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Chronic Suppurative Osteomyelitis of the Mandible Case

Chronic Suppurative Osteomyelitis of the Mandible Case

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200 Australian Dental Journal 2005;50:3.
Chronic suppurative osteomyelitis of the mandible: Casereport
SC Yeoh,* S MacMahon,† M Schifter‡
Osteomyelitis of the maxillofacialskeleton is rare in developed countries such asAustralia. This case report describes the successfulsurgical treatment of chronic suppurativeosteomyelitis (CSO) of the mandible in a 75 year oldman. The precipitant factor was thought to be aretained tooth root in the (right) posterior body of the mandible.
Treatment included a pre-surgical courseof antibiotics (clindamycin 300mg, p.o. q.i.d. fortwo weeks) followed by removal of the retainedroot, surgical débridement of the affected bone, theintra-oral draining sinus, and resection of thecutaneous sinus tract. Specimens were taken forbacterial cultures and antibiotic sensitivity testing,and the resected tissue sent for histopathologicalreview.
On clinical and radiographic review at threemonths, the patient was well, completely symptomfree and the osteomyelitis had fully resolved.
This case report demonstrates thetypical features of CSO. The combination of antibiotic therapy and surgical débridement waseffective in the treatment of chronic suppurativeosteomyelitis of the mandible utilizing intravenoussedation, and so averting the need for a generalanaesthetic.
Key words:
Osteomyelitis, chronic, surgery, clindamycin,débridement.
Abbreviations and acronyms:
CSO = chronic suppurativeosteomyelitis; p.o. = per oral (by mouth); q.i.d. = quarterin die (four times a day).
(Accepted for publication 5 November 2004.)
Osteomyelitis of the maxillofacial skeleton, inparticular, of the mandible is rare in developedcountries such as Australia. Osteomyelitis is aninflammation of bone and bone marrow that developsin the jaws usually after a chronic infection.
It may beclassified as acute, subacute or chronic, depending onthe clinical presentation. This decline in prevalence canbe attributed to the increased availability of antibioticsand the progressively higher standards of oral anddental health. Despite these advances, there remainselect groups of patients who have an increased risk of developing osteomyelitis: specifically those who haveundergone radiotherapy affecting the mandible (whichmay result in a specific form of osteomyelitis termedosteoradionecrosis), and the immunocompromised,
including uncontrolled diabetics, and patients onimmunosuppressive therapy, such as high dosecorticosteroids, needed for transplant recipients and thetreatment of auto-immune disorders.As the general population ages and retain their teethfor longer, combined with the declining availability of oral health professionals, particularly in the publicsector, as well as in remote rural and regional centres, itis thought that the incidence of osteomyelitis mayincrease. Therefore, dentists will need to be aware of clinical features and management of this uncommondisease.The primary cause of chronic osteomyelitis of thejaws is infection by odontogenic microorganisms.
Itmay also arise as a complication of dental extractionsand surgery, maxillofacial trauma and the subsequentinadequate treatment of a fracture, and/or irradiationto the mandible.
The typical age of presentation is in the fifties to thesixties, with males more likely to be affected. Thecommonest site is the posterior body of the mandible.The incidence, outside of those who have received headand neck radiotherapy and the immunocompromised,is increased in patients who have poor oral hygiene andare abusers of alcohol or tobacco.
CSO can develop without an intervening acutephase. Some authors have suggested that osteomyelitismust be present for at least one month before it is
*Registrar, Oral Medicine/Oral Pathology, Department of OralMedical and Surgical Sciences, Westmead Centre for Oral Health,Westmead Hospital, Westmead, NSW.†Visiting Oral Surgeon, Department of Oral Medical and SurgicalSciences, Westmead Centre for Oral Health, Westmead Hospital,Westmead, NSW.‡Head, and Staff Specialist (Oral Medicine), Department of OralMedical and Surgical Sciences, Westmead Centre for Oral Health,Westmead Hospital, Westmead, NSW.
Australian Dental Journal 2005;50:(3):200-203
termed ‘chronic’, as this suggests that the disease isrefractory to the host defences, or to initial therapy –usually oral antibiotics (as in this case).
