Journal of Advanced Clinical & Research Insights (2016), 3, 220223

CASE REPORT

Chronic suppurative osteomyelitis: A case report

Keywords Abstract
Case report, etiopathogenesis of The term osteomyelitis encompasses a wide group of infectious diseases involving the
osteomyelitis, management of osteomyelitis,
disease of the bone and/or bone marrow further extending to periosteum. It is a disturbing
suppurative osteomyelitis
disease and involves a series of causative host and pathogen factors. The primary cause of
Correspondence
this disease is usually taught to be microbiological especially Staphylococcus aureus and
Dr. S. Swetha Kamakshi, Department of Oral Staphylococcus epidermis. The diagnosis of osteomyelitis is strenuous, mainly in the early
Medicine and Radiology, Bangalore Institute stages, and this disease is at all times complex to treat. Eradicating microorganisms and
of Dental Sciences and Research Centre, recuperating circulation in the regions involved, in the early stages have been the mainly
Hosur Road, Bengaluru - 560 029, Karnataka, employed treatment modalities. The case presented here is of chronic osteomyelitis with
India. E-mail: [email protected] an extraoral draining sinus. Surgical debridement and oral antibiotics were considered as
the treatment of choice.
Received 28 July 2016;
Accepted 24 September 2016

doi: 10.15713/ins.jcri.143

Introduction region since 10 months. The pain was sudden in onset, rapid in
progression which was sharp, intermittent in nature that partially
Osteomyelitis known since yesteryear was first described in 1852 subsided on application of clove oil followed by subsequent self-
by Chassaignac. Osteomyelitis is derived from the prehistoric medication with analgesics which provided him symptomatic
Greek words osteon meaning bone and muelinos meaning relief. The patient later was asymptomatic for 6 months. 3months
marrow.[1] Osteomyelitis of jaws is a common disease but ago patient observed an extraoral swelling on the left middle,
dreadful due to its need for prolonged therapy, which sometimes third of the face along with sharp severe shooting pain which
results in disfigurement and dysfunction of the affected area.[2] lasted for 3days for which he self-medicated with antibiotics for
In the recent past, the occurrence of osteomyelitis of the jaws has 3days and was symptom-free post the medications. 1 month ago
declined because of the availability of newer antimicrobial agents patient observed a reddened area on the left lower border of the
and also improved dental care. Improper use of antibiotics, poor mandible with dull intermittent pain followed by pus discharge.
oral hygiene maintenance, malnutrition, emerging strains of The patient then presented to our department for treatment of
resistant microorganisms to certain antibiotics, and radiation this condition.
therapy are the main causes that can be attributed to increasing A thorough general physical examination was performed with
cases of osteomyelitis across the globe. Some other factors that no significant abnormalities observed. The vitals were checked
also predispose an individual to osteomyelitis of jaw is virulence and were observed to be within normal limits.
of the microorganism, compromised vascular intriguing and On extra oral examination, patient had no gross facial
perfusion in the host bone at the local, regional or systemic level, asymmetry and no signs of swelling were present. There was the
and environment distressing host resistance or defense.[2,3] presence of an extraoral draining sinus on the left parasymphysis
region 1 cm below the inferior border of the mandible with
Case Report pinpoint bleeding areas with no signs of tenderness and
paresthesia [Figure2].
A 22-years-old male patient reported to the Department of Oral On intraoral examination, there was the presence of grossly
Medicine and Radiology, with a complaint of pus draining from decayed carious teeth with respect to 36 and 37 with no signs
his lower left jaw region [Figure1a and b]. The patient gave a of mobility but tender on percussion. Soft tissue examination
history of pain present with respect to his lower left back tooth reveals no signs of erythema, edema or vestibular swelling, but

220 Journal of Advanced Clinical & Research Insights Vol. 3:6 Nov-Dec 2016
Suppurative osteomyelitis of jaw Kamakshi, et al.

