Chronic osteomyelitis of the jaws: A 7-year retrospective clinico-surgical evaluation in a tertiary hospital in Northwest Nigeria :Mujtaba Bala, Ramat Oyebunmi Braimah, Abdulrazaq Olanrewaju Taiwo, Sufiyanu Umar Yabo, Bashar Aliyu, Scientific Dental Journal

ORIGINAL ARTICLES
Year : 2023 | Volume : 7 | Issue : 1 | Page : 1--5

Chronic osteomyelitis of the jaws: A 7-year retrospective clinico-surgical evaluation in a tertiary hospital in Northwest Nigeria

Mujtaba Bala¹, Ramat Oyebunmi Braimah², Abdulrazaq Olanrewaju Taiwo², Sufiyanu Umar Yabo³, Bashar Aliyu¹,
¹ Department of Dental and Maxillofacial Surgery, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
² Department of Oral and Maxillofacial Surgery, Faculty of Dental Sciences, Usmanu Danfodiyo University, Sokoto, Nigeria
³ Department of Oral and Maxillofacial Surgery, Faculty of Dental Sciences, Usmanu Danfodiyo University, Sokoto, Nigeria; Department of ENT, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria

Correspondence Address:
Mujtaba Bala
Department of Dental and Maxillofacial Surgery, Usmanu Danfodiyo University Teaching Hospital (UDUTH), PMB 2370, Sokoto 840241
Nigeria

Abstract

Background: The incidence of chronic osteomyelitis of the jaw has declined in the developed world. However, it is still a burden in Northwestern Nigeria. Chronic osteomyelitis of the jaw occurs more commonly in the mandible, with sequestrectomy or jaw resection being the main treatment modality for the developing climes. Objective: The objective of this study was to describe the pattern of clinical presentation of this disease condition and to highlight the important aspects of its management. Methods: This was a retrospective analysis of chronic osteomyelitis seen and managed over a 7-year period. Sociodemographics, etiology, clinical features, investigations, and treatment modality were analyzed using SPSS version 25.0. Results: There were 36 (73.5%) males and 13 (26.5%) females in the age range of 7–87 years, with a mean ± standard deviation of 27.67 ± 21.13 years. The duration of symptoms ranged from 4 months to 3 years. Odontogenic infections were the main cause of osteomyelitis (44 [89.8%]), and the mandible (39 [79.6%]) was the most affected maxillofacial bone. The presenting complaints included pain, discharging sinuses, and swelling. Comorbidities, such as diabetes and hypertension, were recorded in five patients (10.2%). Plain radiographs and computed tomography scan were the imaging modalities. The majority, 36 (73.5%), had a sequestrectomy. There was no statistically significant difference between the affected jaw and the type of surgical procedure performed (χ² = 1.801, df = 2, P value 0.406). Conclusion: This study found chronic osteomyelitis to be more common in the mandible and was mainly caused by an odontogenic infection. Prolonged antibiotic use, sequestrectomy, and jaw resection were used as the main approaches to its management in our locality.

How to cite this article:
Bala M, Braimah RO, Taiwo AO, Yabo SU, Aliyu B. Chronic osteomyelitis of the jaws: A 7-year retrospective clinico-surgical evaluation in a tertiary hospital in Northwest Nigeria.Sci Dent J 2023;7:1-5

How to cite this URL:
Bala M, Braimah RO, Taiwo AO, Yabo SU, Aliyu B. Chronic osteomyelitis of the jaws: A 7-year retrospective clinico-surgical evaluation in a tertiary hospital in Northwest Nigeria. Sci Dent J [serial online] 2023 [cited 2023 Jun 9 ];7:1-5
Available from: https://www.scidentj.com/text.asp?2023/7/1/1/377191

Full Text

Background

Osteomyelitis of the jaw is an inflammatory condition of the jawbones that involves the medullary cavity and adjacent cortex.[1] The jaw can be affected, but the mandible is more commonly affected.[2] It is an infectious condition that is mainly of odontogenic origin as a result of the interplay of mixed microbial activity.[1] Organisms implicated include Staphylococcus aureus, Staphylococcus albus, Haemolytic streptococci, and Gram-negative organisms such as Klebsiella, protease, Escherichia coli, Pseudomonas, and anaerobes, including bacteroides and fusobacteria. Some specific microbial forms, such as mycobacterium tuberculosis, treponema palladium, and actinomysis Israeli, have also been identified as causative organisms in osteomyelitis of jawbones.[3] Osteomyelitis can be classified as acute or chronic and suppurative or nonsuppurative. Chronic osteomyelitis has an insidious onset, minimal pain, and a slow increase in the size of the jaw, with subsequent sequestra formation.[4] Chronic osteomyelitis can be managed surgically with saucerization, decortication, sequestrectomy, and jaw resection. Supportive and medical treatment before and after surgery is necessary for a favorable outcome.[5]

