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Journal of Indian Society of Pedodontics and Preventive Dentistry Official publication of Indian Society of Pedodontics and Preventive Dentistry
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Year : 2011  |  Volume : 29  |  Issue : 2  |  Page : 176-179

Chronic suppurative osteomyelitis of the mandible

Department of Pedodontics and Preventive Dentistry, Rama Dental College, Hospital and Research Centre, Kanpur, Uttar Pradesh, India

Date of Web Publication9-Sep-2011

Correspondence Address:
K Mallikarjun
Department of Pedodontic and Preventive Dentistry, Rama Dental College, Hospital and Research Centre, A-1/8, Lakhanpur, Kanpur 208 024, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-4388.84696

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Osteomyelitis is an infection of the bone or bone marrow, usually caused by pyogenic bacteria or mycobacterium. Osteomyelitis, inflammatory process of the bone and its structures, can be acute or chronic. Taking a journey from a nonsurgical approach to a surgical one, it appeared to be one osteomyelitis revenge against all our efforts. The pain, the pus, the new bone formation, and all the trouble, this case showed it all. The injudicious use of antibiotics and delay in providing the requisite treatment can cause devastating effects as in the case of an 11-year-old child. A case report on treating osteomyelitis through medication and realizing that surgical excision remains the only realistic approach, the report talks about the investigations and treatment planning done to deal with it.

Keywords: Bone marrow, osteomyelitis, pyogenic bacteria

How to cite this article:
Mallikarjun K, Kohli A, Kumar A, Tanwar A. Chronic suppurative osteomyelitis of the mandible. J Indian Soc Pedod Prev Dent 2011;29:176-9

How to cite this URL:
Mallikarjun K, Kohli A, Kumar A, Tanwar A. Chronic suppurative osteomyelitis of the mandible. J Indian Soc Pedod Prev Dent [serial online] 2011 [cited 2022 Aug 18];29:176-9. Available from: http://www.jisppd.com/text.asp?2011/29/2/176/84696

   Introduction Top

The word "osteomyelitis" originates from the ancient Greek words osteon (bone) and muelinos (marrow) and means the infection of the medullary portion of the bone. [1] It can be classified as acute, subacute, or chronic, depending on the clinical presentation. The decline in prevalence can be attributed to the increased availability of antibiotics and the progressively higher standards of oral and dental health. [2] Chronic suppurative osteomyelitis is an often preferred term in Anglo-American texts [3] (Bernier et al. 1995; Topazian 1994, 2002) and can mostly be used interchangeably with the term "secondary chronic osteomyelitis," which is predominantly used in the literature from continental Europe (Hjorting-Hansen 1970; Panders and Hadders 1970; Schelhorn and Zenk 1989). Suppurative osteomyelitis can involve all three components of the bone: periosteum, cortex, and marrow. Clinically and radiographically, a broad spectrum ranging from an aggressive osteolytic putrefactive phase to a dry osteosclerotic phase may be observed (Eyrich et al. 1999). [1]

   Case Report Top

An 11-year-old girl reported to the Department Of Pedodontics, Rama Dental College Hospital and Research Centre, with long-standing pain and pus in the lower left tooth region since 1 year. She had undergone treatment for it under various general dental practitioners, but there was no relief. The patient had pain, pus, and swelling for last 1 year. The nature of pain was dull, intermittent, and radiating which aggravated on eating food and subsided after taking medication. She had undergone extraction of 73, 5 days back, and was referred to the department by a dental surgeon with the radiographs as he was not able to reach to a diagnosis. On general examination, the patient was pale, malnourished, and weak. An extra-oral examination of the left side revealed a diffused nontender swelling which was hard in consistency, and the overlying skin color was normal. On intraoral examination, 74 was grossly decayed. Localized swelling was seen extending from 32 to the distal aspect of 75. The swelling involved the marginal and attached gingiva and buccal vestibule in the same region [Figure 1]. The overlying mucosa appeared to be erythamatous associated with a draining intraoral sinus in the region of 74 [Figure 2]. Buccal vestibular obliteration was seen. The swelling was soft in consistency, tender on palpation, and associated with draining sinus. Buccal vestibular tenderness was present. A provisional diagnosis of chronic periapical abscess in relation to 74 with a differential diagnosis of chronic suppurative osteomyelitis, Garre's osteomyelitis, or infected periapical cyst was made.
Figure 1: Intraoral preoperative view of the lesion

