Archives of Medicine and Health Sciences 2019 7(2):251-253
Chronic osteomyelitis can be a protracted disease often caused by inadequate curettage, injudicious use of antibiotics, and unnecessary delay in treating infected teeth. Failure of treatment of the odontogenic infection may result in decreased vascularization of the affected tissues, walling-off the infected area by relative avascular tissue, the formation of sequestra or reactive sclerosis of the bone. Here, we report a case of sclerosing type of osteomyelitis with periosteal reaction as seen in a middle-aged woman, highlighting how inadequate curettage following a common procedure such as extraction could lead to an uncommon complication.
| Introduction |  |
Osteomyelitis is an inflammatory process of the medullary and cortical bone, most commonly affecting the mandible in the maxillofacial skeleton. The presentation of the disease may vary depending on the age of the patient, the clinical stage of the disease, and the pathogenesis of the infection. Among the sclerosing type, focal sclerosing osteomyelitis occurs in young individuals with a male disposition, whereas diffuse sclerosing osteomyelitis may be found in any age group, in both sexes, but most frequently in younger to middle-aged women, the disease often restricted to one-half of the mandible.[1] Here, we report a case of sclerosing osteomyelitis as a result of incomplete tooth extraction.
| Case Report | |
A 45-year-old female patient visited our dental outpatient department with a complaint of swelling on the right side of the lower jaw for 2 months. Her history revealed that 2 months earlier, she underwent extraction of the right lower back tooth due to recurrent pain. The swelling was gradual in onset 1 week after the extraction; initially, it was small in size and it gradually increased to the size at the time of presentation. The patient's medical history showed that she was anemic. There was moderate swelling with well-defined borders in the right lower border of the mandible, which was hard in consistency, fixed, and nontender. Paresthesia was present. No sinus tracts were present extraorally. Intraoral examination revealed an edentulous space in the 45 region with no vestibular obliteration or tenderness [Figure 1]. The case was provisionally diagnosed as chronic osteomyelitis, and the differential diagnosis considered was central ossifying fibroma.
 | Figure 1: Frontal view (a) and lateral view (b) of the patient showing swelling on the lower border of mandible and Intraoral edentulous area in 45 region (c) Click here to view |
Digital panoramic radiograph was advised, which revealed ill-defined osteolytic and osteosclerotic areas with involvement of the inferior alveolar nerve canal [Figure 2]. Cone-beam computed tomography (CBCT) was then taken to identify cortical involvement, and the buccal and lingual cortices along with the lower border of the mandible were found to be destructed. Periosteal bone formation was also appreciated [Figure 3]. These findings substantiated the clinical diagnosis of chronic osteomyelitis. Operative intervention was then decided on, and 10 units of packed red blood cell transfusion was done 4 h before the surgery.
 | Figure 2: Orthopantomography showing bony changes in the right body of mandible extending from 45 to 48 region Click here to view |
 | Figure 3: Cone-beam computed tomography three-dimensional reconstruction in axial view (a) and sagittal view (b). Axial section showing buccal and lingual cortical destruction (c) and sagittal section showing proliferation of periosteum (d) Click here to view |
Decortication of the buccal cortex was done on the right side by osteotomizing the defect. The bone was drilled by making bur cuts every 2 mm on the mesial and distal portion of the osteotomized segment until a healthy bone was obtained [Figure 4]. Thorough irrigation was done using gentamicin and betadine. Indwelling closed surgical site irrigation was placed and secured. Extraction of left mandibular second premolar to the third molar, right mandibular first molar, and left maxillary second and third molars was done as they were all found to be either grossly decayed or root stumps. After curettage and a thorough wash, the extraction sockets were sutured using 3-0 vicryl. After achieving complete hemostasis, extraoral closure was done in layers using 3-0 vicryl and 4-0 ethilon. Pressure dressing was placed at the operated site. General anesthesia was reversed and extubated and the patient was shifted to postoperative uneventfully.
 | Figure 4: Incisional biopsy done in the right body of mandible Click here to view |
Histopathological examination of the specimen showed mature bony trabeculae, woven bone, and a sheet of fibrocollagenous tissue densely infiltrated by mixed inflammatory cell infiltrate, giving an impression of chronic sclerosing osteomyelitis.
The patient was recalled after 1 month for follow-up [Figure 5].
 | Figure 5: Postoperative clinical image (a) and orthopantomography (b) showing resolution of lesion after 1 month Click here to view |
| Discussion | |
There are numerous classifications for osteomyelitis with a lack of international consensus on their definitions. One such classification includes suppurative and nonsuppurative osteomyelitis. It can also be classified based on duration as acute and chronic, the latter being a disease process lasting for longer than 4 weeks.[2]
Various types of chronic osteomyelitis are recognized: chronic focal sclerosing, chronic diffuse sclerosing, periostitis ossificans (Garre's osteomyelitis), and osteomyelitis due to specific infections. The nonsuppurative type is a chronic inflammatory process, distinguished from the suppurative type by the absence of pus and/or fistulas and/or sequestrations. The term nonsuppurative does not necessarily include the absence of pathogens, and Actinomyces and Eikenella corrodens have found to be associated with the condition.[3]
In young individuals with good immune response, the body responds to infection by bone proliferation. However, these features are seen in a middle-aged woman in this case. Stimulation of the endosteal bone leads to sclerosing osteomyelitis, while periosteal stimulation produces proliferative periostitis. Clinically, this reactive process accounts for the hard swelling of the jaw and subsequent facial asymmetry that patients may present with.[4]
Imaging plays a central role in the diagnosis and management of osteomyelitis. Diagnosing osteomyelitis on the basis of bone sclerosis is difficult. Terms like Garre's osteomyelitis are used to identify lesions with a large amount of periosteal reaction, but periosteal reaction may be seen in any type of osteomyelitis, depending on the osteoblastic cells in the periosteum.[5]
The radiological findings, as seen on plain film radiographs, are radiolucency surrounded by radiopaque areas, loss of trabecular pattern, moth-eaten appearance, and shortening of tooth roots. Features directly linked to osteomyelitis are periosteal bone formation and sequestra. Plain radiographs are also useful for assessing the progression of disease, by comparing changes seen on follow-up films.[6]
CBCT sufficiently depicts osteomyelitic lesions such as osteolytic and osteosclerotic areas, ill-defined cortical borders with periosteal reaction, buccal/facial and lingual cortical destruction, sequestrum formation, pathological fractures, and the involvement of vital structures such as the inferior alveolar nerve canal as in the reported case.[7]
Decortication, sequestrectomy, and saucerization can frequently be carried out by an intraoral approach, thus avoiding disfiguring scars. When indicated, immediate reconstruction, using a free bone graft to the mandible, can also be carried out.[8],[9] Among the various treatment options for primary chronic osteomyelitis, several studies show that decortication with removal of necrotic tissue has good prognosis and is a less aggressive and more functionally and esthetically acceptable procedure.[10],[11]
| Conclusion | |
Delay in treatment of infected teeth, inappropriate curettage of periapical lesions, and inadequate use of antibiotic coverage may lead to persistence of infection in the jaws, which may present either as a suppurative condition or a hard sclerosing lesion. Gentle curettage of the socket and/or postoperative antibiotics is standard protocols after extraction of a tooth with a periapical radiolucency, failure of which could lead to uncommon complications which would require hospital admission and surgical intervention as in our case. Either way, appropriate medical and prompt surgical treatment is required to prevent the condition from progressing into any further complication.
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.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | |
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| Figures |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
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