The incidence of chronic osteomyelitis has been reduced, especially in the developed world, due to an efficient healthcare system. However, it is still a burden in our clime. This study aimed to describe the pattern of clinical presentation of chronic osteomyelitis and highlight the important aspects of its management.

Materials and Methods

This was a retrospective analysis of chronic osteomyelitis of the jaw bones seen and managed at the Oral and Maxillofacial Surgery Clinic of the Usmanu Danfodiyo University Teaching Hospital Sokoto for 7 years (January 2015–January 2022). Ethical approval was obtained from the research and ethics committee of the institution with the approval number SKHREC/065/2022. Patients who presented with and managed chronic osteomyelitis of the jaw irrespective of gender were recruited for this study. Patients with an incomplete record as per the study parameters were excluded. The patients’ age, gender, level of education, and occupations were recorded. The etiology, clinical features, investigations (computed tomography [CT], full blood count and differentials, retroviral screening, and random and fasting blood sugar), and treatment modality were also recorded. The data obtained were analyzed electronically using IBM SPSS software version 25 for windows (Armonk, NY: IBM Corp).

Results

There were 36 (73.5%) males and 13 (26.5%) females in the age range of 7–87 years, with a mean ± standard deviation of 27.67 ± 21.13 years. Most of the affected patients were in the first decade (1–10 years) as depicted in [Table 1]. The duration of symptoms ranged from 4 months to 3 years. Odontogenic infections constituted 44 (89.8%) of the patients, whereas nonodontogenic infections constituted five (10.2%) [Figure 1]. Infection of the mandibular first molar (15 [30.6%]) was found to be the main odontogenic cause of osteomyelitis. Regarding jawbone involvement, the mandible was found to be affected in 39 patients (79.6%) and the maxilla in 10 (20.4%). All patients had varying complaints, including pain, discharging sinuses, and swelling. Comorbidities, such as diabetes and hypertension, were recorded in five (10.2%) patients. Plain radiographs and CT scans were the imaging modalities. The majority (36 [73.5%]) had sequestrectomy, while 13 (26.5%) patients had jaw resection (12 mandibulectomies and 1 maxillectomy), as shown in [Figure 2]. Only four cases (30.8%) had a reconstruction plate inserted after jaw resection (n = 13). No significant difference was found between the affected jaw and the type of surgical procedure (χ2 = 0.184, df = 1, P value 0.180) [Table 2].{Table 1} {Figure 1} {Figure 2} {Table 2}

Discussion

Chronic osteomyelitis of the jaws is a relatively common disease in underdeveloped and developing countries.[6] It is a slow but persistent process characterized by the presence of few systemic symptoms when compared to acute osteomyelitis.[7] Chronic osteomyelitis was found to occur more commonly in male patients based on the results of this study, like the majority of findings in the literature.[8],[9],[10] Poor attitudes toward oral health, as well as more incidence of premedication in males, have been proposed as the reason for male predilection.[11]

Chronic osteomyelitis mostly affects adults, with a peak incidence mostly at the 4th and 5th decades.[8],[9] However, this study found it to be more common in the 1st decade of life. Malnutrition, poor oral health, parental negligence toward their children, and poverty could explain the findings of our study. Endemicity of the cancrum oris in children in our study could also be the reason for the high occurrence of osteomyelitis in the early part of life. Some studies have reported chronic osteomyelitis to be more common in the elderly population due to its vulnerability to comorbidities.[6],[11] Poor oral health and the presence of predisposing factors that could occur at different age ranges could play a more important role in the occurrence of chronic osteomyelitis. Certain predisposing factors play a vital role in the onset and severity of osteomyelitis, including conditions affecting host resistance, such as diabetes mellitus, tuberculosis, severe anemia, leukemia, and malnutrition.[6] Additionally, conditions affecting jaw bone vascularity, such as radiation, osteoporosis, malignancies, and fibrous dysplasia, have also been noted.[12] Diabetes mellitus and malnutrition were the most prominent comorbidities in our study. Retroviral disease was identified as a predisposing factor in one of our patients.

