it is diagnosed by an area of exposed bone in the mandible, maxilla, or palate that typically heals poorly or does not heal over a period of 6 to 8 weeks. The diagnosis is primarily a clinical one, but imaging studies such as computed tomography can be helpful. Approximately two thirds of cases involve the mandible and the rest involve the maxilla. The lesion is painful in many, but not all, patients, and infection is often present. In one unusual case, osteonecrosis of the external auditory canal developed in a patient with myeloma who had received intravenous zoledronic acid and amidronate. 28 Predisposing factors for the development of osteonecrosis of the jaw appear to be dental disease, dental surgery (e.g., tooth extraction), oral trauma, periodontitis, and poor dental hygiene. The risk factors for developing ONJ include trauma, female gender, advanced age, edentulous regions, radiotherapy, chemotherapy, steroid therapy, blood dyscrasias/metastatic disease, anemia, coagulopathy, surgical dental procedures, alcohol or tobacco use, prior infection, and bisphosphonate therapy. 29-32 Although there have been some reports in the literature about osteonecrosis caused by steroids, this form is different from ONJ in the sense that steroid-induced osteonecrosis does not cause bone exposure. 1, 33 ONJ in connection with bisphosphonate use was first reported in 2003 34 , or 5 to 10 years after these drugs were approved in the United States for their current indications; it was rarely seen before then. Most of the reported cases (95%) have been associated with zoledronic acid or Pamidronate given