case_images: PMC4124701_01
case_images: (a) Clinical image. Chronic suppurated apical periodontitis of tooth 37. Notice the fistula in the buccal area of this molar. (b) Radiological image. Notice the periapical radiolucent lesion in tooth 37.
case_images: CRIM2014-281313.001.jpg
case_images: PMC4124701_01_CRIM2014-281313.001.jpg
case_images: fig1
case_images: At that time the patient was diagnosed with multiple myeloma stage III asymptomatic and only 2 doses of zoledronic acid (4 mg), once per month, have been administrated via IV. After a thorough clinicoradiological examination, a chronic suppurated apical periodontitis of tooth 37 was confirmed (Figures 1(a) and 1(b)).
case_images: (a) Panoramic radiograph. Notice the correct healing of the socket after 6 months of the molar 37 extraction. (b) Periapical radiograph. Observe the satisfactory bone density in the socket after 6 months of extraction.
case_images: CRIM2014-281313.002.jpg
case_images: PMC4124701_01_CRIM2014-281313.002.jpg
case_images: fig2
case_images: Two months later, bisphosphonate treatment was reintroduced with calcium supplementation and six months after the tooth extraction the clinicoradiological control of this localization was normal (Figure 2).
case_images: Clinical image. Progression of the lesion. (a) Notice the incipient mucositis and light tumefaction on the affected area. (b) Six weeks later, notice the bone exposure and how the lesion is expanding in mesial direction. ((c) and (d)) Eight weeks later, notice the increase of bone exposure and a characteristic sinus tract with its active exudation.
case_images: CRIM2014-281313.003.jpg
case_images: PMC4124701_01_CRIM2014-281313.003.jpg
case_images: fig3
case_images: According to the clinical features and the presence of a sinus tract (Figures 3(a)-3(d)), antibiotic treatment was initiated, Amoxicillin 500 mg/8 h.
case_images: (a) Panoramic radiograph. Notice in the affected area a high bone density image. (b) CT image. Notice a lingual thin fissure line in the affected area.
case_images: CRIM2014-281313.004.jpg
case_images: PMC4124701_01_CRIM2014-281313.004.jpg
case_images: fig4
case_images: The radiological report was not conclusive for osteonecrosis images, and only a lingual thin fissure line was observed in the affected area among a high bone density image (Figure 4).
case_images: Microscopic appearance. (a) Necrotic bone fragment with acute inflammatory reaction with polymorphonuclear. H&E. Original magnification 20x. (b) Notice also the large bacterial aggregate consistent with Actinomyces. H&E. Original magnification 20x.
case_images: CRIM2014-281313.005.jpg
case_images: PMC4124701_01_CRIM2014-281313.005.jpg
case_images: fig5
case_images: However, after 2-month follow-up the biopsy was indicated and its histopathological analysis confirmed the final diagnosis: osteonecrosis with Actinomyces infection (Figures 5(a) and 5(b)).