-rays, CT scans provide three-dimensional visualization, allowing for a more detailed assessment of cortical and trabecular bone integrity. Findings associated with ONJ include irregular bone resorption, cortical disruption, and sequestra.

Cone-beam CT (CBCT) is particularly useful in dental settings, as it delivers detailed images with lower radiation exposure than conventional CT. This modality effectively detects early cortical perforations and subtle bone density changes that may not be visible on standard X-rays. Additionally, CT imaging helps differentiate ONJ from other jaw pathologies, such as cysts or tumors, by providing precise anatomical details. Given its ability to detect structural changes earlier than traditional radiographs, CT is often recommended when ONJ is suspected but not yet radiographically apparent.

Oral Tissue Changes in Moderate Cases

As ONJ progresses, oral tissue deterioration becomes more evident. Initial mucosal irregularities give way to pronounced ulcerations, often exposing larger sections of necrotic bone. Patients frequently experience persistent discomfort, ranging from mild tenderness to sharp, localized pain, particularly when chewing or speaking. The affected mucosa may appear inflamed, with deep redness surrounding the exposed bone, signaling ongoing soft tissue irritation and potential secondary infection. Unlike early-stage lesions, these wounds fail to heal despite standard care.

Gingival tissue weakens, leading to recession and detachment from the underlying bone. This creates pockets where bacterial colonization can thrive, increasing the risk of infection. Infected sites often present with pus discharge, a foul odor, and a persistent bad taste. As necrotic bone fragments loosen, small sequestra may become visible within the lesion, sometimes spontaneously exfoliating or requiring debridement. The surrounding soft tissues exhibit varying degrees of fibrosis, contributing to a firm, indurated texture.

The spread of necrosis may extend beyond the initial site, affecting adjacent regions and leading to irregular tissue borders that resist healing. Granulation tissue, a marker of normal wound repair, is often absent or poorly developed. Instead, the exposed bone remains dry and avascular. As necrosis advances, oral function deteriorates, with some patients experiencing difficulty in maintaining proper jaw mobility due to pain and localized swelling.

Advanced Structural Defects in Severe Conditions

In advanced ONJ, bone integrity is severely compromised, leading to extensive necrosis and mechanical instability. Large sections of exposed bone, often discolored and brittle, dominate the affected area, with pronounced sequestration where dead bone separates from surrounding tissue. Unlike earlier stages, where necrotic fragments may exfoliate gradually, severe cases often require surgical intervention to remove devitalized bone. The remaining structure appears irregular and eroded, with sharp edges that can traumatize adjacent soft tissues, worsening ulcerations and secondary infections.

Progressive bone loss can weaken the mandible or maxilla, resulting in pathological fractures. In the mandible, spontaneous fractures compromise jaw function, making mastication and speech difficult. In maxillary cases, necrosis may spread into the sinus cavities, leading to chronic oroantral fistulas and persistent sinus infections. This deterioration often causes facial asymmetry, particularly when large segments of bone resorb without regeneration. The loss of structural support affects overlying soft tissues, contributing to hollowed facial contours and a visibly sunken appearance.

Distinct Observations in Different Jaw Regions

ONJ presentation varies between the maxilla and mandible due to differences in vascular supply, mechanical function, and anatomical structure. Recognizing these distinctions helps tailor treatment and predict potential complications.

In the mandible, ONJ tends to be more aggressive due to its limited blood supply. The inferior alveolar artery provides the primary vascular network, but its terminal nature makes mandibular bone more vulnerable to ischemic damage. As a result, necrotic bone in this region is often more extensive, with larger sequestra and slower healing. Severe cases may lead to pathological fractures, complicating treatment. The rigid cortical bone of the mandible also delays infection clearance, increasing the risk of chronic osteomyelitis.

In contrast, the maxilla has a richer blood supply, which can result in a less aggressive disease course but allows ONJ to spread into adjacent structures like the maxillary sinus. Oroantral fistulas—abnormal connections between the oral cavity and sinus—are a common complication, leading to persistent sinus infections and nasal discharge. Despite the maxilla’s better healing potential, advanced cases can still result in significant bone loss, affecting facial aesthetics and prosthetic rehabilitation.

Techniques for Documenting ONJ Images

Accurate documentation of ONJ through imaging and photography is essential for monitoring disease progression and assessing treatment responses. High-quality visual records help track changes over time and identify patterns that aid in early diagnosis.

Clinical photography captures external and intraoral manifestations of ONJ. Proper lighting and angulation ensure clear images of exposed bone, mucosal ulcerations, and surrounding tissue changes. Close-up macro photography is particularly useful for detailing sequestra formation and granulation tissue presence.

Advanced imaging modalities like CBCT and MRI provide structural and vascular insights. CBCT scans offer three-dimensional views of affected bone, while MRI highlights areas of reduced blood supply. Combining these techniques with clinical photography ensures a comprehensive approach to ONJ evaluation, leading to more informed treatment decisions.