Paper 276 Disc

International Journal of Paediatric Dentistry 2001; 11: 304±308

Tuberculous osteomyelitis of the mandible: a case report

A. P. BHATT & AMRITA JAYAKRISHNAN

Department of Oral Pathology, Yenepoya Dental College, Rajiv Gandhi University,
Karnataka, India

Summary. Osteomyelitis of jaws caused by infection with Mycobacterium tuberculosis is

uncommon, especially in children. We present a case of tuberculous osteomyelitis in a
young child. Its clinical presentation, with features similar to a dento-alveolar abscess,
underline the importance of considering it in the differential diagnosis of jaw lesions.
We discuss of the diagnostic techniques, management and preventive measures, and
stress the importance of history taking during clinical examination.

Introduction tongue, gingiva, and tooth sockets. Jaw involve-

ment may present as osteomyelitis [3,6].
Tuberculosis is a systemic disease usually caused by
Poor socio-economic conditions with inadequate
Mycobacterium tuberculosis. Mycobacterium avium,
nutrition and lack of hygiene are predisposing
Mycobacterium bovis, Mycobacterium Kansasii, and
factors to infection [7]. However, improvements in
Mycobacterium scrofulaceum have also been impli-
public health awareness, improved hygiene and
cated [1]. Initial lesions are usually pulmonary,
Bacille Calmette-Guerin (BCG) vaccination have
although an increase in extra pulmonary tubercu-
reduced the incidence of pulmonary tuberculosis
losis has been reported over the past few years.
[3]. Resurgence of tuberculosis in some countries
These frequently involve the head and neck, with
has been due to increase in infection with human
the most common presentation being a mass in the
immunode®ciency virus, which decreases cell
cervical region [2].
mediated immunity, the primary defence against
Oral tuberculous lesions are usually secondary to
tubercle bacilli. In these individuals a high in-
pulmonary involvement. Systemic symptoms in
cidence of extrapulmonary tuberculosis is detected,
these cases may be absent and oral ®ndings may
especially in lymph nodes and bone marrow.
be the ®rst manifestation of disease [3,4]. Primary
Infection in these individuals may be by atypical
oral tuberculosis is rare as an intact oral mucosa:
mycobacterium, such as Mycobacterium avium-
the cleansing action of saliva, salivary enzymes,
intracellulare complex [2,3,8].
tissue antibodies and oral saprophytes act as
The diagnostic methods for tuberculosis include
barriers to infection. Any breach in these defence
puri®ed protein derivative test (PPD), chest radio-
mechanisms, such as abrasions, tears, chronic
graphs, acid-fast staining and culture of sputum
in¯ammation, poor oral hygiene, tooth eruption,
smears, ®ne needle aspiration biopsy specimens of
extraction sockets, periodontal disease, carious
lymph nodes, as well as histopathological exam-
teeth with pulp exposure, or sites irritated by
ination of incisional biopsy specimens. The pre-
restorations may lead to infection by tubercle
sence of caseating granulomas in tissue sections is
bacilli [3,5,6]. The clinical presentation may be as
highly suggestive of tuberculosis but not de®nitive.
ulcers, erythematous patches, indurated lesions
Culture in Lowenstein±Jensen media under aerobic
with granular surface, nodules, ®ssures or as jaw
conditions for six to eight weeks is required for a
lesions. The most common sites involved are
de®nitive diagnosis [2].
Tuberculous osteomyelitis of the mandible is
Correspondence: Dr Amrita Jayakrishnan, 2, Malvern court, quite rare and forms less than 2% of skeletal
Ashley road, Epsom, Surrey, KT18 5BA, UK. tuberculosis [9]. The spread of infection may be
304 # 2001 BSPD and IAPD

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Tuberculous osyeomyelitis of the mandible 305

through an extraction socket, mucosal tear asso-

ciated with an erupting tooth, regional extension of
a soft tissue lesion to underlying bone, or by
haematogeneous spread [10]. It may present as
apical osteitis, periodontitis with horizontal bone
loss, or as a widespread destructive osteolytic lesion.
In the absence of systemic symptoms it may be
mistaken for a dental abscess [4,9,11,12].
We present a case of tuberculous osteomyelitis of
the mandible in a young child, in whom pulmonary
involvement was detected subsequently. The
changes in clinical presentation and increased
incidence of infection by atypical mycobacteria in
the past decade presents a diagnostic dilemma to the
clinician. Hence, a discussion of the diagnostic Fig. 1. Panoramic radiograph showing an ill-de®ned radiolucency
techniques and management of such cases in the extending postero-inferiorly from the apical region of mandibular
dental clinic is included. right permanent ®rst molar.

