Introduction
Osteomyelitis is nothing but an inflammation of the bone marrow that has a tendency to progress. This differentiates the dentoalveolar abscess, “dry socket” and “osteitis,” seen in infected fractures from osteomyelitis. It usually involves adjacent cortical plates and often periosteal tissues. Osteomyelitis of the jaws is predominantly a disease of the mandible, whereas the maxilla by virtue of its vascularity and thin cortical plates is less frequently involved.
Diminished local and systemic host defences can contribute to emergence of disease as well its clinical course. Osteomyelitis has been found to have association with multiple systemic diseases including diabetes, malignancies, malnutrition, acquired immunodeficiency syndrome etc. Medications like steroids, chemotherapeutic agents, and bisphospho-nates alter vascular dynamics of bone and hence predispose to osteomyelitis. Local conditions adversely affecting blood supply can also predispose host to bony infection.1
Oral tubercular lesions are either primary or secondary. Primary tubercular lesions are rare and younger patients are more often affected and are usually associated with cervical lymphadenopathy. In majority of cases, primary lesion remains painless. Secondary lesions, on contrary, are more common and seen mostly in older people. Lesions are superficial ulcers, patches, or destruction of jaw bones, that may be in form of tubercular osteomyelitis.2
Depending on clinical presentation, suppurative osteomyelitis may typically be acute or chronic. Acute osteomyelitis which is characterised by inflammation and suppuration within the marrow space needs to be suspected when there is onset of paresthesia of inferior alveolar nerve, despite absence of radiological signs. This drifts into chronic phase when inadequately treated, or host defence attains partial control or when pus within marrow spaces finds its way out by cortical perforation and sinus tract formation.
Other forms of non-suppurative osteomyelitis include osteoradionecrosis (ORN), bisphosphonate related osteonecrosis of the jaws (BRONJ), Garre` osteomyelitis, chronic recurrent multifocal osteomyelitis of children, and chronic sclerosing osteomyelitis. 3
Tubercular osteomyelitis of mandible is rare as compared to flat bones, it is always suspicious especially when positive history of systemic infection or medical treatment is denied. So, diagnosis can be based on histological findings. 4
In clinical practice of oral and maxillofacial surgery it presents as an enigma for clinician in terms of diagnosis and treatment. Delay in recognition of infection may result in a protracted course of treatment and increased surgical morbidity. 1
This case emphasizes consideration of tuberculosis in differential diagnosis of intraoral mandibular swelling and osteomyelitis of jaw. In present case we have discussed 45-year-old women with tuberculous osteomyelitis, its diagnosis, management and its manifestation in maxillofacial region. We used Cone Beam Computed tomography (CBCT) to explore dimensions of lesion to diagnose destructive extent of lesion.
Case Report
A young 45-year-old female reported to our clinic with complaint of mobile teeth. On examination, poor oral hygiene detected for which treatment of extraction is undertaken.
After a year she visited back to clinic with complain of swelling and pus draining from lower labial vestibule in relation to lower right region for past 20 days and pus discharge from same region since 5 days. Swelling occurred spontaneously and was associated with moderate to severe, continuous and localized pain. History revealed that he had been experiencing mild fever and weakness for 1 month.
On clinical examination, diffuse swelling was seen in right mandibular region. Swelling was abrupt in onset and had not changed much in overall dimensions. There was no associated toothache, pain, fever or swelling anywhere else in body. She had no prior medical and family history of treatment for any chronic infective disease. Intraoral pus drainage and swelling. No extraoral swelling and pus drainage. Patient was vitally and systemically stable. Apart from that, there was no other complaint. She had missing 47,46,36. Moderate periodontal bone loss w.r.t mandibular teeth.
