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International Journal of Paediatric Dentistry 2000; 10: 240±244

Garre's osteomyelitis of an unusual origin in a 8-year-old

child. A case report

CONSTANTINE OULIS, ELIAS BERDOUSIS, GEORGE VADIAKAS &

GEORGE GOUMENOS
1
Department of Paediatric Dentistry, 2Department of Periodontics, University of Athens,
Greece

Summary. Garre's osteomyelitis is a type of chronic osteomyelitis that primarily a€ects

children and adolescents. Although the disease is well described in the dental literature
and is usually associated with an odontogenic infection resulting from caries, a number
of other causative factors have been occasionally reported, such as a dental extraction or
a mild periodontitis. There have also been cases of unknown aetiology. This paper
describes a case of Garre's osteomyelitis in an 8-year-old child, in whom the condition
arose following a local periodontal infection in an ectopically erupting ®rst permanent
molar that was in infraocclusion. The lesion remained unresolved for a period of over
6 months as a result of misdiagnosis, following a number of unsuccessful treatment
attempts. Identi®cation of the true cause and treatment through periodontal surgery
resulted in lesion resolution and resolved the diagnostic problem. Dentists should be
aware that the periodontium may be a potential source of infection for Garre's
osteomyelitis in children, particularly in the presence of ectopically erupting posterior
teeth. In such cases, periodontal treatment should be sucient to treat the disease and
extraction of the tooth involved may not be necessary.

Introduction matic with no accompanying general and local signs

of in¯ammation, although the clinical picture may
Garre's osteomyelitis is a speci®c type of chronic
vary widely. Little or moderate pain either sponta-
osteomyelitis characterized by peripheral reactive
neous or elicited by palpation, along with trismus,
bone formation as a response to a mild local
temperature elevation and malaise have been
infection, which was ®rst described by Carl Garre
reported [7±9]. The overlying skin may also show
in 1893 [1]. Since its ®rst description a number of
signs of in¯ammation, such as redness or even sinus
cases a€ecting the long bones have been reported in
tracts and either serum or pus on exploration [10].
the medical literature, while in dentistry the
Radiographically, the occlusal view is character-
mandible has been the primary site of location [2±
istic for the disease showing a focal overgrowth of
4]. The lesion is characterized by a localized
bone in the outer surface of the cortex of the
thickening of the periosteum with a reactive
a€ected area resulting in an apparent duplication of
deposition of osteoid and new cortical bone derived
the cortical layer. The bony duplication has been
from the periosteum [5,6]. Clinically, this reactive
described as cortical onion skinning because of the
process accounts for the hard swelling of the jaw
successive deposition of layers of subperiosteal bone
and the subsequent facial asymmetry with which
[11,12].
patients may present. The lesion is usually asympto-
The majority of cases reported in the past have
involved young patients, primarily children and
Correspondence: George Vadiakas, 22 Kodrou Str., 15 231, adolescents [4], with an odontogenic infection
Halandri, Athens, Greece. subsequent to caries being by far the most common

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Garre's osteomyelitis of unusual origin 241

causative factor [13]. Other indicating factors (a)

include a recent dental extraction or a mild period-
ontitis, while there have been cases where no cause
was found [10,12]. Although infection of the
periodontal tissues has been mentioned in the
literature as a potential aetiologic factor, to our
knowledge no previous case has been reported that
associates the disease with periodontal infection in a
paediatric dental patient.
The purpose of this report was to present a case of
Garre's osteomyelitis of an unusual origin, because it
resulted from a localized periodontal infection in an
erupting ®rst permanent molar in a child.
(b)