Case report
A four-year-old girl was referred to the paediatric
dental clinic for diagnosis of a rapidly spreading
swelling of the right cheek. She had undergone
extraction of the primary right ®rst molar a month
before, following which the swelling developed.
A physical examination revealed that the child
was well-nourished and afebrile. Extraorally, a
®rm, tender swelling of the right side of mandible
extending from the body to the angle was
observed. The right submandibular lymph nodes
were enlarged, tender and mobile. Intra oral
examination revealed a ®rm, tender swelling in
the right buccal sulcus extending from the healed
Fig. 2. Photomicrograph showing granulomas with Langhan's
extraction socket of mandibular right primary ®rst type giant cells, epithelioid cells, and lymphocytes.
molar (84) to the anterior margin of mandibular
ramus. The mandibular right primary second
molar (85) was intact, with no evidence of carious Further examination to rule out a systemic
involvement. The mandibular right permanent disease revealed no history of cough or weight±
®rst molar (46) had emerged. Oral hygiene was loss. Her family was of good socio-economic
satisfactory. status. However, on enquiry it was revealed that
A panoramic radiograph revealed a poorly the father had been treated for spinal tuberculosis
de®ned radiolucency extending posterio-inferiorly a year earlier.
from the apical region of mandibular right perma- A chest radiograph revealed non-homogeneous
nent ®rst molar [Fig. 1.]. opacities in the apex and mid zone of the left lung,
Light microscopic examination of a haematoxylin and hilar and mediastinal lymphadenopathy [Fig.
and eosin stained incision biopsy specimen showed 3.]. Sputum smears were negative for acid-fast
areas of granuloma formation with Langhans giant bacilli. A puri®ed protein derivative test produced
cells and epithelioid cells surrounded by dense a positive reaction. Haematological examination
collections of lymphocytes and plasma cells [Fig. revealed lymphocytosis.
2.]. Based on this a provisional diagnosis of a The patient was started on a course of rifampi-
granulomatous infection was given. cin, isoniazid, and pyrazinamide by her physician.

# 2001 BSPD and IAPD, International Journal of Paediatric Dentistry 11: 304±308

306 A. P. Bhatt & A. Jayakrishnan
Fig. 3. Postero-anterior chest radiograph reveals non-
homogeneous opacities in the apex and midzone of left lung
and hilar and mediastinal lymphadenopathy.
The intraoral lesion was thoroughly curetted,
removing all necrotic tissue followed by irrigation
with antiseptic solution. Culture of the curetted
material produced colonies of Mycobacterium
tuberculosis sensitive to rifampicin, isoniazid,
and pyrazinamide.
On examination six weeks later complete sub-
sidence of the oral swelling and radiologic evidence
of healing was observed.
Discussion
Oral tuberculous lesions are quite rare, considering
the incidence of systemic involvement, the reason
being inhibition by saliva and intact oral mucosa [3,5].
Oral lesions usually present as ulcers or as
indurated areas with granular surface. Involvement
of jaws by tuberculous osteomyelitis is quite
uncommon and is more likely to a€ect older
individuals [3,4,6,12]. A few cases secondary to
pulmonary tuberculosis have been reported in
young children [9,11].
The mechanism of spread of infection is by direct
inoculation, through tooth extraction sockets,
# 2001 BSPD and IAPD, International Journal of Paediatric Dentistry 11: 304±308
Paper 276 Disc
through any breach in the mucosa during tooth
eruption, spread from adjacent soft tissue sites or by
haematogenous spread [10]. In our case the symp-
toms were reported a month following extraction of
a deciduous tooth. The involvement of bone could
have been due to the passage of expectorated bacilli
through the extraction socket of 84 or probably
during eruption of 46. A haematogenous route
cannot be excluded.
Symptoms such as swelling, pain, loosening of
teeth, and even displacement of developing tooth
germs have been reported [9,11]. Cervical lympha-
denopathy, producing discrete or matted masses
which are usually non-tender, may be the presenting
feature in some [2].
Radiographically, a blurring of trabecular de-
tails producing a di€use radiolucency, loss of
supporting bone, or even a mixed radiolucent-
radiopaque lesion may be seen [9±11]. A di€er-
ential diagnosis of such a presentation would
include mainly a dento-alveolar abscess. A biopsy
is indicated to rule out odontogenic cysts, tumours,
as well as other systemic diseases. In tuberculous
osteomyelitis, light microscopic examination typi-
cally shows areas of caseation necrosis with
Langhan's giant cells, epithelioid cells and lym-
phocytes. Such features are produced by other
types of mycobacteria, as well as by fungi. A
de®nitive diagnosis requires culturing of fresh
tissue, which takes 6±8 weeks for a positive culture
[2]. Recently, the BACTEC system which is an
automated detection system for Mycobacteria has
reduced the time to diagnosis of tuberculosis [13].
Examination of tissue sections by acid-fast stain-
ing methods may produce negative results due to
paucity of bacilli in oral lesions [14]. This method
does not di€erentiate the various types of myco-
bacteria. Fine needle aspiration biopsy of lymph
nodes can achieve a de®nitive diagnosis without
open biopsy, both by acid-fast staining and by
culture methods. Diagnosis can be speeded by use of
Polymerase chain reactions for Mycobacterium
tuberculosis DNA [2].
Chest radiographs are essential to rule out
pulmonary tuberculosis, even in those without
systemic signs and symptoms of disease [3]. In this
case, positive ®ndings on chest radiographs helped
in making a provisional diagnosis and initiating
treatment. Acid-fast smear and culture of laryngeal
swabs is of value in con®rming pulmonary tubercu-
losis in cases of negative sputum smears [15].

