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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 16  |  Issue : 3  |  Page : 133-137

Management of a case of diffuse sclerosing osteomyelitis


1 Department of Conservative Dentistry, Amrita School of Dentistry, AIMS, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
2 Al Hinaee Health Centre, Musandam, United Arab Emirates
3 Department of Endodontics, Amrita School of Dentistry, AIMS, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
4 Department of Public Health Dentistry, Amrita School of Dentistry, AIMS, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India

Date of Submission17-May-2020
Date of Decision29-May-2020
Date of Acceptance01-Jul-2020
Date of Web Publication09-Oct-2020

Correspondence Address:
Dr. A Akhila
Thakidiyil, Ponnadu PO, Alappuzha, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AMJM.AMJM_37_20

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  Abstract 


Definitively diagnosed disease-directed therapy leads to the rapid resolution of clinical illness and decreases the chances of developing chronic ailments. Appropriate diagnosis is crucial in initiating such therapies which can be made straightforward with the assistance of modern diagnostic aids. Osteomyelitis is an inflammatory disease of the bone and its marrow contents. This disease can have multifarious clinical and histopathologic presentations. Osteomyelitis of the jaws has proved to be a challenging condition to effectively diagnose, treat, and cure. However, there are various diagnostic aids which help in the identification of the condition. The diagnosis is usually based on a thorough evaluation of the patient history and clinical presentation, imaging techniques, culturing, and histologic analysis. Cone-beam computed tomography (CBCT) has proved to emerge as a promising diagnostic aid in relation to osteomyelitis. CBCT offers different views that give a clear insight into the extent of involvement of the disease. Treatment of this condition includes two lines of management – conservative approach and surgical approach. The conservative approach includes the use of antibiotics, hyperbaric oxygen therapy which improves the availability of antibiotics at the localized site, especially with the sclerosing variant. Surgical interventions are usually confined to the extraction of extremely mobile teeth, debridement of fragments of bone, and incision and drainage of fluctuant areas. Additional surgical procedures are considered if the infection persists, and these include sequestrectomy, saucerization, decortication, or resection followed by reconstruction. A case of diffuse sclerosing osteomyelitis arising from nonvital teeth managed using the surgical approach is presented here.

Keywords: Bone scintigraphy, cone-beam computed tomography, corticotomy, hyperbaric oxygen therapy, osteomyelitis


How to cite this article:
Akhila A, Kumar SS, Prabath Singh V P, Vijaykumar S. Management of a case of diffuse sclerosing osteomyelitis. Amrita J Med 2020;16:133-7

How to cite this URL:
Akhila A, Kumar SS, Prabath Singh V P, Vijaykumar S. Management of a case of diffuse sclerosing osteomyelitis. Amrita J Med [serial online] 2020 [cited 2020 Oct 30];16:133-7. Available from: https://www.ajmonline.org.in/text.asp?2020/16/3/133/297556




  Introduction Top


Acquisition of the right diagnosis is a fundamental facet of health care, as it furnishes necessary information about a patient's health condition and leads to ensuing health-care decisions.[1],[2],[3] An odontogenic infection is an infection of the alveolus, jaws, or face which arises from a tooth or its neighboring structures and is one of the most generally confronted infections. These infections can emerge from dental caries, deep-seated restorations or failed endodontic therapy, pericoronitis, and periodontal diseases.[4]

Osteomyelitis of the jaws most frequently arises from dental infections, and persistent infected roots can be accounted as one of the most complicating sequelae of dental caries. Infection which has extended into the bone is more arduous to resolve as a result of the establishment of a bacterial biofilm with its innate shielding mechanisms.[5],[6]

The most common types of bacteria that cause osteomyelitis are Staphylococcus (including methicillin-resistant Staphylococcus aureus), Pseudomonas, and Enterobacteriaceae. Less commonly, Gram-negative bacteria cause osteomyelitis.[7] Osteomyelitis of the jaws can be of various types such as acute osteomyelitis, chronic suppurative and nonsuppurative osteomyelitis, diffuse sclerosing osteomyelitis, and Garre's osteomyelitis.[8],[9],[10]

The signs and symptoms of osteomyelitis depend on the type which includes pain, which can be moderate to severe, swelling, redness, and tenderness in the affected area, irritability, lethargy, or fatigue often with fever, chills, and sweating.[9] In severe cases, drainage from an open wound near the infection site or through the skin may be present.[11],[12]

The diagnosis of osteomyelitis can often be challenging, and because of the marked tendency toward recurrence observed in the chronic forms, the treatment procedures should be planned meticulously.