Several reports have concluded that CSO can only betreated successfully by a combination of antimicrobialtherapy with surgery – either sequestrectomy ordecortication of the affected bone.
The aim of surgery is to eliminate all of the infected and necroticbony tissue, and if incomplete may lead to persistenceof the osteomyelitis.
Case report
A 75 year old man was referred to the Departmentwith a five month history of an enlarging swelling thatwas discharging pus from a cutaneous sinus present onthe right inferior border of the mandible (Fig 1). Onexamination, the patient was asymptomatic, afebrile,with normal pulse and blood pressure, and there wasno regional lymphadenopathy. There was no limitationof mouth opening, and on specific testing there was noparaesthesia of the right lower lip and mental area.His medical history was essentially non-contributory.He had mild cardiovascular disease, namely wellcontrolled angina and hypertension managed with aNitrolingual Pumpspray (glyceryl trinitrate) andAtacand (candesartan cilexetil) respectively.Significantly, this did not represent a contraindicationto the use of intravenous sedation for the subsequentoral surgery that he needed. He had no known allergies,and denied any tobacco or alcohol use.On intra-oral examination, the patient had a partial,reasonably well maintained dentition. A draining sinuswas noted on the crest of the right edentulous alveolarridge in the area that one would expect to find the 46
Australian Dental Journal 2005;50:3. 201
Fig 1.
Initial presentation of the cutaneous sinus.
Fig 2.
Initial presentation of the intra-oral draining sinus (see arrow).
Fig 3.
Initial OPG showing the area of mottled radiolucency/radioopacity.
202 Australian Dental Journal 2005;50:3.
(Fig 2). This area was slightly tender to palpation.These clinical features were typical of CSO as describedby Koorbusch
et al 
and Hudson.
OPG, periapical and mandibular occlusalradiographs demonstrated, in the area of the rightposterior body of the mandible, a localized mottledarea of mixed radiolucency /radio-opacity which wasovoid in shape, and measured 20mm at its greatestdiameter. It extended from the crest of the alveolarridge to the inferior alveolar canal (Fig 3). This wasconsistent with the radiologic features of osteomyelitisdescribed in the literature.
The radiographssuggested that there may have been a retained toothroot in the centre of the affected area. This wasconfirmed on subsequent surgical débridement.A clinical diagnosis of CSO of the mandible wasmade. Management entailed a two week course of oralclindamycin (300mg p.o. q.i.d., followed by surgicaldébridement of the affected area (Fig 4), removal of thetooth root and resection of the cutaneous sinus tract (Fig5) utilizing intravenous sedation, at which timehistological samples and microbial cultures were alsotaken. Clindamycin was chosen because of its broadantibacterial coverage, including activity againstanaerobic organisms, commonly present in chronic‘mixed’ odontogenic infections, and its establishedpotential to penetrate well, and achieve high therapeuticconcentrations, in bone.
The results of the microbiological cultures showednormal oral flora and some aerobic Gram-negativebacilli, which were sensitive to clindamycin. This wasconsistent with the microbiological findings reportedby Gentry.
The histopathology demonstrated chronicinflammation and fibrosis. These findings, incombination with the clinical picture, were consistentwith chronic suppurative osteomyelitis.Three months after the original surgery repeatradiographs were taken. There was no clinical orradiological evidence of residual infection (Fig 6 and 7).
This case report demonstrates the typical features of CSO, a rare but well-described potential complicationof chronic odontogenic infections, that dentists maymore frequently encounter. Management entailed acourse of antibiotics in combination with surgicaldébridement. This is consistent with the publishedprotocols of van Merkesteyn
et al 
Kim and Jang,
et al 
It has been suggested that the minimum duration of antibiotic therapy to treat CSO is two weeks.
However,it has been suggested by Bamberger
that a minimumof four weeks is indicated. Some reports have alsoadvocated the use of hyperbaric oxygen in thetreatment of this condition, especially in the irradiatedmandible.
In the present case, the patient wasprescribed a four week course of oral clindamycin,which, in combination with surgical débridement wassuccessful.
Fig 4.
Intra-oral lesions after surgical débridement.
Fig 5.
Resection of cutaneous sinus.
Fig 6.
Extra-oral surgical site at three month review.

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