Periostitis ossificans versus Garrè's osteomyelitis. Part I. What did Garrè really say?

A Child With Recurrent Jaw Swelling

A 9-year-old male presented with a 2-year history of recurrent left-sided jaw swelling. Physical examination revealed a hard mass at the left ramus of the mandible. What is your diagnosis?

Chronic Osteomyelitis With Proliferative Periostitis of the Mandible in a Child: Report of a Case Managed by Immunosuppressive Treatment

BACKGROUND

Osteomyelitis with proliferative periostitis is a relatively uncommon inflammatory condition of the jaws, mainly characterized by periosteal formation of reactive bone. It primarily affects children and adolescences, also referred to as Garre's osteomyelitis, more frequently involving the molar region of the mandible. Cases lacking an obvious source of infection may have an immunologically mediated etiopathogenesis, falling under the spectrum of primary chronic osteomyelitis or chronic recurrent multifocal osteomyelitis (CRMO).

CASE REPORT

Herein, we present a case of chronic osteomyelitis in a 6.5-year-old girl, who suffered from recurrent painful episodes of swelling of the mandible for the last 2 years, previously requiring hospitalization and administration of intravenous (IV) antibiotics and NSAIDs with limited responsiveness. The biopsy showed features consistent with osteomyelitis with proliferative periostitis. The patient was initially managed with an IV combination antibiotic regimen with only partial improvement. The possibility of an autoimmune mechanism in the context of primary chronic osteomyelitis or CRMO was considered, and immunosuppressive therapy (TNF inhibitor etanercept along with corticosteroids and methotrexate) was administered, resulting in clinical resolution.

CONCLUSIONS

Osteomyelitis and its childhood variants are relatively rare and their management presents several challenges. Although typically treated with administration of antibiotics, possibly along with surgical intervention, other treatment modalities may be necessary for resilient and persistent cases. In a subset of cases, especially in the absence of local infectious factors, immunologically mediated mechanisms may play an important role and appropriate immunosuppressive therapy may be effective.

Sclerosing osteomyelitis of Garré: A confusing clinical diagnosis

We describe a rare case of sclerosing osteomyelitis of Garré in a 63-year-old woman with uncontrolled right thigh pain. She had suffered from lower back pain and radiating pain on the right lower leg for a year and 4 months and so had spine surgery 8 months ago. But the right thigh pain persisted, and the levels of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) remained abnormal. Right femur radiographs showed cortical thickening on the proximal femur. Magnetic resonance images showed T2 hypersignal intensity lesions in the proximal femur. Under suspicion of osteoid osteoma or sclerosing osteomyelitis, surgery was performed with biopsy, bone curettage, and drilling. The culture was negative, and the biopsy showed chronic osteomyelitis. Despite surgery, the levels of CRP and ESR still remained abnormal. After using venous antibiotics, the pain subsided and CRP and ESR levels turned to normal. Followed by 6 weeks of oral antibiotics, pain was relieved after 1-year follow-up.

A rare case: sclerosing osteomyelitis of the frontal bone

The patient presented in this study had a form of chronic sclerosing osteomyelitis (CSO) that is rarely reported in calvarial bones and has never been reported in the frontal bone in the literature. We aimed to contribute to the literature with this case study. In this study, we report a 14-year-old girl who presented with swelling and pain in the frontal bone and underwent treatment due to CSO. The patient had no history of trauma and chronic infection. We conclude that CSO should be considered in the differential diagnosis of the patients presenting with cranial swelling whose diagnosis cannot be established based on the radiological findings.

'Autoreconstruction' of the Mandible-Report of a Case

Bisphosphonate-related osteonecrosis of the jaw (BRONJ) was first mentioned in the literature in 2003. Since then, several reports have been published referring to this disease. The etiology of BRONJ still remains unclear. The treatment of BRONJ also remains a topic of discussion between those who are in favor of a conservative treatment and those who are convinced that surgical treatment gives the best results. In this case report, a patient is presented with BRONJ in the mandible which has been treated surgically in combination with antibiotic treatment. During surgery it appeared that a large part of the jaw was sequestrated full-thickness with, at the same time, formation of a substantial amount of subperiosteal bone that was formed around the BRONJ, supporting the sequestrated part of the mandible and, after sequestrectomy, serving as a neo-mandible. This case shows the capacity of the jawbone despite bisphosphonate use to regenerate itself.