A 60-year-old male patient presented to the department of conservative dentistry and endodontics, with the complaint of pain and swelling in the lower right back region. The patient gave a history of pain in relation to his lower right back tooth for 6 months. The pain was gradual in onset and radiated to involve the entire mandible and up to the right temporal area. The patient gave a history of root canal treatment in relation to the tooth in question 1 year back. The past history reveals the patient having pain which attenuated following the completion of root canal treatment. After remaining asymptomatic for a period of 1 month back, the patient observed a swelling on the right side of the face at which point the patient reported.

A complete general physical examination was carried out with no conspicuous abnormalities. The vital signs were evaluated and were confirmed to be within the normal limits. Extraoral examination revealed a diffuse swelling on the right side of the cheek just above the lower border of the mandible. It was tender on palpation. Intraoral examination showed the presence of a restoration in relation to 44 which was tender on percussion. There were no significant anomalies with respect to surrounding soft tissues.

The other intraoral findings included missing teeth in relation to 14, 2, 7, 46, and 48 and dental caries in relation to 26 and 36.

Based on the history and clinical findings, a provisional diagnosis of persistent apical periodontitis was made. The clinical differential diagnosis was thought to be metabolic bone disorders and florid cemento-osseous dysplasia.

Intraoral periapical radiograph revealed overinstrumented canal with compromised root dentin in relation to 44 and the presence of a periapical radiolucency in relation to the root apex [Figure 1]. A cone-beam computed tomography (CBCT) with FOV 10 × 10 was taken which revealed a sclerosing pattern of bone on the entire right side of the mandible [Figure 2].
Figure 1: Intraoral periapical radiograph revealing overextended preparation and periapical radiolucency in relation to 44

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Figure 2: Coronal view of cone-beam computed tomography revealing completely sclerosed pattern on the right side of mandible

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A diagnosis of diffuse sclerosing osteomyelitis was made.

To assess the severity of the disease, bone scintigraphy was advised for the patient. The soft-tissue and skeletal phase images revealed increased deposition of technetium-99m-methylene diphosphonate in the right mandibular region [Figure 3]. Single-photon emission computed tomography (SPECT) imaging was also done for the patient. The lesion showed increased absorption of radionuclide in the involved area [Figure 4].
Figure 3: The soft-tissue and skeletal phase images obtained through bone scintigraphy revealing increased deposition of technetium-99m-methylene diphosphonate in the right mandibular region

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Figure 4: Single-photon emission computed tomography images showing increased absorption of radionuclide in the involved area

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As an initial treatment, two cycles of hyperbaric oxygen therapy (HBOT) were planned for the patient. After a period of 2 months, the second round of HBOT was carried out. The patient was reviewed after this, during which SPECT imaging was repeated for the patient. The lesion showed a significant improvement in terms of decreased radionuclide absorption [Figure 5].
Figure 5: Single-photon emission computed tomography imaging done after second round of hyperbaric oxygen therapy showing reduction in absorption of radionuclide

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Although there was considerable remission of symptoms, recrudescence was observed within a period of 4 months. This indicated increased mineralization leading to the development of symptoms.

Thus, a more invasive management of the condition was advised which included selective corticotomy of the right mandible. Administration of amoxicillin 500 mg orally for 4 days preceding the surgery was done. The procedure was carried out under general anesthesia which involved raising a full-thickness flap and removing the cortical bone leaving intact the medullary vessels [Figure 6]. Postoperatively, the patient was put on amoxicillin 500 mg orally thrice daily and metronidazole 400 mg orally thrice a day for 5 days along with analgesics.
Figure 6: Surgical approach involving raising a full-thickness mucoperiosteal flap followed by corticotomy of right mandible leaving intact the medullary vessels and periosteum

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The surgical specimen was subjected to histopathological analysis. The microscopic findings showed a paucity of inflammation with predominant sclerosis and fibrosis, confirming the chronic phase of the lesion.

The patient was followed up for 1 month and is scheduled for a review period of 1 year. There was the remission of symptoms with the absence of postoperative complications.