Case report
An 8-year-old caucasian boy was referred to a
paediatric dental practice for evaluation and treat-
ment of a hard mass involving the left side of the
mandible. According to the parents, approximately
5 months earlier an asymptomatic swelling had
appeared in the left side of the lower face, which
within a period of a few days enlarged and caused
diculty in opening of the mouth (Fig. 1a). The
patient was taken to a general practitioner who
registered occlusal caries on the ®rst and second left (c)
primary molars, as well as a sound erupting ®rst
permanent molar, but no signs of periapical
pathology (Fig. 1b). Oral ampicillin was prescribed
for 3 days and the swelling subsided until 2 weeks
later when it reappeared. A second 3-day course of
antibiotics was given and the patient referred to an
oral surgeon for evaluation. An occlusal radiograph
taken at that time showed a buccal enlargement of
the bone at the lateral side of the body of the
mandible in the area of the second primary and ®rst
Fig. 1. (a) Swelling at the left side of the lower face. (b) Periapical
permanent molars. A tentative diagnosis of Garre's radiograph of the involved molars ± no signs of periapical
osteomyelitis was made and a third course of pathology. (c) Panoramic radiographic view following the root
antibiotic therapy for 15 days prescribed. This canal treatment.
produced no improvement in the size of the
swelling. Pulpotomies on both left primary molars swelling overlying the left mandibular angle causing
were performed followed by root canal treatment on obvious facial asymmetry. The swelling was hard,
the second primary molar and, ®nally, extraction of ®rm and slightly tender to palpation. The overlying
that tooth with no e€ect on the swelling size (Fig. skin was red and a sinus tract was present in the
1c). On the contrary, a sinus tract appeared on the area of the swelling (Fig. 2a). No cervical lympha-
skin area overlying the mandibular mass. The denopathy was present. The intraoral examination
patient was then referred to a paediatric dentist revealed a bony hard swelling extending from the
for re-evaluation. left ®rst primary molar to the angle of the left
The patient was a well developed, well nourished mandible. The swelling was smooth and had
child in no acute distress and with an uneventful eliminated the mucobuccal fold in the area of the
past medical history. Extraorally, there was a ®rst permanent molar. The overlying mucosa was

# 2000 IAPD and BSPD, International Journal of Paediatric Dentistry 10: 240±244

242 Constantine Oulis et al.
(a)
(b)
Fig. 2. (a) Facial view of the sinus tract. (b) Buccal periodontal
pocket at the left ®rst permanent molar.
normal in colour and texture. The patient was in the
mixed dentition with multiple restorations in the
posterior primary teeth, as well as unrestored
carious lesions but no signs or symptoms of
periapical pathology. Both mandibular ®rst perma-
nent molars were below the occlusal plane, erupting
ectopically in a buccal direction. No major occlusal
abnormalities were noticed. The radiographic ®nd-
ings were in accordance with the clinical impression
in providing no evidence of periapical infection.
The clinical and radiographic ®ndings were
considered to be indicative of Garre's osteomyelitis.
Odontogenic infection consequest to caries was
exluded as an aetiologic factor. Despite the absence
of signs of acute in¯ammation in the periodontal
tissues, examination with a periodontal probe
showed an 8 mm periodontal pocket buccal to the
left mandibular ®rst permanent molar. The patient
was therefore referred to a periodontist for evalua-
tion and surgical exploration of the area (Fig. 2b).
A full thickness buccal ¯ap was elevated and
gingival curettage performed. At surgery the buccal
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Paper 199 Disc
bone plate appeared intact, a bone biopsy was
performed and the sample sent for histologic
evaluation. The ¯ap was repositioned and sutured.
One week following curettage the sinus tract had
disappeared and the swelling had begun to subside.
Histopathology revealed reactive bone formation
together with ®ndings of chronic in¯ammation.
Trabeculae of lamellar bone were present, radially
arranged to the cortical bone and separated by loose
connective tissue showing foci of in¯ammatory cells
such as lymphocytes and plasma cells. These
®ndings were consistent with a diagnosis of Garre's
osteomyelitis. A new swelling started to develop
involving the area buccally to the erupting contral-
areral teeth. Since this appeared to have the same
characteristics, and a buccal periodontal pocket was
noted on the ectopically erupting right ®rst perma-
nent molar, periodontal surgery was again recom-
mended and carried out. One month later the
original swelling was barely noticeable and 6
months following the surgical procedure facial
contour was normal and there was no evidence
of recurrence.
Discussion
Garre's osteomyelitis is a well described pathologic
entity in the dental literature. Because the majority
of the reported cases are sequels to an odontogenic
infection due to caries, the disease is most often
associated with a deep carious lesion and periapical
pathology. In the present case, both clinical and
radiographic evidence were in accordance with the
diagnostic features of Garre's osteomyelitis. How-
ever, three practitioners had erroneously related the
condition to an infected pulp due to caries even in
the absence of a true periapical pathology. Failure
to reach the correct diagnosis had resulted in several
unsuccessful attempts at treatment. This was
responsible not only for prolonging the course of
the disease, but also for allowing progression of the
pathology, including the development of a sinus
tract on the skin.
The periodontium has been reported by a number
of authors as a potential source of infection for
Garre's osteomyelitis where the in¯ammatory pro-
cess may initiate and progress to a bony lesion
[10,14]. However, to our knowledge no previous
case has been presented where a periodontal
infection was clearly the true causative factor for
the development of the disease. Loveman [15]