A puri®ed protein derivative test should be done
routinely, although a positive reaction may be due
to BCG vaccination. False negative results may be
produced in the immuno-compromised [2,3].
The increase in incidence of acquired immunode-
®ciency syndrome requires every clinician to be alert
to the possibility of tuberculous infection, which
may vary in its clinical presentation. The histo-
pathology in such cases may not show a granulo-
mata due to absence of the usual in¯ammatory
response [16]. Furthermore, atypical mycobacterial
infection in such cases may not respond to
antituberculous chemotherapy [2].
Management of tuberculous osteomyelitis in-
volves complete drainage of abscesses and removal
of necrotic bone, in combination with antitubercu-
lous chemotherapy with a combination of drugs
such as rifampicin, isoniazid, ethambutol and
pyrazinamide [9]. This can be started even before
culture sensitivity results and continued for 6±12
months. The cervical masses usually subside follow-
ing chemotherapy and need not be excised [2].
Preventive measures such as PPD testing and
BCG vaccination of siblings and contacts should be
undertaken soon after diagnosis of tuberculosis in
an individual. In this case such measures at the time
of the father's illness could have prevented infection
in the child.
The importance of considering tuberculous os-
teomyelitis in the di€erential diagnosis of jaw
lesions, which fail to heal following routine therapy,
is stressed here as an early diagnosis can prevent
serious systemic spread. This also allows adequate
precautions to be taken, to prevent infection of
dental health care workers.
ReÂsumeÂ. L'osteÂomyeÂlite des maÃchoires due aÁ My-
cobacterium tuberculosis est rare, notamment chez
l'enfant. Un cas d'osteÂomyeÂlite tuberculeuse est
deÂcrit chez un jeune enfant. Son aspect clinique,
avec des caracteÂristiques similaires aÁ un abceÁs
dento-alveÂolaire, souligne l'importance du diagnos-
tic di€eÂrentiel lors de leÂsions des maÃchoires. Les
techniques de diagnostic, de prise en charge, les
mesures preÂventives sont discuteÂes, et mettent en
eÂvidence l'importance de l'anamneÁse lors de l'ex-
amen clinique.
Zusammenfassung. osteomyelitis der Kieferknochen
verursacht durch die Infektion mit Mycobacterium
tuberculosis ist selten, gerade bei Kindern. Wir
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Paper 276 Disc
Tuberculous osyeomyelitis of the mandible 307
berichten einen Fall von tuberkluoÈser Osteomyelitis
bei einem jungen Kind. Klinisch imponierte der Fall
mit Symptomen aÈhnlich eines dentogenen Abszesses,
was die Erfordernis unterstreicht, diese Diagnose in
di€erentialdiagnostischen UÈberlegungen bei Kiefer-
laÈsionen mit einzubeziehen. Die Diagnostik, Ther-
apie und PraÈvention werden diskutiert, und die
Bedeutung der Anamneseerhebung hervorgehoben.
Resumen. La ostomielitis de los maxilares causada
por una infeccioÂn por el mycobacterium tubercu-
losis es poco comuÂn, especialmente en ninÄos. Se
informa de un caso de osteomielitis tuberculosa en