  Discussion Top


Osteomyelitis of the jaws is an unusual condition that has been related to numerous etiologies inclusive of odontogenic infections, systemic conditions such as diabetes, autoimmune diseases, malignancies, malnutrition, and acquired immunodeficiency syndrome.[10] The appropriate diagnosis of the type of osteomyelitis is crucial for the successful management of the same. The various etiological factors leading to the development of osteomyelitis include diseases induced secondary to trauma or infection, vascular insufficiency, hematogenous spread, and radiation therapy.[11] Possible cause of disease, in this case, was odontogenic infection in relation to the right mandibular teeth.

The significance of imaging in osteomyelitis is to ascribe the condition, to find out its involvement, and to determine the improvement after treatment. According to a study by Taori et al., conventional computed tomography (CT) is a beneficial approach of preoperative evaluation.[12] However, CBCT renders a reduced dose, lower-cost substitute to conventional CT, and guarantees to augment the system of oral and maxillofacial radiology.[13],[14] The complete calcification of the medullary bone and periosteal reaction were evident through the CBCT. Analyses by Pai et al. and Lee et al. further corroborate that the creation of images in three dimensions with CBCT allows these anatomic entities to be viewed both dimensionally and anatomically accurate without distortion, magnification, and superimposition.[15],[16]

Triple-phase bone scans have high sensitivity for detecting osteomyelitis in nonviolated bone, even in the early stages of infection.[17] Rohlin suggested that the period of latency between stimulus might give rise to clinical symptoms, and the increased apatite formation revealed by scintigraphy is often shorter than that of the structural change revealed by radiography.[18],[19]

SPECT/CT has increased the diagnostic value of procedures performed with many single-photon-emitting radiopharmaceuticals.[20],[21] SPECT/CT studies as an add-on to scintigraphy have been extensively applied to evaluate infectious diseases in various clinical scenarios.[22] Sexton and Spelman in 2003 and Erba et al. in 2014 have elaborated in their studies that SPECT/CT precisely defines the disease burden, thus allowing patient risk stratification and facilitating therapeutic decision-making with an overall accuracy of 84.1%.[23],[24]

HBOT enhances oxygen tension in the tissues, thus resisting the local effects of hypoxia in medullary infections and facilitates hemangiogenesis and reestablishment of blood flow in the tissues.[25],[26] Improved oxygen tension enhances the destruction of polymorpholeukocytes, fibroblastic and osteoclastic functioning, and the generation of oxygen radicals which causes the eradication of anaerobes and facultative anaerobes.[27] The overall efficacy of this adjuvant therapy, however, remains controversial. In the present case, HBOT enhanced the antibiotic availability in the sclerosed area of the mandible which is in accordance with a study by Andel et al.

Treatment of osteomyelitis of the jaws can be complicated by the presence of teeth and persistent exposure to the oral environment. Prolonged antibiotic therapy often extending from weeks to months may be recommended. These can either be administered intravenously or orally. According to a classic study by Spellberg, serum levels of parenterally delivered β-lactam antibiotics usually exceed target minimum inhibitory concentrations of pathogenic bacteria in most cases. Furthermore, orally administered fluoroquinolones, linezolid, and trimethoprim attain bone concentrations up to 50% than that achieved intravenously.[28] Invasive treatment options as put forward by Baltensperger and Eyrichinclude sequestrectomy, saucerization, decortication, and closed-wound suction irrigation, etc.[29],[30] In a few advanced cases, the entire segment of the infected jaw may have to be resected. Decortication or corticotomy had to be executed in the present case as the symptoms persisted even after two cycles of HBOT.[31] Often in some refractory cases, surgical debridement may have to be repeated. A mandatory review of the patient extending up to 1 year or longer is recommended.

Thus, a chronic case of osteomyelitis of sclerosing variant can be managed by appropriate diagnosis and a treatment approach including antibiotic administration, use of adjunctive aids such as HBOT, and invasive approaches including decortication and even resection of the affected segment.

Acknowledgment

I offer my prayers and gratitude at the lotus feet of my beloved Amma, Sadguru Sri Mata Amritanandamayi Devi, the Chancellor of Amrita University, for giving me the opportunity to be a part of the great institution.

Also, I express my heartfelt thanks and gratitude to Dr. Prabath Singh V.P, the Head of the Department of Conservative Dentistry and Endodontics, Amrita School of Dentistry, for his valuable guidance.

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.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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