there was tenderness on the buccal vestibule with respect to daily and metronidazole 400 mg orally thrice a day for 5 days
36and 37 region on palpation [Figure3]. along with analgesics. Postoperatively, the patient was followed
The other intraoral findings included grossly destructed up for 1 month. The wound healing was uneventful with the
carious teeth with respect to 26, 36 and missing teeth with absence of post-operative complications.
respect to all the 4 s premolars.
Based on the history and clinical findings a provisional
diagnosis of the Chronic alveolar abscess with respect to Discussion
36, 37 was arrived. The clinical differential diagnosis was Chronic osteomyelitis is a bone infection that is branded
thought to be chronic suppurative osteomyelitis, cervicofacial as inflammatory processes that results in destruction of
actinomycosis. bone.[1,2] The principal reason of chronic osteomyelitis is
Pre-operative routine investigations were performed. The frequently microbiological odontogenic infection, complications
patient was subjected to a panoramic radiograph, which revealed post extraction, unsatisfactory amputation of necrotic bone,
ill-defined radiolucent areas arising from the apex of the distal early cessation of antibiotic therapy, inappropriate choice
root of 36 superiorly and extending inferiorly up to the inferior of antibiotics, poor diagnosis of the condition, trauma, and
alveolar nerve canal. Mediolaterally, ill-defined radiolucency
insufficient management for fracture or irradiation to the
is seen extending from distal aspect of 34 to distal aspect of 37
mandible.[3,4] Possible cause of disease, in this case, was
with interspersed radiopaque mass adjacent to distal aspect of 36
odontogenic infection in relation to the left lower molar teeth.
suggestive of sequestrum formation [Figure4].
The various sources of infections that could lead to
A diagnosis of chronic suppurative osteomyelitis was derived
osteomyelitis are:
based on clinical and radiographic manifestation.
1. Osteomyelitis caused secondary to infection or trauma
The treatment planned initially included administration of
amoxicillin 500mg orally for 2days preceding surgery followed
by surgical drainage and curettage of the area involved. Post the
surgery the patient was put on amoxicillin 500mg orally thrice

Figure 3: Intra oral picture showing grossly destructed teeth wrt

a b Figure4: An orthopantompograph showing diffused radiolucency

Journal of Advanced Clinical & Research Insights Vol. 3:6 Nov-Dec 2016221
Kamakshi, et al. Suppurative osteomyelitis of jaw

