| Abstract|| |
Osteomyelitis is an inflammatory condition of the bone, beginning in the medullary cavity and haversian systems and extending to involve the periosteum of the affected area. Although other etiological factors, such as traumatic injuries, radiation, and certain chemical substances, among others, may also produce inflammation of the medullary space, the term "osteomyelitis" is mostly used in the medical literature to describe a true infection of the bone induced by pyogenic microorganisms. Tuberculous osteomyelitis is an uncommon disease entity. Here, we present a case of osteomyelitis of mandible leading to pathological fracture of mandible, in which pulmonary tuberculosis involvement was detected only subsequently. The oral physicians thus play a crucial role in recognizing high-risk patients and initiating prompt isolation and evaluation.
Keywords: Mandible, osteomyelitis, pathological fracture, tuberculosis
|How to cite this article:|
Gadgil RM, Bhoosreddy AR, Upadhyay BR. Osteomyelitis of the mandible leading to pathological fracture in a tuberculosis patient: A case report and review of literature. Ann Trop Med Public Health 2012;5:383-6
|How to cite this URL:|
Gadgil RM, Bhoosreddy AR, Upadhyay BR. Osteomyelitis of the mandible leading to pathological fracture in a tuberculosis patient: A case report and review of literature. Ann Trop Med Public Health [serial online] 2012 [cited 2020 Feb 22];5:383-6. Available from: http://www.atmph.org/text.asp?2012/5/4/383/102071
| Introduction|| |
Osteomyelitis of the jaws is a disease that has affected mankind since prehistory. Today, medical and dental specialists continue to treat osteomyelitis of various types with the recognition that osteomyelitis of the jaws differs significantly from osteomyelitis of the long bones and at other skeletal sites. These differences are due to a different group of pathogens, the presence of teeth, a different blood vessel density, an oral environment, a thin mucosa as opposed to skin, one jaw that is mobile and the other that is fixed, the more frequent presence of foreign bodies, and the commonality of head and neck radiotherapy. 
Tuberculosis (TB) is a chronic infectious, granulomatous disease caused in humans by Mycobacterium tuberculosis and less frequently by Mycobacterium bovis.  The disease infects an estimated 20%-43% of the world's population. Mycobacterium avium, bovis, kanasasii, and scrofulaceum have also been implicated.  Pulmonary tuberculosis remains the most common form of the disease, but any organ system can be involved.  Skeletal tuberculosis accounts for 6.6% of extra-pulmonary cases thought to occur secondary to lympho-hematogenous dissemination to the bone at the time of initial pulmonary infection with local reactivation at a later date. Tuberculous osteomyelitis of the jaws constitutes less than 2% of it; therefore, involvement of head and neck region is rare. 
| Case Report|| |
A 38-year-old, married male patient, a public transport driver by occupation, reported to the department of oral medicine and radiology with a chief complaint of pain in the lower right back region of the jaw since 4 months. Swelling was present in the same region since 15 days and pus discharge through the skin since 8 days. The pain was initially intense and gradually became dull aching in nature, associated with fever followed by exfoliation of the tooth 2 months back, leading to deranged occlusion. A swelling was noticed in the same region 15 days back which pointed out extraorally to drain in the right submandibular region associated with severe discomfort during eating.
Patient had limping gait because of gangrene of the left foot, which was operated 6 years back for which patient was hospitalized for 15 days, but the gangrene is still present. Patient is a chronic alcoholic and consumes about 300 ml-500 ml of alcohol daily since last 15 years. Patient also had a habit of cigarette smoking; 5-6 cigarettes daily since 5-6 years. Patient has had about 12-15 kg weight loss with evening rise in temperature, sometimes with chills since 4 months. Patient looked pale and weak.
Patient had a noticeable asymmetry of the face, and an extra oral swelling seen in the right side of the mandible, approximately 5 cm × 4 cm in size, with a limited mouth opening and a scar seen on the right submandibular region associated with an extraoral draining sinus. The skin surrounding the sinus is puckered and erythematous and slight pus-like discharge evident from the sinus [Figure 1].
On an intra-oral examination, a tooth is missing in the mandibular right posterior region (46) as suggested by the patient in the history. A deranged occlusion and badly carious 47 with tenderness to percussion with 45 and 47. Crepitus between 45 and 47 felt with slight abnormal mobility of the mandibular right anterior fragment. Intraoral exposed bone in the lower right buccal vestibule was also seen [Figure 2].
|Figure 2: Intraoral exposed bone in the mandibular right buccal vestibule|
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Based on the history and clinical evaluation, a provisional diagnosis of chronic suppurative osteomyelitis of the mandible with a possible pathologic fracture was established.
Considering the patients past medical history, his occupation and recent weight loss following hematological tests were advised:
Complete blood cell counts
Hemoglobin %, bleeding, and clotting time
Blood glucose levels (fasting and post-prandial)
Tri dot (screening for HIV)
Other radiographic investigations advised were:
Intraoral periapical radiograph (IOPA) with 45 47 region.
Cross-sectional mandibular occlusal view
Lateral oblique view for Rt. body of the mandible
PA chest view (screening for tuberculosis)
All hematological tests were non-contributory, except for mild anemia.