The findings in this study revealed mandibular involvement to be 3.9 times greater than maxillary involvement. This agrees with many other studies in the literature.[1],[3],[13] Several reasons have been suggested for this finding, including the avascular nature of the dense cortex of the mandible, a high incidence of carious mandibular first molar, and mandibular predisposition to trauma.[3],[14] The mandibular body region was the most affected, except in one isolated case in which the whole mandible was involved [[Figure 3]A and B].{Figure 3}

Chronic osteomyelitis is usually polymicrobiological and could result from odontogenic infection, noma, temporomandibular joint ankylosis, postdental extraction complications, trauma, inappropriate use of antibiotics, radiation therapy, and, rarely, manifestations of systemic diseases such as diabetes mellitus and leukemia.[15] Our study reported that odontogenic infections, mostly from carious first molars or complications arising from their extraction, were the main cause in 89.8% of the study population. This finding is in tandem with many previous studies.[3],[16] Other causes, including infected maxillofacial implants and trauma, constitute 10.2% of all other cases. This study recorded varying clinical features, including pain, swelling, discharge, trismus, sequestration, decortication, and paresthesia. These findings are like the clinical findings in most previous studies.[17],[18] However, paresthesia of the lower lip was recorded in 22.4% of this study’s population.

Despite advances in the field of imaging and the diagnostic tools used in the management of patients with osteomyelitis, plain radiographs remain germane. Plain radiographs demonstrate sequestra formation, proliferative periostitis, or irregular bone formation with ill-defined borders suggestive of chronic osteomyelitis.[3] Plain radiographs, such as posterior–anterior, right and left oblique lateral, occipitomental view, and orthopantomogram, were the majority of the imaging modalities used in our study. CT scans and magnetic resonance imaging could have been better at delineating the pathological complexity and extent of bone marrow involvement. CT scans were available for only two (4%) of our study population due to serious financial constraints. Microbiological culture and sensitivity (MCS) were performed in all cases and positive for staphylococcus in only one case. Considering the mixed nature of the orofacial microorganisms, the poor MCS result may be due to the anaerobic nature of some of the microbes (especially the obligate anaerobes), which require special transport media that are not available in our setting. Another possibility is the chronicity of osteomyelitis in some cases where patients could have been using antibiotics before presenting to our clinic.

The goal of the treatment of chronic osteomyelitis is to eradicate microorganisms and support healing.[19] This can be achieved by removing the source of infection and reestablishing vascular permeability to the infected area.[20] Medical, supportive, and surgical therapies were instituted in our patients. An effective and longer duration of antibiotics plays a significant role in the management of chronic osteomyelitis.[19] Age-dependent doses of clindamycin, as well as metronidazole, were administered before and after surgery empirically, with a favorable outcome in the current study. Antibiotics alone can provide palliation only in cases of chronic osteomyelitis, especially due to the presence of necrotic bone.[20] The choice of clindamycin was made because of its bone and soft tissue penetrating ability.

The management of necrotic bone in chronic osteomyelitis involves surgical removal. Surgical treatment includes debridement, incision, and drainage, sequestrectomy, saucerization, decortication, and jaw resection.[21] All the patients in our study underwent debridement, and the majority, 36 (73.5%), had sequestrectomy, while 13 (26.5%) patients had jaw resection (12 mandibulectomies and one maxillectomy). The extensive nature of the disease, particularly because of its late presentation, was the reason for the choice of sequestrectomy and mandibulectomy. The critical role of adequate tissue removal has been emphasized by Montonen et al.[22] who described unfavorable outcomes with insufficient surgical extent and retention of some associated teeth. Bevin et al.[23] similarly highlighted that conservative surgical treatment of chronic osteomyelitis invariably leads to multiple recurrences, although aggressive management may result in significant morbidity and a subsequent need for reconstruction. Four cases in this study had reconstruction plates inserted after mandibular resection. No statistically significant difference was found between the affected jaw and the type of surgical procedure. This is likely due to the frequency of sequestrectomy performed in the study population.

Conclusion

This study found chronic osteomyelitis to be more common in the mandible and was mainly caused by an odontogenic infection. Prolonged antibiotics, sequestrectomy, and jaw resection were used as the main approaches to its management in our locality.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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