reported a number of cases of mandibular subper-
iosteal swellings in children where no periapical
pathology was found. The only feature in common
with the case reported here was the presence of an
erupting permanent molar. Gorman [16] presented a
case of periostitis ossi®cans in the mandible where
the tooth responsible was an erupting second molar
covered partially by a gingival ¯ap. The site of the
entry of infection was thought to be pericoronal. In
this case, extraction of the tooth was necessary for
resolution of the lesion. There have been other cases
in the dental literature where the pathological
process could not be explained by the factors more
commonly involved with Garre's osteomyelitis
[14,17±19]. In most of these, treatment was provided
by means of extraction or surgical management, or
by repeated conservative treatment, but the aetiol-
ogy was characterized as unknown. In some
instances, the disease had followed an unusually
long course [17].
In only one of these reports was there any
mention of the periodontium as a potential site of
infection. Even in this case, although the question
was asked as to whether an erupting tooth could
provide the focus of in¯ammation for the reactive
lesion, the possibility was not further explored [14].
In our case, the absence of evidence of periapical
infection and the presence of a developing ®rst
molar that was erupting ectopically and was in
infraocclusion made us suspect the periodontium as
an inciting factor. Such a tooth position could
account for the presence of a periodontal defect and
favour the development of a bacterial infection that
is dicult to eradicate. The history of the disease
along with the diagnostic features justi®ed a surgical
exploration of the lesion. This veri®ed the suspected
aetiologic involvement of the periodontium. Surgi-
cal removal of the pathologic material and recon-
touring of the periodontal tissues produced
resolution of the lesion, although antibiotic therapy
alone had proved inadequate to eliminate the
infection. Extraction of the tooth was not consid-
ered as a treatment of choice once the causative
factor had been identi®ed.
Garre's osteomyelitis most often exhibits typical
clinical and radiographic characteristics that help
the clinician to reach a di€erential diagnosis.
However, this case suggests that where no obvious
causes can be found, one should be aware that the
disease may originate from the periodontal tissues,
although this is less common. Particularly in
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Garre's osteomyelitis of unusual origin 243
patients that present with a bony lesion indicative
of Garre's osteomyelitis in the area of an ectopically
erupting ®rst permanent molar, and where a
necrotic pulp has been excluded as aetiologic factor,
the possibility of periodontal involvement should be
explored. In such a case, a more conservative
periodontal surgical approach has de®nite advan-
tages over tooth extraction and should be sucient
to treat the disease.
ReÂsumeÂ. L'osteÂomyeÂlite de Garre est une forme
d'osteÂomyeÂlite a€ectant essentiellement les enfants
et adolescents. Bien que cette maladie est bien
deÂcrite dans la litteÂrature dentaire et est habituelle-
ment associeÂe aÁ une infection dentaire d'origine
carieuse, d'autres facteurs ont eÂte occasionnellement
raporteÂs: extraction dentaire, parodontite leÂgeÁre.
Dans certains cas, l'eÂtiologie est inconnue. Cette
article deÂcrit un cas d'osteÂomyeÂlite de Garre chez un
enfant de 8 ans apparue apreÁs une infection
parodontale locale au niveau d'une premieÁre mo-
laire permanente ectopique en infraocclusion. La
leÂsion a persiste pendant 6 mois aÁ cause d'un
diagnostic erroneÂ, apreÁs plusieurs tentatives de traite-
ment infructueuses. L'identi®cation de la veÂritable
cause, et le traitement par chirurgie parodontale a
permis l'eÂradication de la leÂsion et reÂsolu le probleÁme
de diagnostic. Les dentistes devraient savoir que le
parodonte peut eÃtre une source potentielle d'infec-
tion pour l'osteÂomyeÂlite de Garre chez l'enfant, en
particulier dans le cas de dents posteÂrieures faisant
leur eÂruption en position ectopique. Dans de tels
cas, le traitement parodontal devrait eÃtre susant
pour traiter la maladie et l'extraction de la dent en
cause peut ne pas eÃtre neÂcessaire.
Zusammenfassung. Garres Ostomyelitis ist ein Ty-
pus eine chronischer Osteomyelitis welche primaÈr
Kinder und Jugendliche befaÈllt. Obwohl diese
Krankheit gut in der dentalen Literatur beschrieben
wird so wird sie, in Regal mit einer infektion in der
Folge von Karies, verbunden. Ebenso wurden
Extraktionen und milde Periodontitis als Ursache-
faktoren erwaÈhnt. FaÈlle mit unbekannten Ursache
sich ebenfalls bekannt. Diese Arbeit beschreibt einer
Fall mit Garres Ostomyelitis bei einer, 8 jaÈhrigen
Kind bei welchen eine periodonte infektion verur-
sacht durch eine ektopikalen Durchbruch mit
infraokklusin eines ersten Molaren. WaÈhrend 6
Monate wurde der Zustand falsch diagnostiziert
und falsch behandelt. Als die richtige Ursache

