History of the present illness
This is an 82-year-old white female from Spain diagnosed with osteoporosis a few years prior.  She was treated with Fosamax at a dosage of 70 mg per week for three years.  The patient presented to the Department of Oral Medicine at Valencia University complaining of pain in the right posterior mandible.  Upon examination, the right posterior mandibular alveolar ridge was found to be covered with intact mucosa except for a small ulcer with a small fistula.  The skin overlying that area, however, showed evidence of a cutaneous fistula (Fig 1) oozing pus and blood.  A panoramic radiograph confirmed that the origin of the cutaneous fistula was in the posterior mandible (Fig 2).  The patient’s past medical history is significant for arthritis and osteoporosis.


Fig. 1 This is a clinical view of the lesion after six months of conventional treatment.  The submandibular skin shows a cutaneous fistula.

Fig. 2 This is a panoramic radiograph demonstrating a large and ill-defined radiolucent radiopaque lesion in the right posterior mandible with a pathologic fracture and bony sequestration.