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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 : 2021  |  Volume : 39  |  Issue : 2  |  Page : 225-228

Cold abscess of dental origin in a 7-year-old child

Department of Pediatric and Preventive Dentistry, Army College of Dental Sciences, Secunderabad, Telangana, India

Date of Submission20-Aug-2020
Date of Decision06-Dec-2020
Date of Acceptance02-Apr-2021
Date of Web Publication29-Jul-2021

Correspondence Address:
Dr. M Divya Banu
Department of Pediatric and Preventive Dentistry, Army College of Dental Sciences, Secunderabad - 500 083, Telangana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JISPPD.JISPPD_359_20

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Abscess related to an infected tooth is mostly associated with pyogenic infection, but sometimes, it can be asymptomatic and indicate a chronic condition. This case report shows cold abscess with a draining sinus due to dental origin. A 7-year-old female patient complained of pain with respect to grossly decayed tooth and recurrent swelling with no response to medications. After investigations and management of the lesion, it was concluded as abscess due to chronic granulomatous infection. Cold abscess is a classical manifestation of tuberculosis with no signs of inflammation. More than 60% of cases of this pathology occur in patients below 15 years old. It needs various clinical, histopathological, and laboratory investigations. Although rare, it should be considered as a differential diagnosis when no improvement occurs postroutine therapy to prevent serious complications. Furthermore, various precautions should be taken by the clinicians to prevent cross-infection.

Keywords: Biopsy, cold abscess, decayed tooth, dental origin, mandible, osteomyelitis, swelling, tuberculosis

How to cite this article:
Ganesh M, Priya V K, Banu M D, Shilpa G, Challa SK, R Krishna Murthy V V. Cold abscess of dental origin in a 7-year-old child. J Indian Soc Pedod Prev Dent 2021;39:225-8

How to cite this URL:
Ganesh M, Priya V K, Banu M D, Shilpa G, Challa SK, R Krishna Murthy V V. Cold abscess of dental origin in a 7-year-old child. J Indian Soc Pedod Prev Dent [serial online] 2021 [cited 2022 Aug 11];39:225-8. Available from: http://www.jisppd.com/text.asp?2021/39/2/225/322506

   Introduction Top

A cold abscess is a localized collection of pus without signs of inflammation, most commonly associated with tuberculosis (TB).[1] TB is a chronic granulomatous lesion which is caused by Mycobacterium tuberculosis, it was discovered in 1882 by a German scientist Robert Koch. The WHO reports that TB accounts for almost 3 million deaths annually, especially in developing nations.[2] It is usually missed in listing the differential diagnosis of oral lesions due to its rare occurrence and no pathognomic signs.

Tuberculous osteomyelitis more commonly affects young individuals. Rarely affected bones are flat bones, skull, and mandible (Sachs, 1977). Hence, tuberculous osteomyelitis in the jaw bone occurs rarely.[3] Oral lesions of TB contributes to 0.5%–1% of all the TB reported cases.

This article reports the rare case of a 7-year-old girl who complained of chronic submandibular swelling which was suspected to be a dental abscess later diagnosed as a cold abscess of dental origin confirmed as primary tubercular osteomyelitis of the mandible.

   Case Report Top

A 7-year-old female patient reported to the Department of Pediatric and Preventive Dentistry, Army College of Dental Sciences, with a chief complaint of pain in the lower left back tooth region with an extraoral swelling in the left submandibular region for the past 1 week.

The history was elicited from the parents of the patient who revealed that swelling was spontaneous and frequent for the past 4 months with periods of remission and repeated fever episodes with no significant relief even after a repeated course of antibiotics prescribed by dentists (augmentin and metronidazole). No significant medical or family history was elicited.

The patient had an average built, was afebrile, and moderately nourished, although she experienced generalized weakness.

On local examination, there was a diffuse extraoral swelling on the left submandibular region measuring approximately 4 cm × 1 cm [Figure 1]. The swelling was tender, soft with no raise in temperature, and nonfluctuant [Figure 2]. The lymph nodes were palpable and tender in the left submandibular region.
Figure 1: Extraoral swelling

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Figure 2: Extraoral swelling

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Intraoral examination revealed grossly decayed tooth no. 75 with tenderness on percussion [Figure 3] and no significant soft tissue pathologies or swelling. Orthopantomograph revealed radiolucency involving enamel, dentin, and pulp of crown and periapical area of the distal root of 75 extending till furcation area [Figure 4]. The provisional diagnosis included submandibular space infection or dentoalveolar abscess with dental caries in relation to 75. The abscess was drained followed by extraction of the decayed tooth [Figure 5].
Figure 3: Grossly decayed 75

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Figure 4: Preoperative orthopantomograph

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Figure 5: Extraction WRT 75

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On review, the swelling was persistent without any regression. The pus discharge noticed may be due to infected tooth socket which was thick and yellow colored with blood on palpation [Figure 6]. Differential diagnoses included tuberculous osteomyelitis affecting the mandible and malignant tumor of the jaw bone. Ultrasonography showed hypoechoic collection. No abnormality in chest X-ray was observed. Complete blood count analysis and erythrocyte sedimentation rate were normal. Serum HIV, hepatitis B surface antigen, and Mantoux test were negative. Later, aspiration biopsy [Figure 7] and excisional biopsy were done.
Figure 6: Pus discharge on palpation