244 Constantine Oulis
erkannt wurde ein chirurgischer periodontaler Eingri€
durchgefuÈhrt und loÈste die Probleme. ZahnaÈrzte
muÈssen sich bewusst sein, dass das Periodontium eine
moÈgliche Ursache der Garres Osteomylitis sein kann,
besondes bei falschen Durchbruch. In solchen FaÈllen
genuÈgt eine periodontale Therapie, ohne Extraktion
des betro€enen Zahnes.
Resumen. La osteomielitis de Garre es un tipo de
osteomielitis croÂnica que afecta de forma primaria
en ninÄos y adolescentes. Aunque la enfermedad estaÂ
bien descrita en la literatura dental y esta asociada
generalmente con una infeccioÂn odontogeÂnica re-
sulado de la caries, ocasionalmente se ha informado
de varios factores causales, tales como extraccioÂn
dental o la periodontitis moderada. TambieÂn ha
habido casos de etiologõÂ a desconocida. Este artõÂ culo
describe un caso de osteomielitis de Garre en un
ninÄo de 8 anÄos, en el que la entidad aparecio tras
una infeccioÂn periodontal en un primer molar que
erupcionaba ectoÂpicamente y estaba en infraoclu-
sioÂn. La lesioÂn permanecio sin resolverse durante un
perõÂ odo de 6 meses como resultado de un diagnoÂs-
tico equivocado, tras varios intentos de tratamiento
sin eÂxito. La identi®cacioÂn de la causa verdadera y el
tratamiento mediante cirugõÂ a periodontal produjo la
resolucioÂn de la lesioÂn y se resolvio el problema
diagnoÂstico. Los odontoÂlogos deberõÂ an tener en
cuenta que el periodonto, puede ser una fuente de
infeccioÂn de la osteomielitis de Garre en los ninÄos,
especialmente en presencia de dientes posteriores
que erupcionan ectoÂpicamente. En tales casos, el
tratamiento periodontal debe ser su®ciente para
tratar la enfermedad y puede no ser necesaria la
extraccioÂn del diente.
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