Chronic suppurative osteomyelitis of the mandible: Case report

Abstract

Background: Osteomyelitis of the maxillofacial skeleton is rare in developed countries such as Australia. This case report describes the successful surgical treatment of chronic suppurative osteomyelitis (CSO) of the mandible in a 75 year old man. The precipitant factor was thought to be a retained tooth root in the (right) posterior body of the mandible. Methods: Treatment included a pre-surgical course of antibiotics (clindamycin 300mg, p.o. q.i.d. for two weeks) followed by removal of the retained root, surgical débridement of the affected bone, the intra-oral draining sinus, and resection of the cutaneous sinus tract. Specimens were taken for bacterial cultures and antibiotic sensitivity testing, and the resected tissue sent for histopathological review. Results: On clinical and radiographic review at three months, the patient was well, completely symptom free and the osteomyelitis had fully resolved. Conclusion: This case report demonstrates the typical features of CSO. The combination of antibiotic therapy and surgical débridement was effective in the treatment of chronic suppurative osteomyelitis of the mandible utilizing intravenous sedation, and so averting the need for a general anaesthetic.Key words: Osteomyelitis, chronic, surgery, clindamycin, débridement.Abbreviations and acronyms: CSO = chronic suppurative osteomyelitis; p.o. = per oral (by mouth); q.i.d. = quarter in die (four times a day).

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“…Vicentii, orphyromonas gingivalis Veillonella parvula, Enterococcus faecalis, Campylobacter gracellis and Neisseria mucosa invade the tooth through the enamel and dentin, infecting the pulp causing necrosis, periodontitis and formation of the periapical abscess, rich in anaerobic bacteria. Usually this process is acute and renders the patient to seek medical attention [4][5][6][7][8][9][10][11][12][13][14][15][16][17][18]. With the passing of time between six months and 30 years, added to the partial and temporal recovery, symptoms may be masked meanwhile the infectious process continues and intensifies, becoming chronic.…”

“…With the passing of time between six months and 30 years, added to the partial and temporal recovery, symptoms may be masked meanwhile the infectious process continues and intensifies, becoming chronic. At this point, the purulent material finds a way out through an abnormal canal that connects the alveolar abscess with an orifice in the interior of the mouth (intraoral sinus tract), or into the skin (extraoral sinus tract) [6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21]. Based on a recent report, extraoral fistulas are more common in women and adults and intraoral fistulas are usually found in children [16].…”

“…Only 50% of the patients feel pain or dental sensitivity, but there may be evident drainage which can produce esthetic problems [19]. The most common fistulas are associated with mandibular teeth in 80 to 87% of the cases, in a proportion of 4:1 between mandibular and maxillary unions and more common in anterior dental pieces like canine or incisor than posterior teeth [2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18]. In other rare occasions it has been documented otherwise [13][14][15].…”

“…Usually it can misguide the diagnostics, as there are other entities that can generate fistulas, pyogenic granuloma, salivary gland fistulas, congenital fistulas, infected cysts, deep mycosis infections, actinomycosis, thyroid cyst, pustules, furuncles, reactions to foreign bodies, skin carcinomas such as basal cell and squamous cancer, inverted follicular keratosis, dacryocystitis, suppurative lymphadenitis, tertiary syphilis and tuberculosis [27,28]. Rarely periapical abscess and fistulas generate complications, as mentioned before, osteomyelitis and sepsis [6]. Treatment consists of the elimination of the infectious agent through endodontic work if the piece can be recovered, in 12.7% of cases [21].…”

“…This last is rare, but easily misdiagnosed due to the amount of differential diagnoses which may be mistaken, for so patients could undergo unnecessary antibiotic therapy, allowing the infection to be chronic [3,4]. Fortunately, life threatening complications such as osteomyelitis and sepsis are not very common [5,6]. Whenever a patient has a facial o cervical fistula, it is mandatory a complete oral exploration looking for an odontogenic abscess besides a fibrous tissue (fistula) on the mandibular angles, cheeks or chin that connects jugal with gingival mucosa, causing the skin retraction [7][8][9].…”