Orthopantomogram (OPG-sectional) and Cone beam computed tomography (CBCT) views showed Irregular mixed osteolytic lesion with permeative border infiltrating the medullary portion of bone in right para-symphysis and body region extending from mesial portion of 43 to 47 region with maximum dimensions of 41.9mm x 7.9 mm M-D and B-L respectively. Superiorly the Lesion is extending from crestal bone level in 45-46 region and inferiorly up to superior border of mandibular canal in 45-47 region with discontinuity of cortical outline of mandibular canal at multiple sites in that region. Lesion involves crestal and middle portion of alveolar bone with involvement of IAN (inferior alveolar nerve) in 45- 47 region. Multiple sparse areas of bony trabeculae noted within the lesion separated from surrounding bone. Thinning and destruction of buccal and lingual cortical plate also noted. No evident root resorption noted w.r.t involved teeth. Separate focal periapical hypodense area involving periapex also noted w.r.t 43. Single root which bifurcates into two: buccal and lingual involving apical root portion noted. Separate focal periapical hypodense area suggestive of periapical lesion seen w.r.t 42. Single root with single canal which bifurcates into two in middle root portion and fuses together in apical root portion to exit through a single apical foramen (1-2-1 canal configuration). Separate focal periapical hypodense area involving periapex also noted w.r.t 31. Single root with single canal observed w.r.t 31. Extraction socket with destruction of buccal cortical plate involving crestal third portion of alveolar bone noted w.r.t 36. according to the CT scan findings it was provisional diagnosis of osteomyelitis.
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The patient was operated under local anaesthesia and affected area lesion was excised. Curettage of the necrotic tissue performed in the right condylar region and suture were placed.
The excised tissue was sent for histopathologic examination, which showed soft tissue of soft tissue showing ill-defined epithelioid granulomas with Langhans giant cells with necrotic material [Figure 3]. Histopathologic report confirmed the diagnosis of TB. GeneXpert TB test and culture test were advised. Myco-bacterium tuberculosis complex was detected in GeneXpert TB and culture test.
Final diagnosis was confirmed. Physician for Anti Tubercular Treatment (ATT) regimen {Rifampicin (600 mg) Isoniazid (300 mg), Ethambutol(800mg), Pyrazinamide(750mg), Vitamin B6, D, calcium supplements} and was kept on periodic follow up. On 3 months postoperative follow up, the intra oral lesion got resolved. [Figure 4 A-DFigure 5]
1 year follow- up radiograph was done which shows adequate bone formation in the region of the lesion. [Figure 6]
Discussion
TB is caused by bacteria mycobacterium tuberculosis, which is an aerobic, non-motile, non-capsulated, non-spore forming and rod-shaped organism.5 Tuberculous lesions may be primary or secondary. Primary tuberculosis of oral cavity is very rare.6 In primary oral tuberculosis organisms are directly inoculated on oral mucosa of a person who has not been previously infected. Role of trauma is controversial, as stratified squamous epithelium of oral cavity normally resists direct penetration by tubercle bacilli. In secondary oral tuberculosis coexists with pulmonary disease. Self-inoculation take place from infected sputum or hematogenous seeding.7
Primary tuberculosis is commonly observed in children and adolescents. Usually involves gingiva, mucobuccal folds or extraction sites, and often associated with enlarged cervical lymph nodes.8 Secondary tuberculosis coexists with pulmonary disease in all age groups specially occur in middle-aged and older people. Most frequently occurring lesion is painful ulcer, characterized by irregular edges with minimal induration.9 Ulcer base may be granular or covered with pseudo membrane. The dorsal surface of tongue is affected most commonly followed by palate, buccal mucosa and lips followed by salivary glands, tonsils and uvula.
Tubercular osteomyelitis of maxilla is very rare. Tubercular osteomyelitis of mandible is more common than maxilla, as it contains lesser amount of cancellous bone. Diagnosis is confirmed by histopathological examination, presence of acid-fast bacilli in tissue section, or by culture of tubercular bacilli. In majority of cases,single biopsy may not suffice because granulomatous changes may not be evident in early lesions.10
In present case we discussed here illustrative case of tuberculous osteomyelitis, its diagnosis, management and its manifestation in maxillofacial region, here Cone Beam Computed tomography (CBCT) was used to explore third dimension of the lesion to diagnose the destructive extent of the lesion.
Conclusion
Tuberculosis infection of the gingival is relatively rare; oral lesions would most commonly be secondary to pulmonary tuberculosis. Clinicians’ awareness will help in early diagnosis and prevent complications considering tuberculosis in the differential diagnosis of gingival enlargement. Hence, awareness of rare form of oral tuberculosis makes early diagnosis and prevents further spread of disease.