Garre's sclerosing osteomyelitis caused by salmonella group D in a patient with systemic lupus erythematosus: an unusual complication

We report the case of a 35-year-old male, who was diagnosed with systemic lupus erythematosus (SLE) in 2010 based on the presence of articular, serous, renal, immune, and hematologic involvement. He also had secondary antiphospholipid syndrome (APS). He was treated with prednisone 10 mg per day, hydroxychloroquine 200 mg per day, methotrexate 12.5 mg per week, leflunomide 20 mg per day, and oral anticoagulation previous to the present event. He presented to emergency room with a 7 day disease duration characterized by pain in the left thigh, which increased with physical activity, resulting in claudication; he also had malaise and fever. The X-ray films showed periostitis of the lower half of the left femur with bone marrow narrowing; the scintigraphy showed marked increased uptake in the middle and distal thirds of the left femur, and magnetic resonance imaging (MRI) showed thickening and hyperintensity of the cortex of the diaphysis and distal epiphysis of the femur and endosteal irregularity. Empirical treatment was started with vancomycin for 3 weeks. Femur biopsy and cultures were performed, isolating Salmonella spp. group "D" Vi (-); treatment with cotrimoxazole and ceftazidime for 4 weeks followed by doxycycline and cotrimoxazole for 4 months were given with a favorable functional outcome. This is an unusual case of a young adult with Garre's sclerosing osteomyelitis associated to SLE and caused by salmonella. The literature is reviewed and the clinical conditions predisposing to this infection are discussed, particularly in patients with SLE.

Periostitis ossificans (Garrè's osteomyelitis): An unusual case

Garrè's sclerosing osteomyelitis is a specific type of chronic osteomyelitis that mainly affects children and young adults and is commonly associated with odontogenic infection. The paper describes an unusual case of Garrè's osteomyelitis in an 11-year-old boy, in whom the condition arose following poor oral hygiene and periodontal problems in relation to permanent mandibular left first molar. Clinically the patient presented with bony hard, nontender swelling and the occlusal radiograph revealed pathognomic feature of "onion skin" appearance.

Garré's sclerosing osteomyelitis: case report

The aim of this study was to report on a rare case of Garré’s sclerosing osteomyelitis. The patient was a 54-year-old woman with a history of treatment for lupus using corticoids for 20 years, and for osteoporosis using alendronate for five years. She presented edema and developed a limitation of left knee movement one year earlier, with mild effusion and pain on metaphyseal palpation, but without fever. She was in a good general state, without local secretion. Images of her knee showed trabecular osteolysis of the distal metaphysis of the femur and a periosteal reaction in both proximal tibias and both distal femurs, compatible with chronic osteomyelitis of low virulence and slow progression. Magnetic resonance imaging showed T2 hypersignal in the femur and tibia. Curettage was performed on the left distal femur, with release of secretion, but this was negative on culturing. A biopsy showed chronic infection and inflammation, fibrosis, xanthogranulomatous reaction and foci of suppuration. Antibiotic therapy was administered for six months. The etiology was not clarified: bacterial infection was suspected, but culturing was generally negative. The chronic process was maintained by low-virulence infection or even after treatment. The differential diagnoses were fibrous dysplasia, syphilis, pustulosis palmoplantaris, rectocolitis, Crohn's disease, SAPHO (synovitis, acne, pustulosis, hyperostosis and osteitis) and Paget's disease. The unifocal diseases were osteoid osteoma, Ewing's disease, osteosarcoma and eosinophilic granuloma.

Sclerosing osteomyelitis of Garré: management of femoral pain by intramedullary nailing

We describe a case of chronic sclerosing osteomyelitis of Garré in a 50-year-old woman occurring in her right femur and presenting with uncontrolled pain. The patient was initially treated with intramedullary reaming of the femur, but 3 years later re-presented with similar symptoms. This required further reaming and intramedullary nailing, achieving good clinical outcomes and lasting pain relief at 8-year follow-up.

Juvenile mandibular chronic osteomyelitis: multimodality imaging findings

BACKGROUND AND PURPOSE

Juvenile mandibular chronic osteomyelitis is a rare entity that predominantly affects children and adolescents, but little is known about the factors that contribute to the recurrent course and eventual resolution of this disease. Here, we describe new findings of soft tissue and mandibular nerve canal involvement.

MATERIALS AND METHODS

Four patients with mandibular diffuse sclerosing osteomyelitis are presented; all were followed with CT, a few also with MRI and bone scan. We recorded imaging findings of lesion location, pattern of bone formation, presence and evolution of lytic lesions, mandibular nerve, and soft tissue involvement.