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Figure 2: IOPAR of the sinus tract with the gutta-percha point

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Her panoramic radiograph revealed a radiolucent, diffuse osteolytic lesion apical to 74 [Figure 3]. Fluid aspiration was done in the area and was sent for a culture sensitivity test. Extraction was done with respect to 74 and the socket was curetted and the patient was placed on antibiotics (inj. Virexim T 1 g, ΍ BD; inj. Amikacin 250 mg, BD; inj. Novaclox 500 mg, ΍ BD). The medication was given for a period of 2 weeks, under the supervision of a pediatrician. The postextraction recall after 2 weeks showed a slight reduction in the swelling but pain persisted in the area. Another panoramic radiograph was taken which showed the presence of a visibly demarcated radiolucency on the lower border of the mandible in the region of 33, 34 with the involvement of 33, 34 in the lesion.
Figure 3: Orthopantomographic view of the lesion

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A surgical intervention was sought; the infected area was opened, necrotic bone was removed and area debrided [Figure 4]. Then 33, 34 were extracted and fresh bleeding was induced in the affected area, and the tissue was sutured back. The necrotic bone along with the extracted teeth was sent for histopathology, which confirmed the diagnosis of "chronic suppurative osteomyelitis" [Figure 5].
Figure 4: Intraoral view during the sequestrectomy

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Figure 5: Histological view of the chronic suppurative osteomyelitis

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The patient was kept on antibiotics; analgesics and betadine mouth wash were prescribed. A regular recall after every 3 days was kept for a period of 2 weeks and then weekly for a period of 2 months. The affected area showed complete healing clinically [Figure 6], and a panoramic radiograph was taken. The radiograph showed healing in the area where previously the osteolytic lesion was present [Figure 7].
Figure 6: Postoperative view

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Figure 7: Postoperative orthopantomographic view

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   Discussion Top

This case report demonstrates the typical features of chronic suppurative osteomyelitis, a rare but well-described potential complication of chronic odontogenic infections that a dental surgeon may more frequently encounter. Marx and Mercuri (1991) were the first and only authors to define the duration of an acute osteomyelitis until it should be considered as chronic. They set an arbitrary time limit of 4 weeks after the onset of disease. [1],[3] It is by far the most common osteomyelitis type. The primary cause of chronic osteomyelitis of the jaws is infection caused by odontogenic microorganisms. It may also arise as a complication of dental extractions and surgery, maxillofacial trauma, and the subsequent inadequate treatment of a fracture, and/or irradiation to the mandible. [2] The four primary factors which are responsible for deep bacterial invasion into the medullar cavity and cortical bone and hence the establishment of the infection are as follows: (1) number of pathogens, (2) virulence of pathogens, (3) local and systemic host immunity, and (4) local tissue perfusion.

