To the Editor: Osteonecrosis of the jaw, recently reported in patients treated with bisphosphonates, may be analogous to the historic occupational disease “phossy jaw”.1,2

Phossy jaw was osteonecrosis of the jaw caused by exposure to white phosphorus during the manufacture of matches. “Lucifer” strike-anywhere matches were first produced in 1833. They were made by dipping the match ends into a mixture containing white phosphorus.3 Workers were exposed to fumes from the white phosphorus during mixing and spreading of the dip material, and dipping, drying and boxing of the matches.3,4

The first case series, comprising 22 cases, was reported in Vienna in 1845.5 About 11% of those exposed developed the disease.5 The average period from first exposure to diagnosis was 5 years.4,5 Occasionally, this period was as short as a few months.5 The mandible and maxilla could be affected, the mandible in 60% of cases (Box).3 Dental decay was considered a prerequisite, and preventive measures included dental surveillance and treatment within the factories.4 In that pre-antibiotic era, phossy jaw was fatal in about 20% of cases, usually because of septicaemia or meningitis.5

Donald Hunter, British doyen of occupational medicine, commented: “It was the most distressing of all the occupational diseases because it was very painful and was accompanied by a foul fetid discharge that made its victims almost unendurable to others. It was obstinate and chronic, the treatment was agonising and the final result was a distressing disfigurement. It was this disfiguring effect plain to every observer that made phosphorus poisoning so notorious and led to determined efforts for its abolition in every civilised land.”5

In 1906, several European countries banned the manufacture and importation of white phosphorus matches at the Berne Convention.4,5 A safe substitute, sesquisulfide, had been discovered by a French chemist and successfully used for manufacture of strike-anywhere matches in 1898.4,6

In the United States, John Andrews published a report in 1910 of 150 cases of phossy jaw from 15 of 16 match factories then in operation.4,6 The Diamond Match Company, which held the American patent rights for sesquisulfide, waived their rights, thereby allowing the entire US match industry to use this alternative.6 Congress then passed the Esch law, which imposed a prohibitive tax on white phosphorus matches and banned their import and export.4,6

Eventually safety matches were developed that used amorphous red phosphorus, which did not have the toxic properties of white phosphorus.5

Phosphorus necrosis of the jaw

A Deformity resulting from excision of entire lower jaw in a case of phosphorus necrosis. (Case of Dr John P. Andrews, The Occupational Diseases, W Gilman Thompson, D Appleton & Co, New York, 1914).

B Phosphorus necrosis of entire lower jaw excised by Mr McCarthy in 1884 (London Hospital Medical College Museum).