2. Osteomyelitis caused secondary to infection caused due to must also and always be sent to the microbiology laboratory
vascular insufficiency for detection of specific microorganisms.[6] Histopathologically
3. Osteomyelitis caused due to hematogenous spread of shows an amplified quantity of osteoblasts, thick trabecula of
infection bone, and fibrous tissue substitute in the marrow spaces with
4. Osteomyelitis caused due to radiation therapy. pathologic bone remodeling and the existence of numerous
Initially, the infection involves the mineralized marrow chronic inflammatory cells.[11]
tissues that promote suppurative infection, hyperplasia, and According to Chihara etal., the remission of the disease
resorption.[2-4] The disease becomes established in the calcified which is defined as the absence of any sign of infection in the
portion of the bone when pus in the medullary cavity or beneath initial or contiguous location at least 1 year after the end of
the periosteum leads to impediment of blood supply. The microbial therapy is the primary goal of treatment.[1,12] The
necrosis ensues once ischemia sets in. Tissue necrosis entails varied pathogenesis of osteomyelitis mandates specific treatment
as proteolytic enzymes are liberated with the destruction of strategies which focus on eradicating the infection along with
bacteria along with vascular thrombosis and ischemia. When preserving the integrity and function of the bone involved.[12]
pus accumulates, intramedullary pressure increases, resulting Early antibiotic treatment before widespread destruction
in vascular collapse, venous stasis, and further ischemia.[4,5] Pus produces the best prognostic results. The antibiotic to be
accumulating underneath the periosteum elevates it from the administered is dependent on the causal pathogen and its pattern
cortex and thus further reduces the vascular supply.[6] As this of susceptibility. Intravenous or oral administration of antibiotics
continues to accumulate, the periosteum is breached followed for 4 weeks is the most commonly employed treatment plan in
by the development of mucosal or cutaneous abscesses and cases of acute osteomyelitis. The drugs commonly used are beta-
fistulae.[7] lactams, penicillin derivative, fluoroquinolones, rifampicin, and
Osteomyelitis of the mandible is more common than because glycopeptides.[12,13]
blood supply to maxilla is far more extensive. Besides infection, Radiation induces tissue hypoxia, hypocellularity, and
compromise of the blood supply is a decisive factor in the hypovascularity within normal cells resulting in loss of balance
establishment of osteomyelitis, so osteomyelitis occurs more resulting in cell death and collagen lysis that surpass the
commonly in the mandible than in the maxilla since mandible homeostatic mechanisms consequential in osteoradionecrosis.
is dense, poorly vascularized cortical plates, and dependent on This condition is treated with hyperbaric oxygen therapy.[14]
the sole blood supply from the neurovascular bundle of inferior In this therapeutic procedure 100% oxygen in an increased
alveolar system.[5,7,8] atmospheric pressure. Acontrolled randomized study of Marx
In its acute stage, suppurative osteomyelitis of the mandible etal.[15] compared the utilization of HBO versus antibiotic
is usually characterized by deep-seated intense pain, high coverage in the prevention of ORN. Both groups had 37patients
intermittent fever, paresthesia of the mental nerve, and a clearly included. The group that received the antibiotic prophylaxis,
identifiable cause. In established suppurative osteomyelitis, 11 patients developed ORN, whereas only two patients
clinical symptoms include pain, fever, and constitutional developed ORN who only received HBO dives. HBO briefly
symptoms. Immediate aggressive antibiotic therapy may prevent elevates tissue oxygen tension, thereby activates fibroblastic
progression to the periosteum.[8,9] Within 2weeks from the time proliferation and further oxygen-dependent collagen synthesis.
of its onset, the involved teeth tend to be mobile and become This aids in angiogenesis of the radiated area. The Marx protocol
highly sensitive to percussion. Pus exudes in the region of the is usually adapted for treatment of ORN of jaws.[15]
gingival sulcus and then destroys mucosal and cutaneous barriers The management of chronic cases is always additionally
resulting in fistulae. Clinical findings in chronic mandibular intricate and requires multidisciplinary approach. The localized
osteomyelitis are lokoregional pain, fever, swelling, discharge lesion is eradicated through surgical debridement along with
with purulent content, intra-and extra-oral fistula, and trismus. antimicrobial therapy as followed in our case too. In severe
Sometimes they also present with neuropalsy, pathological chronic cases, the treatment is surgical debridement followed
fracture. Our patient reported to us with dull aching pain with by systemic antibiotic therapy for 4-6weeks and local antibiotic
extraoral draining sinus in the left side of the mandible.[2,5,9] drug delivery.[16]
The radiologic examination generally presents with
radiolucent areas, bony destruction and sequestrum formation.
Conclusion
The distinctive features of osteomyelitis are the occurrence
of sequestra and laminations of periosteal newly formed bone. Osteomyelitis is known to be a profound bone infection
Positive radiographic observation is commonly not prompt but with momentous morbidity and higher rate of recurrences.
secondary, except in cases with an associated fracture. In this This requires ideal treatment plan for the management of
case, there was evidence of ill-defined radiolucency along with this condition with medications mainly aimed at targeting
the presence of sequestrum formation.[3,10] the microbiological specimen identified. These patients
The various other investigatory procedures that could be should compulsorily be on regular follow-up so as to keep a
incorporated in such cases CT and bone scintigraphy.[2,3] The check over the prognosis and aid in the prevention of further
obtained specimens of the soft tissue and bone post the surgery complications.

222 Journal of Advanced Clinical & Research Insights Vol. 3:6 Nov-Dec 2016
Suppurative osteomyelitis of jaw Kamakshi, et al.

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