In a healthy individual with sufficient host immunity mechanisms, these factors form a carefully balanced equilibrium. If this equilibrium is disturbed by altering one or more of these factors, deep bone infection establishes. [1] Usually, there is an underlying predisposing factor like malnutrition, alcoholism, diabetes, leukemia, or anemia. Other predisposing factors are those that are characterized by the formation of avascular bone, e.g., therapeutically irradiated bone, osteopetrosis, Paget's disease, and florid osseous dysplasia. [2],[4],[5] Osteomyelitis is more commonly observed in the mandible because of its poor blood supply as compared to the maxilla, and also because the dense mandibular cortical bone is more prone to damage and, therefore, to infection at the time of tooth extraction. [1],[2] The most common symptoms and signs include pain, exposed bone, cheek swelling, and discharge/drainage. [6] Management entailed a course of antibiotics in combination with surgical debridement (sequestrectomy). The improvement of local vascularization is further accomplished by surgical decortication, exceeding conventional surgical debridement, which not only removes the poorly vascularized (infected) bone but also brings well-vascularized tissue to the affected bone, thus facilitating the healing process and allowing antibiotics to reach the target area; therefore, surgery and antibiotics are to be considered the major columns in treating osteomyelitis of the jaws. [1],[2],[4],[5],[7] Selecting antibiotics is based mostly on isolating bacteria from the cultures. [3],[6],[8] Empiric antibiotics are started (with pending cultures) providing adequate coverage for streptococci and anaerobic bacteria such as Actinomyces and Prevotella. Penicillin remains the drug of choice. Other alternatives which may be used as a combination regimen include clindamycin, fluoroquinolones, metronidazole, a variety of cephalosporins, carbapens, Vancomycin in combination with other antibiotics, and tetracyclines. [6],[8] Although of rare occurrence, the differential diagnosis of osteomyelitis's radiological picture includes tumors, which can also mimic the scintigraphic findings, other bone destructive pathologies, fibrous dysplasia, metastases (especially originating from the prostate), and Paget's disease. Especially, in cases with significant periosteal reaction, the differentiation from osteosarcoma has to be kept in mind. [9],[10],[11] However, the disease is completely curable and can lead to reversal of all destructive bony changes, if treated early with a judicious use of antibiotics and surgical intervention, thus emphasizing the fact that a well-executed, timely treatment plan does have a high healing rate.

   References Top

1.Baltensperger M, Eyrich G. Osteomyelitis of the Jaws. Springer: Berlin Heidelberg; 2008 Nov 07.  Back to cited text no. 1
2.Yeoh SC, MacMahon S, Schifter M. Chronic suppurative osteomyelitis of the mandible: Case report. Aust Dent J 2005;50:200-3.  Back to cited text no. 2
3.Marx RE. Chronic osteomyelitis of the jaws. In: Laskin D, Strass R, editors. Oral and maxillofacial surgery clinics of North America. Saunders: Philadelphia; 1992. p. 367-81.  Back to cited text no. 3
4.Koorbusch GF, Fotos P, Goll KT. Retrospective assessment of osteomyelitis: Etiology, demographics, risk factors, and management in 35 cases. Oral Surg Oral Med Oral Pathol 1992;74:149-54.  Back to cited text no. 4
5.Kim SG, Jang HS. Treatment of chronic osteomyelitis in Korea. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;92:394-8.   Back to cited text no. 5
6.Chukwudum Uche, Robert Mogyoros, Amy Chang. Osteomyelitis of jaw: A retrospective analysis, Internet J Infect Dis 2009 7:23-26.   Back to cited text no. 6
7.Van Merkesteyn JP, Groot RH, van den Akker HP, Bakker DJ, Borgmeijer-Hoelen AM. Treatment of chronic Suppurative osteomyelitis of the mandible. Int J Oral Maxillofac Surg 1997;26:450-4.  Back to cited text no. 7
8.Hudson JW. Osteomyelitis of the jaws: A 50-year perspective. J Oral Maxillofac Surg 1993;51:1294-301.  Back to cited text no. 8
9.Vezeau PJ, Koorbusch GF, Finkelstein M. Invasive squamous cell carcinoma of the mandible presenting as a chronic osteomyelitis: Report of a case. J Oral Maxillofac Surg 1990;48:1118-23.  Back to cited text no. 9
10.Pruckmayer M, Glaser C, Nasel C, Lang S, Rasse M, Leitha T. Bone metastasis with superimposed osteomyelitis in prostate cancer. J Nucl Med 1996;37:999-1001.  Back to cited text no. 10
11.Schulze D, Blessmann M, Pohlenz P, Wagner KW, Heiland M. Diagnostic criteria for the detection of mandibular osteomyelitis using cone-beam computed tomography. Dentomaxillofac Radiol 2006;35:232-5.  Back to cited text no. 11


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]

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