Radiology · patient case question
What is the most likely radiographic finding in Patient C's jaws?
Patient case: Five medication lists in one session
Patient: Four separate patients
Chief Complaint: A: denture soreness. B: needs an antibiotic before an extraction. C: routine review. D: brought in obtunded by her daughter.
Background: A, 68-year-old male: benign prostatic hyperplasia on terazosin, hyperlipidaemia on simvastatin. Denture stomatitis diagnosed today and systemic fluconazole considered. B, 90-year-old female: frail, on no regular medication. C, 71-year-old female: rheumatoid arthritis on methotrexate, osteoporosis on oral alendronate for six years. D, 79-year-old female: long-standing hypothyroidism, ran out of levothyroxine some weeks ago.
Vital Signs: D: T 94.6°F · HR 48 bpm · RR 8 · BP 96/58 mmHg · drowsy and confused
Findings: A: erythematous denture-bearing palatal mucosa. C: panoramic radiograph taken for pre-operative assessment.
Show answer and explanation
Correct answer: A. Generalised reduced bone density with a thinned inferior cortex and coarse trabeculation
- A. CORRECT. The underlying disease is OSTEOPOROSIS, and the drugs slow its progression without reversing it. Expect the radiographic signs of generalised osteopenia: a THINNED MANDIBULAR INFERIOR CORTEX — a recognised incidental screening sign on panoramic films — with reduced overall density and a sparser, coarser trabecular pattern. What alendronate does NOT do is make the jaws look dense.
- B. Diffusely dense bone with obliterated marrow spaces describes OSTEOPETROSIS, a failure of osteoclastic resorption — the opposite of this patient's disease.
- C. Punched-out radiolucencies without a corticated rim are characteristic of MULTIPLE MYELOMA.
- D. A ground-glass pattern suggests FIBROUS DYSPLASIA, or the generalised granular change of hyperparathyroidism. Neither is expected here.
Note: The two management points that matter more than the radiograph. First, MRONJ risk from the oral bisphosphonate: low for oral therapy under about four years, rising beyond that, and this patient is at six. Second, methotrexate adds impaired healing and immunosuppression — and NSAIDs must be used with caution alongside it, because they reduce methotrexate's renal clearance and can precipitate toxicity, which makes acetaminophen the safer analgesic.