On IOPA with 45 47 region: A diffuse radiolucency in the crown of 47, involving the enamel and dentin, suggestive of caries and ill-defined periapical radiolucency seen with 45 47 [Figure 3].
On cross-sectional occlusal view of the mandible: Overriding of lower border of the mandible with 45 47 region, suggesting pathological fracture [Figure 4].
On lateral oblique view for the right body of the mandible and OPG: Diffuse ill-defined radiolucency with interspersed radio-opacity seen extending from mesial of 44 to distal of 47, involving entire height of the mandible from the alveolar crest up to the lower border of the mandible, showing a moth-eaten appearance. Loss of continuity of the lower border of the mandible [Figure 5] and [Figure 6].
Chest PA view showed extensive active Koch's infiltration seen at the left mid zone. Right upper zone fibrotic with Koch's infiltration of hilum and mediastinum. The chest X-ray suggested bilateral active Koch's more on the left side [Figure 7].
The possibility of skeletal and pulmonary tuberculosis cannot be ruled out as the patient also had a gangrene of the left foot, which even after surgical treatment did not improve.
A diagnosis of chronic suppurative osteomyelitis of the right side of the body of the mandible leading to pathological fracture coexisting with pulmonary tuberculosis was clear.
| Discussion|| |
Despite all the benefits associated with the advances in medicine and dentistry, the development of microorganisms resistant to commonly used antibiotics, the increased number of patients treated with steroids and other immunocompromising drugs, and the rising incidence of AIDS, diabetes, and other medically-compromising conditions have led to resurgence in the incidence of osteomyelitis of the jaws secondary to systemic conditions. 
Systemic factors which alter host immunity and may facilitate development of acute and secondary chronic osteomyelitis of the jawbones are diabetes mellitus, autoimmune disorders, AIDS, agranulocytosis, anemia (especially sickle cell), leukemia, syphilis, malnutrition, chemotherapy, corticosteroid and other immunosuppressive therapy, alcohol and tobacco, drug abuse, prior major surgery, herpes simplex virus infection, herpes zoster, and cytomegalovirus infection. 
Although tuberculosis is rare in developed countries, it is very common and endemic in developing countries.  A resurgence of tuberculosis has been documented in both developed and developing countries since 1986. The most important reason for this is the association between tuberculosis and the spread of HIV infection. It is estimated that HIV positive patients have a 113-fold increased risk of contracting tuberculosis, whereas the risk for AIDS is increased 170-fold.  The increasing incidence of tuberculosis and HIV co-infection and the emergence of drug resistance worldwide pose a major threat, particularly in developing nations. 
Tuberculosis of the head and neck region generally involves a mass in the cervical region. Oral manifestations of tuberculosis occur in approximately 3% of cases, involving long-standing pulmonary and/or systemic infection.  Orofacial presentation of tubercular disease includes swelling, pain, loosening of teeth, and even displacement of tooth buds. Other manifestations may include an ulcer, granulomas, involvement of salivary glands and temporomandibular joint, and tuberculous lymphadenitis. 
Tuberculous osteomyelitis is quite rare and constitutes less than 2% of skeletal tuberculosis. Jaw involvement is even rarer and usually affects older individuals. In the younger age group, tuberculous involvement of the jaw is highly unlikely and sporadic instances have been reported in the literature. The spread of infection may be through an extraction socket or mucosal opening associated with an erupting tooth or by regional extensions of soft tissue lesions to underlying bone or hematogenous spread. Apical osteitis and periodontitis with horizontal bone loss or as a widespread destructive osteolytic lesion are some of the various types of clinical presentations and may be mistaken for a dental abscess, especially in absence of systemic symptoms.  Orofacial tuberculosis is often difficult to diagnose, and it should be a rare but important consideration in the differential diagnosis of lesions that appear in the oral cavity.  Current recommendations for the treatment of osseous tuberculosis include a 2 month initial phase of isoniazid, rifampin, pyrazinamide, and ethambutol followed by a 6 to 12 month regimen of isoniazid and rifampin. 
In a case of pathological mandibular fracture, the surgeon will frequently be facing a scenario of a systemically immunocompromised individual, with grossly infected bone which is non-viable.  In cases where there is little or no potential for normal union, the bone is excised until normal bleeding bone is encountered. The continuity defect created is maintained with a locking reconstruction plate and then reconstructed primarily or secondarily. This treatment method is used for cases of osteoradionecrosis, bisphosphonate osteonecrosis, and osteomyelitis. 
| Conclusion|| |
This case illustrates the importance of a high index of suspicion when evaluating a patient with an unusual destructive bone lesion, particularly in a susceptible epidemiologic and clinical setting.  Although a rare occurrence, the presence of tuberculosis must lurk in the deepest recesses of the dental professional's mind when clinical findings of osteomyelitis do not conform to routine therapy. 
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Rajeev M Gadgil
101, Professor, Department of Oral Medicine and Radiology, M.G.V.'s K.B.H. Dental College and Hospital, Panchavati, Nashik-422003, Maharashtra
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]