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Figure 7: Aspiration biopsy In Relation To Extraoral Swelling

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Histopathology report was suggestive of necrotizing granulomatous lesion favoring cold abscess. The final diagnosis was made as tuberculous osteomyelitis of the mandible (cold abscess of dental origin). The patient was prescribed antitubercular drugs (isoniazid, rifampicin, pyrazinamide, and ethambutol) based on RNTCP-DOTS regimen Cat I which elicited a better response in the patient. The patient follow-up was done for 1 year with no recurrence of the lesion [Figure 8].
Figure 8: Postoperative view

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   Discussion Top

TB is defined as a chronic granulomatous inflammatory disease and one-third of the cases reported in the world occur in India.[4] There are 10%–15% chances of various other systems getting affected such as the oral cavity, renal system, hepatic system, skeletal system, gastrointestinal tract, lymph nodes, and lymphatic system apart from the respiratory system.

Orofacial TB is rare and involves various sites such as the mandible, salivary glands, head, face, tongue and neck lymph nodes, maxilla and maxillary antrum, gingiva, muscles of mastication, and the buccal mucosa. The primary form is more prevalent in children and adolescents, whereas the middle-aged and elderly population (0.005%–1.5% of cases) are more commonly affected by the secondary form.

The prevalence of TB affecting mandible is rare (2% of skeletal TB) with male predominance. Chapotel has reported that almost 60% of cases of tuberculous osteomyelitis can be seen in patients <15 years are of age.[5]

According to Andrade's classification of orofacial TB, the presented case can be categorized as type I.[6]

TB affecting jaws may directly spread from infected sputum, extraction socket, an erupting tooth with a mucosal opening, could have an hematogenous spread or it can spread to the underlying jaws from a soft tissue pathology.[4] The infection leads to slow necrosis of the involved bone. The radiograph shows blurring of the trabeculae and irregular radiolucency along with cortex erosion. Later, formation of soft periosteal abscess (cold abscess) may burst and form single or multiple sinuses extraorally or intraorally, leading to pathological mandibular fracture and sequestration.[7] Chaudhary et al. reported a case of TB involving mandible in a 4-year-old child who was diagnosed after failure of response to antibiotics.[2] Mishra et al. diagnosed a primary TB involving mandible where recovery was noticed after 2 years of antitubercular treatment.[8] Saurabh et al. described a case of tuberculous osteomyelitis affecting the mandible in a 15-year old male with chronic progressive swelling of the jaw and no response to antibiotics.[9]

Tuberculous osteomyelitis may represent as cold abscess, lumpy jaw, intraoral or extraoral sinus, pathologic fracture, or sequestration.[4] The diagnosis must be made by histological examination, nucleic amplification assays, or polymerase chain reaction. In advanced cases, there can be osteoporosis, bone lysis, sclerosis, and periostitis.[10] Once diagnosed, it should be treated with antitubercular medicines along with the removal of foci of infection like an infected tooth and if required, surgical debridement should be done.

Guidelines for infection control given by CDC 2003 can be utilized in the dental operatory to limit the spread of infection.

   Conclusion Top

Although the occurrence of tuberculous osteomyelitis is uncommon, it should be considered as an alternative diagnosis when the lesion does not respond to routine therapy. Early diagnosis helps in better prognosis, bone healing, and avoiding serious complications such as tuberculous meningitis. Since it is a contagious disease, it is important for the dental professionals to follow the guidelines and proper methods to prevent cross-contamination.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Faure E, Souilamas R, Riquet M, Chehab A, Pimpec-Barthes FL, Manac'h D, et al. Cold abscess of the chest wall: A surgical entity? Ann Thorac Surg 1998;66:1174-8.  Back to cited text no. 1
Chaudhary S, Kalra N, Gomber S. Tuberculous osteomyelitis of the mandible: A case report in a 4-year-old child. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;97:603-6.  Back to cited text no. 2
Bhatt AP, Jayakrishnan A. Tuberculous osteomyelitis of the mandible: A case report. Int J Paediatr Dent 2001;11:304-8.  Back to cited text no. 3
Jain P, Jain I. Oral manifestations of tuberculosis: Step towards early diagnosis. J Clin Diagn Res 2014;8:ZE18-21.  Back to cited text no. 4
Chapotel S. Tuberculous mandibularie. Rev Odent 1930;51:444-5.  Back to cited text no. 5
Andrade NN, Mhatre TS. Orofacial tuberculosis – A 16-year experience with 46 cases. J Oral Maxillofac Surg 2012;70:e12-22.  Back to cited text no. 6
Kumar S, Kumar R, Singh M. Primary tubercular osteomyelitis of mandible: Rare presentation of a common disease. Indian J Tuberc 2012;59:36-8.  Back to cited text no. 7
Mishra YC, Bhoyar SC. Primary tuberculous osteomyelitis of mandible. A case report. J Indian Dent Assoc 1986;58:335-9.  Back to cited text no. 8
Saurabh S, Mall BB, Somani R, Mishra A. Tuberculous osteomyelitis of the mandible: A rare case report. J Indian Acad Oral Med Radiol 2014;26:439-41.  Back to cited text no. 9
  [Full text]  
Bansal R, Jain A, Mittal S. Orofacial tuberculosis: Clinical manifestations, diagnosis and management. J Family Med Prim Care 2015;4:335-41.  Back to cited text no. 10
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]


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