[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-0-en-105":3,"doc-seo-459663-105":59,"doc-detail-459663-en":130},{"code":4,"msg":5,"data":6},0,"success",[7,13,18,23,28,33,38,43,48,51,55],{"id":8,"doc_module":4,"doc_module_name":9,"category_name":10,"show_sort_weight":11,"slug":12},1,"Document","Story & Novel",90,"story-novel",{"id":14,"doc_module":4,"doc_module_name":9,"category_name":15,"show_sort_weight":16,"slug":17},2,"Literature",80,"literature",{"id":19,"doc_module":4,"doc_module_name":9,"category_name":20,"show_sort_weight":21,"slug":22},4,"Exam",70,"exam",{"id":24,"doc_module":4,"doc_module_name":9,"category_name":25,"show_sort_weight":26,"slug":27},5,"Comic",60,"comic",{"id":29,"doc_module":4,"doc_module_name":9,"category_name":30,"show_sort_weight":31,"slug":32},6,"Technology",50,"technology",{"id":34,"doc_module":4,"doc_module_name":9,"category_name":35,"show_sort_weight":36,"slug":37},7,"Healthcare",40,"healthcare",{"id":39,"doc_module":4,"doc_module_name":9,"category_name":40,"show_sort_weight":41,"slug":42},8,"Research & Report",30,"research-report",{"id":44,"doc_module":4,"doc_module_name":9,"category_name":45,"show_sort_weight":46,"slug":47},9,"Religion & Spirituality",20,"religion-spirituality",{"id":46,"doc_module":4,"doc_module_name":9,"category_name":49,"show_sort_weight":46,"slug":50},"World Cup","world-cup",{"id":52,"doc_module":4,"doc_module_name":9,"category_name":53,"show_sort_weight":52,"slug":54},10,"Lifestyle","lifestyle",{"id":56,"doc_module":4,"doc_module_name":9,"category_name":57,"show_sort_weight":24,"slug":58},19,"General","general",{"code":4,"msg":60,"data":61},"ok",{"site_id":62,"language":63,"slug":64,"title":65,"keywords":66,"description":67,"schema_data":68,"social_meta":123,"head_meta":125,"extra_data":127,"updated_unix":129},105,"en","bilateral-orocutaneous-fistulas-and-mandibular-osteonecrosis-clinical-correspondence","Bilateral Orocutaneous Fistulas and Mandibular Osteonecrosis - Clinical Correspondence","","A 76-year-old woman with severe osteoporosis and multiple fractures developed bilateral tender submandibular nodules after long-term oral alendronate use, with minimal temporary response to antibiotics. Examination showed nodules fixed to the mandible without intraoral ulceration or drainage. Viridans streptococci grew from cutaneous exudate, and CT demonstrated bilateral mandibular osteonecrosis with adjacent soft-tissue abnormalities. The report frames orocutaneous fistulas as a severe Stage 3 BRONJ manifestation and highlights the need for prompt imaging and multidisciplinary management when lesions persist despite standard therapy.",{"@graph":69,"@context":122},[70,84,105],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":35,"@type":76,"position":81},"https://docshare.wps.com/document/healthcare/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/bilateral-orocutaneous-fistulas-and-mandibular-osteonecrosis-clinical-correspondence/459663/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/bilateral-orocutaneous-fistulas-and-mandibular-osteonecrosis-clinical-correspondence/459663.png","ImageObject",300,407,{"name":92,"@type":93},"Taylor Morgan","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-11-08","2026-09-30",true,{"@type":102,"interactionType":103,"userInteractionCount":14},"InteractionCounter",{"@type":104},"ViewAction",{"@type":106,"mainEntity":107},"FAQPage",[108,114,118],{"name":109,"@type":110,"acceptedAnswer":111},"What condition is described in the case report?","Question",{"text":112,"@type":113},"The report describes bilateral orocutaneous fistulas associated with mandibular osteonecrosis in the setting of bisphosphonate-related osteonecrosis of the jaw (BRONJ).","Answer",{"name":115,"@type":110,"acceptedAnswer":116},"How was the diagnosis supported in the patient?",{"text":117,"@type":113},"Physical examination showed nodules fixed to the mandible without intraoral ulceration or drainage. Bacterial culture grew viridans streptococci, and axial CT revealed bilateral mandibular osteonecrosis with soft-tissue abnormalities.",{"name":119,"@type":110,"acceptedAnswer":120},"Why is early imaging important in similar presentations?",{"text":121,"@type":113},"Persistent mandibular lesions, especially with bisphosphonate exposure and failure of standard antibiotics, should prompt immediate imaging to evaluate underlying osteonecrosis and enable early multidisciplinary management to reduce morbidity and progression.","https://schema.org",{"og:url":83,"og:type":124,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":126,"canonical":83},"index,follow",{"doc_id":128,"site_id":62},459663,1790756542,{"code":4,"msg":5,"data":131},{"doc_id":128,"user_id":132,"nickname":92,"user_avatar":133,"doc_module":4,"category_id":34,"category_name":35,"doc_title":65,"doc_description":67,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":14,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":14,"language":139,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":140,"faqs":141,"seo_title":142,"seo_description":67,"update_tm":129,"read_time":24,"preview_page_count":4},1099523885336,"https://ap-avatar.wpscdn.com/davatar_276721f389ce27ea32af1340a28f341c","International Journal of Dermatology  \nCLINICAL CORRESPONDENCE  OPEN ACCESS   \nBilateral Orocutaneous Fistulas and  \nMandibular Osteonecrosis  \nKrisztian Nemeth1,2  | Mollye Goldberg3 | Zachary Fridirici1  \n1ProHealth Medical Group, New Berlin, Wisconsin, USA | 2Semmelweis University, Budapest, Hungary | 3Syracuse University, Syracuse, New York, USA Correspondence: Krisztian Nemeth ([nemeth.krisztian@semmelweis.hu](nemeth.krisztian@semmelweis.hu))  \nReceived: 17 June 2025 | Revised: 17 July 2025 | Accepted: 21 July 2025  \nFunding: The author received no specific funding for this work.  \nA 76-year-old female with a history of severe osteoporosis and multiple skeletal fractures, treated with oral alendronate for 4 years, presented to our clinic with two tender submandibular nodules overlying the anterior/ventral base of the mandibular body bilaterally (Figure 1) . The first lesion appeared on the  \nFIGURE 1 | Bilateral submandibular nodules.  \nright side approximately 6 months before her visit, followed by a similar lesion on the left side 3 months later. Prior to presentation, she had completed multiple courses of oral antibiotics for presumed infected epidermal cysts versus carbuncles, with only minimal and temporary improvement; symptoms recurred promptly after discontinuation.  \nOn physical examination, both nodules were fixed to the underlying mandible. Intraoral examination was unremarkable, with no mucosal ulceration or drainage. Bacterial culture of the cutaneous exudate grew viridans Streptococci, a common intraoral commensal. Axial computed tomography (CT) imaging revealed bilateral mandibular osteonecrosis extending from angle to angle (Figure 2a) as well as adjacent soft tissue abnormalities (Figure 2b) .  \nBisphosphonate-related osteonecrosis of the jaw (BRONJ) is a rare but serious complication of long-term and/or high-dose antiresorptive therapy. While uncommon, orocutaneous fistulas are considered one of the most severe manifestations of Stage 3 BRONJ [1] . Bilateral or multifocal fistulizing disease, as in our patient, is exceptionally rare. The differential diagnosis includes dental sinus tract, suppurative lymphadenitis, salivary gland lesions, or cutaneous malignancies, all of which are unlikely to present as multifocal or bilateral lesions [2, 3] .  \nBisphosphonates (BPs), including alendronate, are widely used to reduce osteoporotic fracture risk by inhibiting bone turnover. In addition to suppressing osteoclast activity, BPs impair the oral mucosal barrier by inhibiting epithelial cell migration  \nThis is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.  \n© 2025 The Author(s). International Journal of Dermatology published by Wiley Periodicals LLC on behalf of the International Society of Dermatology.  \n374 International Journal of Dermatology, 2026; 65:374–375  \n[https://doi.org/10.1111/ijd.17996](https://doi.org/10.1111/ijd.17996)  \nFIGURE 2 | Axial CT images showing extensive osteonecrosis and soft tissue changes. (a) Red arrow shows fracture of the L mandible,(b): Red chevron shows fat stranding, red arrows show cutaneous changes.  \nand promoting intraoral bacterial overgrowth. When combined with immunosuppressive or cytotoxic therapy—as in cancer patients—these effects are compounded by anti-angiogenesis and suppression of mucosal and tissue immunity. Together, these changes promote bacterial invasion of gingival and periapical tissues, leading to alveolar bone inflammation. If untreated, chronic inflammation may progress to abscess formation and cortical bone erosion, allowing exudate to track through soft tissues and present as visible cutaneous nodules, abscesses, or ulcerations [4] . In our patient, the mandibular cortical bone eroded in two foci, with infection spreading below the mylohyoid and buccin","cbCaicSR3gSXij1B","https://ap.wps.com/l/cbCaicSR3gSXij1B","pdf",332463,"English","# Clinical Correspondence\n## Case presentation and evaluation\n## BRONJ background and differential diagnosis\n## Pathophysiology and incidence\n## Clinical implications and management recommendations","[{\"question\":\"What condition is described in the case report?\",\"answer\":\"The report describes bilateral orocutaneous fistulas associated with mandibular osteonecrosis in the setting of bisphosphonate-related osteonecrosis of the jaw (BRONJ).\"},{\"question\":\"How was the diagnosis supported in the patient?\",\"answer\":\"Physical examination showed nodules fixed to the mandible without intraoral ulceration or drainage. Bacterial culture grew viridans streptococci, and axial CT revealed bilateral mandibular osteonecrosis with soft-tissue abnormalities.\"},{\"question\":\"Why is early imaging important in similar presentations?\",\"answer\":\"Persistent mandibular lesions, especially with bisphosphonate exposure and failure of standard antibiotics, should prompt immediate imaging to evaluate underlying osteonecrosis and enable early multidisciplinary management to reduce morbidity and progression.\"}]","Bilateral Orocutaneous Fistulas and Mandibular Osteonecrosis - Clinical Correspondence | PDF"]