PURPOSE:To report a case series of patients with the nonexposed variant of bisphosphonate-associated osteonecrosis of the jaw-a form of jaw osteonecrosis that does not manifest with necrotic bone exposure/ mucosal fenestration. METHODS: Among 332 individuals referred to 5 clinical centers in Europe because of development of jawbone abnormalities after or during exposure to bisphosphonates, we identified a total of 96 patients who presented with the nonexposed variant of osteonecrosis. Relevant data were obtained via clinical notes; radiological investigations; patients' history, and referral letters. RESULTS:The most common clinical feature of nonexposed osteonecrosis was jaw bone pain (88/96; 91.6%); followed by sinus tract (51%), bone enlargement (36.4%); and gingival swelling (17.7%). No radiological abnormalities were identified in 29.1% (28/96) of patients. In 53.1% (51/96) of the patients; nonexposed osteonecrosis subsequently evolved into frank bone exposure within 4.6 months (mean; 95% confidence interval; 3.6-5.6). CONCLUSIONS: Clinicians should be highly vigilant to identify individuals with nonexposed osteonecrosis, as the impact on epidemiological data and clinical trial design could be potentially significant. Although the present case series represents approximately 30% of all patients with bisphosphonates-associated osteonecrosis observed at the study centers, further population-based prospective studies are needed to obtain robust epidemiological figures.

Recently, jawbone osteonecrosis has been largely reported as a potential adverse effect of bisphosphonate (BP) administration. Because of the peculiar pharmacokinetic and pharmacodynamic features of the BF (mainly for i.v. administration), their efficacy and large use, some major issues have to be taken into account extendedly both by oncologists and by dentists: 1) therapeutic dental protocol for patients with diagnosis of bisphosphonate-related osteonecrosis of the jaw (BRONJ); 2) dental strategies for patients in former or current i.v. BF treatment and in absence of BRONJ signs; 3) strategies for patients before i.v. BF treatment. Clinical features and guidelines for the management of this condition have been investigated and reported, sometimes with unclear indications; hence, on the basis of the literature and our clinical experience, major end points of this paper are providing our run protocols for the issues above described and, finally, focusing on a crucial, but not extensively investigated point: the early and correct diagnosis of BRONJ versus metastatic jaw lesions in cancer patients.

Changing demographics, including an increase in life expectancy and the growing numbers of elderly has recently focused attention on the need for geriatric dental care. Ageing affects oral tissues in addition to other parts of the human body, and oral health (including oral mucosa, lips, teeth and associated structures, and their functional activity) is an integral component of general health; indeed, oral disease can cause pain, difficulty in speaking, mastication, swallowing, maintaining a balanced diet, not to mention aesthetical considerations and facial alterations leading to anxiety and depression. The World Health Organization recommends the adoption of certain strategies for improving the oral health of the elderly, including the management and maintenance of oral conditions which are necessary for re-establishing effective masticatory function. Oral health is often neglected in the elderly, and oral diseases associatedwith aging are complex, adversely affecting the quality of life. Although oral health problems are not usually associated with death, oral cancers result in nearly 8,000 deaths each year, and more than half of these occur at an age of 65 years plus. This report, which is dedicated to geriatric physicians, geriatric dentistry and specialists in oral medicine reviews age-related oral changes in elderly patients and efforts to summarize the effects of aging in hard and soft oral tissues.

Halitosis is a generic term used to describe unpleasant odor emanating from the mouth air and breath, independent of the source where the odor substances originate. It affects between 50 and 65% of the population, but despite its frequency, this problem is often unaccepted and declared as taboo. Ninety percent of patients suffering from halitosis have oral causes: a small, but important percentage, of oral malodor cases have an extra-oral etiology, very often falling into the category of "blood-borne halitosis". Several systemic diseases have been found to provoke malodor or to be a cofactor; bad breath may be an early sign of a serious local or systemic condition. A psychogenic halitosis also exists including the variant "pseudo-halitosis", when the oral malodor does not exist, but the patient believes he or she is suffering severely from it, and the halitophobia, when, instead, there is an exaggerated fear of having halitosis. The aims of this paper are to review both oral and extra-oral causes of halitosis, especially those related to underlying systemic diseases, and to provide the primary care clinician a helpful means for its diagnosis and management. In fact, it is important to determine quickly whether the odor comes from an oral cause or not: if so, it requires referral to a dentist; if not (extra-oral origin alone or combined), its management requires the treatment of the underlying causes. Extra-oral disorders can be the cause in up to 15% of cases.