2. Mahmood S, Keith DJW, Lello GE: When can patients blow their nose and fly after treatment for fractures of zygomatic complex: The need for a consensus. Injury 34:908, 2003 3. DeGorordo A, Vallejo-Manzur F, Chanin K, et al: Diving emer- gencies. Resuscitation 59:171, 2003 4. Klingmann C, Praetorius M, Baumann I, et al: Otorhinolaryngo- logic disorders and diving accidents: An analysis of 306 divers. Eur Arch Otorhinolaryngol 264:1243, 2007 5. Becker GD, Parell GJ: Barotrauma of the ears and sinuses after scuba diving. Eur Arch Otorhinolaryngol 258:159, 2001 doi:10.1016/j.joms.2008.02.013 PAGET’S DISEASE AND BISPHOSPHONATE- ASSOCIATED OSTEONECROSIS OF THE JAWS To the Editor:—Bisphosphonates are a well-known group of drugs that are useful for preventing bone metastasis. 1 These drugs are also used to treat Paget’s disease, both orally or intravenously. Although bisphosphonate-associated osteo- necrosis of the jaws (BON) has been observed, especially in oncology patients, only a few patients with Paget’s disease develop this condition. Moreover, when such patients de- velop high-risk metastatic malignancies, additional bisphos- phonate doses are needed. An 84-year-old man presented at Stomatology Unit–UFPE with maxillary bone exposure that had evolved over 6 months. He had already undergone a partial maxillectomy, including the anterior wall and floor of the left maxillary sinus. His medical history included Paget’s disease affecting the maxilla and hip, treated with 1 infusion of pamidronate (90 mg) and 3 infusions of zolendronic acid (4 mg). He also had a history of nonsimultaneous gastric and prostate ma- lignancies, which caused hypercalcemia secondary to ma- lignancy. Both tumors were treated with surgery, together with 8 infusions of zolendronic acid (4 mg) and 1 of pam- idronate (90 mg) to control malignant hypercalcemia. One year after the last bisphosphonate infusion, the patient reported a spontaneous, slightly painful bone exposure in the anterior left maxilla. On intraoral examination, grade II BON was observed adjacent to the maxillary left canine and between the upper central incisors. There was no history of trauma or dental extraction. He was treated with local debridement and clindamycin (300 mg, 4 times daily), met- ronidazole (400 mg, 3 times daily), and chlorhexidine 0.12% oral rinses for 2 months. The local infection was con- trolled, although healing was only partial after 18 months. Because no pain or discomfort was reported, he is being followed at regular intervals and still has an asymptomatic bone exposure. Not surprisingly, less than 5% of BON cases occur in noncancer patients, which can be classified as a low-risk group. 2 Osteonecrosis is directly related to the duration of bisphosphonate therapy and usually occurs after several months of zolendronic acid treatment or a few years of pamidronate treatment. Generally, patients who receive less than 12 cycles of intravenous bisphosphonates rarely develop this complication. 3 Our patient received 11 cycles of zolendronic acid and 2 cycles of pamidronate, which would be considered an uncommon dose for spontaneous necrotic bone exposure. Interestingly, the largest well- structured trials that analyzed the efficacy of oral and intra- venous bisphosphonate in both Paget’s disease and osteo- porosis failed to report any cases of BON. 4,5 A single dose of 5 mg of zolendronic acid is even more effective than rised- ronate treatment (30 mg/day for 2 months), giving adequate disease control for 6 months. 5,6 Therefore, because 1 or 2 doses of zolendronic acid annually are adequate for con- trolling Paget’s disease, a high incidence of BON should not be expected in this patient group following long-term treatment. Nevertheless, some features of Paget’s disease might in- crease the risk of BON. Some Paget’s patients develop spontaneous pathologic fractures and oral osteonecrosis, regardless of treatment, and this also increases the likeli- hood of developing BON. 7,8 However, such episodes are rare and should not be considered a remarkable risk factor. In summary, long-term intravenous bisphosphonate treat- ment for Paget’s disease increases the likelihood of devel- oping BON, especially when associated with additional doses for managing neoplastic disease. Regular oral exami- nations are important for establishing an early diagnosis and adequate treatment. Acknowledgment The authors were supported by The National Council for Scien- tific and Technological Development (CNPq) and The State of Sao Paulo Research Foundation (FAPESP). The authors declare no con- flict of interest. LUIZ ALCINO GUEIROS, DDS MÁRCIO AJUDARTE LOPES, DDS, PHD Piracicaba, Brazil JAIR CARNEIRO LEÃO, DDS, PHD Recife, Brazil References 1. Bossier S, Magnetto S, Frappart L, et al: Bisphosphonates inhibit prostate and breast carcinoma cell adhesion to unmineralized and mineralized bone extracellular matrices. Cancer Res 57: 3890, 1997 2. Shane E, Goldring S, Christakos S, et al: Osteonecrosis of the jaws: More research needed. J Bone Miner Res 21:1503, 2006 3. Bamias A, Kastritis E, Bamia C, et al: Osteonecrosis of the jaw in cancer after treatment with bisphosphonates: Incidence and risk factors. J Clin Oncol 23:8580, 2005 4. Bone HG, Hosking D, Devogelaer JP, et al: Ten years’ experience with alendronate for osteoporosis in postmenopausal women. N Engl J Med 350:1189, 2004 5. Hosking D: Pharmacological therapy of Paget=s and other meta- bolic bone diseases. Bone 38:S3, 2006 6. Reid IR, Miller P, Lyles K, et al: Comparison of zolendronic acid with risdedronate for Paget’s disease. N Engl J Med 353:898, 2005 7. McMahon P, Tzadik A: Paget’s disease of the bone presenting as an apparent oral antral fistula. Arch Otolaryngol Head Neck Surg 112:668, 1986 8. Thomas DW, Tate RJ, Shepherd JP: Mandibular deformity asso- ciated with Paget’s disease: Case report. Aust Dent J 39:162, 1994 doi:10.1016/j.joms.2008.02.011 SERUM CTX TESTING To the Editor:—I am concerned that the report by Marx et al on osteonecrosis of the jaw associated with the use of oral bisphosphonates (in the December 2007 issue of the Journal of Oral and Maxillofacial Surgery; J Oral Maxillo- fac Surg 65:2397, 2007) may be misinterpreted by the read- ership. Both the lead position of the article in the research section of the Journal and the prominence of its authors have led some of my colleagues to remark that a gold LETTERS TO THE EDITOR 1319