RESULTS

In all patients we found enlargement of the mandibular nerve canal and soft tissue changes on CT and MRI (when available). All patients had ground glass bone patterns in conjunction with lamellated/onion skin new periosteal bone formation on CT, and all patients with follow-up CT had change in lytic lesion locations.

CONCLUSION

Mandibular nerve canal enlargement, soft tissue abnormalities, and change in location of lytic lesions may represent a diagnostic pattern in mandibular diffuse sclerosing osteomyelitis (Garré) that was not previously entirely recognized as such.

Mandibular periostitis ossificans in immature large breed dogs: 5 cases (1999-2006)

This case series describes clinical, radiographic, and histopathological features of mandibular swellings in 5 immature, large breed dogs. The dogs originated from different regions of the United States. In each case, intraoral dental radiography of the jaw swelling revealed a two-layered (double) ventral mandibular cortex. Biopsy was performed in 4 of the 5 puppies, revealing periosteal new bone formation. Resolution of the mandibular swelling was spontaneous in the 4 dogs available for follow-up examination. The authors postulate that the clinical, radiographic, and histopathological presentation of mandibular swelling in these 5 dogs is a distinct pathological entity consistent with an inflammatory condition of the maturing human mandible known as periostitis ossificans.

Misnomers in oral pathology

BACKGROUND

Diseases which involve the oral cavity usually derive their names from either Greek or Latin. These terms are customarily based on etiology or description of the lesion. However, because of various reasons, some of these terms are misnomers.

OBJECTIVE

To review commonly encountered misnomers in oral pathology.

CONCLUSIONS

Most of the misnomers encountered in oral pathology may arise from lack of understanding of underlying etiology, pathogenesis, histopathology, and/or concepts. Some misnomers are due to imprecise translations from word origins, etymological bungles, and/or factual errors. Clinical, histopathological, and/or etymological explanations are used to analyze and elucidate the nature of these misnomers. Alternative terms, where possible, have been suggested.

Osteomyelitis with proliferative periostitis: an unusual case

Chronic osteomyelitis with subperiosteal new bone formation results from periosteal reaction to chronic inflammatory/infectious stimulation. In the maxillofacial region, it has traditionally been termed Garrè's osteomyelitis with proliferative periostitis and more recently periostitis ossificans. The term Garrè's osteomyelitis has been regarded as a misnomer by many authors in the recent literature. The term chronic osteomyelitis with proliferative periostitis, although cumbersome, is considered to be the most accurate description of the pathology. It usually affects the mandible of young patients secondary to dental infection. Management involves removal of the source of infection and antibiotic treatment. We present an unusual case of chronic osteomyelitis with proliferative periostitis affecting the mandible of a 12-year-old patient. The source of infection was related to the developing lower left third molar, which had apparently no communication with the oral cavity.

Diagnosis and classification of mandibular osteomyelitis

To establish a unified classification system for mandibular osteomyelitis, various diagnostic terms were critically assessed and clinicopathologic findings of the lesions were carefully reviewed. We recommend classifying mandibular osteomyelitis into bacterial osteomyelitis and osteomyelitis associated with the synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome. Other diagnostic terms were excluded because they were not appropriate for classification. Diagnostic criteria for bacterial osteomyelitis are suppuration and osteolytic change. The lesions are easily cured by antibiotic treatments. Mandibular osteomyelitis in SAPHO syndrome is characterized by nonsuppuration and a mixed pattern on radiography, with solid type periosteal reaction, external bone resorption, and bone enlargement. The presence of osteomyelitis in other bones, arthritis, or skin diseases (palmoplantar pustulosis, pustular psoriasis, and acne) strongly suggests this syndrome. Antibiotic therapy is usually ineffective and the symptoms of SAPHO syndrome are often persistent.

Periostitis ossificans (Garrè's osteomyelitis) radiographic study of two cases

BACKGROUND

Periostitis Ossificans (PO) is a non-suppurative type of Osteomyelitis, commonly occurring in children and young adults, in mandible. The most common cause for PO is periapical infection of mandibular first molar. Radiographically PO is characterized by the presence of lamellae of newly formed periosteal bone outside the cortex, giving the characteristic appearance of "onion skin".