un ninÄo pequenÄo. Su presentacioÂn clõÂ nica con
caracterõÂ sticas similares a las de un absceso den-
toalveolar subraya la importancia de considerarlo
en el diagnoÂstico diferencial de las lesiones de los
maxilares. Se realiza una discusioÂn de las teÂcnicas
diagnoÂsticas, tratamiento y medidas preventivas y
resaltamos la importancia de la elaboracioÂn de una
historia tomada en el momento del examen clõÂ nico.
References
1 Crompton GK, Haslett C, Chilvers ER. Diseases of the
respiratory system. In: Haslett C, Chilvers ER, Hunter JAA,
Boon NA (eds) Davidson's Principles and Practice of Medicine,
18th edn. London: Churchill Livingstone, 1999: 347±353.
2 Lee KC, Schecter G. Tuberculous infections in the head and
neck. Ear, Nose and Throat Journal 1995; 74: 395±399.
3 Hock-Liew E, Shin-Yu L, Chuang-Hwa Y, Wei-Jen C. Oral
Tuberculosis. Oral Surgery, Oral Medicine, Oral Pathology,
Oral Radiology and Endodontics 1996; 81: 415±420.
4 Kothari P, Bartella L, Carter J, Chan O, Piper K.
Tuberculosis of the mandible in a child. Journal of
Laryngology and Otology 1998; 112: 585±587.
5 McCarthy PL, Shklar G. Diseases of the Oral Mucosa, 2nd
edn. Philadelphia: Lea and Fabinger 1980; 130±137.
6 Dimitrakopoulos I, Zouloumis L, Lazaridis N, Karakasis D,
Trigonidis G, Sichletidis L. Primary tuberculosis of the oral
cavity. Oral Surgery, Oral Medicine, Oral Pathology, Oral
Radiology and Endodontics 1991; 72: 712±715.
7 Harris HW, McClement JH. Pulmonary tuberculosis. In:
Hoeprich PD, (ed) Infectious Diseases, 3rd edn. Philadelphia:
Harper & Row, 1983: 378±404.
8 Young LS, Wormser GP. The resurgence of tuberculosis.
Scandinavian Journal of Infectious Diseases 1994; 93: 9.
9 Wood RE, Housego T, Nortje CJ, Padayachee A.
Tuberculous osteomyelitis in the mandible of a child.
Paediatric Dentistry 1987; 9: 317±320.
10 Mishra YC, Bhoyar SC. Primary Tuberculous
osteomyelitis of mandible. Journal of Indian Dental
Association 1986; 58: 335±339.
11 Erasmus JH, Thompson IOC, Van der Westhuijzen AJ.
Tuberculous osteomyelitis of the mandible: report of a
case. Journal of Oral and Maxillofacial Surgery 1998; 56:
1355±1358.

308 A. P. Bhatt & A. Jayakrishnan
12 Fukuda J, Shingo Y, Miyako H. Primary tuberculous
osteomyelitis of the mandible. Oral Surgery, Oral Medicine,
Oral Pathology 1992; 73: 278±280.
13 Kanchana MV, Cheke D, Natyshak I, Connor B, Warner A,
Martin T. Evaluation of the BACTEC MGIT 960 system for
the recovery of Mycobacteria. Diagnostic Microbiology and
Infectious Diseases 2000; 37: 31±36.
14 Macfarlane TW, Samarnayake LP. Clinical Oral Micro-
biology. London: Butterworth, 1989: 112±115.
# 2001 BSPD and IAPD, International Journal of Paediatric Dentistry 11: 304±308
Paper 276 Disc
15 Thakur A, Coulter JB, Zutshi K, Pande HK, Sharma M,
Banerjee A, Richardson K, Hart CA. Laryngeal swabs for
diagnosing tuberculosis. Annals of Tropical Paediatrics 1999;
19: 333±336.
16 Cutler RR, Baithum SI, Doran HM, Wilson P. Association
between the histological diagnosis of tuberculosis and
microbiological ®ndings. Tuberculosis and Lung Diseases
1994; 75: 75±79.