|Year : 2013 | Volume
| Issue : 4 | Page : 180-182
Tuberculous osteomyelitis of the mandible
Nirima Oza1, Karoon Agrawal2
1 Department of Oral Pathology, Mahatma Gandhi Post Graduate Institute of Dental Sciences, Indira Nagar, Puducherry, India
2 Department of Burns, Plastic and Maxillofacial Surgery, Safdarjang Hospital, New Delhi, India
|Date of Web Publication||22-Jan-2014|
Sri Aurobindo Ashram, Pondicherry - 605 002
In developing countries, tuberculosis is still a prevalent health problem. Purpose of this short communication is to draw an attention that pus discharging extra oral sinus in relation to lytic lesion of the mandible without any odontogenic or any other cause could be due to tubercular infection.
Keywords: child, mandible, osteomyelitis, tuberculosis
|How to cite this article:|
Oza N, Agrawal K. Tuberculous osteomyelitis of the mandible. SRM J Res Dent Sci 2013;4:180-2
A 3½-year-boy reported with the complaint of swelling of the right side of the face since few days. There was no past history of undergone medical or dental treatment for the same. On local examination, there was pus discharging extra oral sinus at the right angle of the mandible also [Figure 1] and [Figure 2]. Mouth opening was normal. The sinus was opening intraorally distal to tooth number 55. There was no evidence of dental caries or any periodontal disease.
|Figure 2: Pus discharging sinus below the lower border and right angle of the mandible|
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Plain radiographs showed diffuse, expansile, osteolytic lesion of right angle of the mandible [Figure 3] and [Figure 4]. Provisionally, the lesion was diagnosed as a case of osteomyelitis of the mandible. Differential diagnosis was an intraosseous malignant lesion with secondary infection. Erythrocyte sedimentation rate was 45 mm/h. Smear and culture collected from the pus were found to be negative for tubercular bacilli. An incisional biopsy was taken. Histopathological examination revealed typical epitheloid granuloma having caseation and Langhan's type of giant cells [Figure 5]. Acid fast bacilli were not demonstrated in the tissue sections.
|Figure 3: Radiograph - PA mandible showing diffuse erosion and lysis of the bone at the angle of the mandible|
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|Figure 4: Radiograph - Lateral oblique view showing diffuse erosion and lysis of the bone at the angle of the mandible|
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|Figure 5: Photomicrograph of incision biopsy showing Langhan's type of giant cells, ×100, H and E|
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Further investigations were carried out to look for the primary lesion. The patient showed strongly positive tuberculin test. Radiograph of chest showed pulmonary tuberculosis. Patient was referred to hospital for tuberculosis and chest diseases for the treatment of tuberculosis. Patient could not be followed-up as he was coming from a far distance.
Chronic pus discharging sinus at the angle of the mandible in a young child without any dental or periodontal lesion with lytic areas in the bone suggests osteomyelitis or a malignancy. Wood and Goaz write in their textbook - "differential diagnosis of oral and maxillofacial lesions" that a secondarily infected bone tumor and chronic osteomyelitis are indistinguishable by clinical or radiographical examination or by the patient interview. Incidence alone, however favors diagnosis of osteomyelitis.  Fineneedle aspiration cytology or open biopsy of the lesion is mandatory for the final diagnosis. In this case, open biopsy was preferred, which revealed features suggestive of tuberculosis though bacilli were not detected. Gupta et al. have quoted that the diagnosis of a case of tuberculosis of mandible is extremely difficult as there are no specific signs pathognomonic of the infection. The only manifestation may be a localized swelling of the jaw and it may be confused with actinomycosis. The diagnosis must be established by histological examination of tissue and demonstration of the organisms in the lesion.  Chapotel described four clinical forms of tuberculosis of the mandible: the superficial or alveolar form, the deep or central form, the diffuse form and acute osteomyelitic form. He describes the deep or central form, in which the lesion involves the angle of the mandible. It is found, almost exclusively in children during the period of eruption of teeth.  The present case belongs to this deep or central form of tuberculous osteomyelitis of the mandible as described by him.
As such the involvement of the mandible by tuberculous infection is extremely rare as it contains less cancellous bone.  Nearly 60% of all cases of tuberculosis of jaw occur in children below the age of 16 years. The mandibular involvement is more frequent than maxilla and alveolar and angle region have greater affinity. 
Although tuberculosis has a definite affinity for the lungs, it can affect any part of the body including the oral cavity. However, rarely, primary tuberculous involvement of the oral structures does occur. Occasionally the recognition of the oral tuberculous lesion precedes the detection of pulmonary tuberculosis  like the present case. In tropical countries, the osteomyelitis of jaw bones especially the mandible, can be a tubercular infection. This diagnosis is essential as the treatment protocol for tuberculosis will be different from that of pyogenic infection and osteomyelitis. Although rare occurrence, the differential diagnosis of tubercular osteomyelitis must always be kept in mind by clinicians, when routine therapy fails to bring about an improvement in the lesions of mandible. Since the involvement of bone occurs in late stages of the disease, the prognosis is poor and death from involvement of internal organs or from tubercular meningitis is common. However, if the lesion is primary and detected early, the disease is completely curable and can lead to reversal of all destructive bony changes. 
| References|| |
|1.||Wood NK, Goaz PW. Differential diagnosis of oral and maxillofacial pathology. 5 th ed. Singapore: Harcourt Brace & company Asia PTE Ltd.; 1998. p. 436. |
|2.||Gupta KB, Manchanda M, Yadav SP, Mittal A. Tubercular osteomyelitis of mandible. Indian J Tuberc 2005;52:147-50. |
|3.||Chapotel S. Tuberculous mandibularie. Rev Odent 1930;51:444-5. Quoted from Meng CM. Tuberculosis of mandible. J Bone Joint Surg 1940;22:17-27. |
|4.||Prabhu SR, Sengupta SK. Bacterial infections due to mycobacteria A. Tuberculosis. In: Prabhu SR, Wilson DF, Daftary DK, Johnson NW, editors. Oral Diseases in the Tropics. Oxford: Oxford University Press; 1993. p. 195-2. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]