CASE REPORTS

Two male children 11 years of age reported to the Department of Oral Medicine with a painless and persistent bony hard swelling in the mandible, with a short duration (Figs 1, 5). Both the patients had grossly decayed mandibular permanent first molar tooth with periapical infection and buccal cortical plate expansion (Figs 2, 6). The radiographic study revealed different appearances, the Orthopantomograph of case I showed a single radiopaque lamella outside the lower cortical border, without altering original mandibular contour (Fig. 3) and in case II showed a newly formed bony enlargement on the outer aspect of the lower cortical border without altering the original mandibular contour (Fig. 7). Occlusal radiograph of both the patients showed two distinct radiopaque lamellae of periosteal bone outside the buccal cortex (Figs 4, 8). Kawai et al. classified PO of mandible into type I and type II, based on whether the original contour of mandible is preserved or not. Each type is further classified into two sub types (Table 1). In case I, the orthopantomographic appearance is characteristic of type I-1 (Fig. 3), but the appearance in occlusal radiograph is characteristic of type I-2 (Fig. 4). In case II, the appearances in both the radiographs are characteristic of type I-2 (Figs 7, 8).

CONCLUSIONS

Apart from the typical onion skin appearance, PO shows various other radiographic appearances. The radiographic appearance of Periostitis Ossificans may reflect the duration, progression and the mode of healing of the disease process. The radiographic classification of PO depends on the type of radiographs taken for evaluation.

Osteomyelitis of the mandible

Before application of any cross-sectional imaging modality, the orthopanoramic view is indispensable in assessing the status of dentition, in recognizing direct radiographic signs of osteomyelitis, or in determining the presence of predisposing conditions such as a fracture or systemic bone disease. The orthopanoramic view is the procedure of choice in follow-up examinations in patients who have osteomyelitis. In acute osteomyelitis, the higher sensitivity of MR imaging for detection of intramedullary inflammation advocates this imaging modality for confirmation of the clinical diagnosis. If surgical treatment is planned, high-resolution CT is required to specify the degree of cortical destruction, the presence of sequestra in particular, and to define the extent of osseous removal required. In chronic osteomyelitis, the higher sensitivity of MR imaging to detect periosteal inflammation and soft tissue involvement advocates this modality to reveal the presence, location, and extent of chronic inflammation. The assessment of persistence or recurrence of chronic inflammation after surgical treatment is by high-resolution CT for the first 6 months following surgery. Finally, scintigraphy is recommended when multi-focal systemic disease is suspected, such as in CRMO and SAPHO syndrome.

Primary chronic osteomyelitis in childhood and adolescence: a retrospective analysis of 11 cases and review of the literature

PURPOSE

Primary chronic osteomyelitis (PCO) of the jaw is a rare, nonsuppurative, chronic inflammation of an unknown cause. The disease is not age specific. So far, only case reports of this disease with an onset in childhood or adolescence have been described.

PATIENTS AND METHODS

Review of the patient data of our department from the past 30 years revealed 11 patients with an early onset of PCO in childhood and during puberty.

RESULTS

Demographic data, clinical course, radiologic and histologic examinations, and treatment modalities are described and compared with the literature with special emphasis on the somewhat confusing terminology used for this pathology.

CONCLUSION

We present a group of 11 patients with an early onset of PCO of the mandible, which, to our knowledge, is the largest described series to date. The series shows the complexity of this disease in a young patient population, demanding a careful evaluation of each case before initiation of therapy.

Gross periostitis ossificans in mandibular osteomyelitis. Review of the English literature and radiographic variation

OBJECTIVE

The purpose of this study was to describe a radiographic variety of gross periostitis ossificans in mandibular osteomyelitis and to determine what types of gross periostitis ossificans are related to a specific form of mandibular osteomyelitis without demonstrable causes.

STUDY DESIGN

We reviewed 20 cases of gross periostitis ossificans in patients with mandibular osteomyelitis that had been reported with illustrations in the English literature, and we reviewed our own 14 cases of gross periostitis ossificans, previously reported. The radiographic features of the 34 cases of gross periostitis ossificans were classified according to the status of original contour and the appearance of gross periostitis ossificans. Histopathologic features were studied in 12 cases.

RESULTS

The 34 cases of gross periostitis ossificans could be classified radiographically into 4 types. Type A, showing an "onion-skin" appearance, was caused by a carious tooth or followed extraction of a tooth. Type B and type C showed a consolidation form; in the 36.8% (7/19) of these cases in which no infectious source could be identified, it was suspected that the condition was caused by a developing unerupted tooth or a dental follicle. Type D was seen in the most chronic stage. Biopsy specimens of 12 cases commonly showed proliferation of newly formed bone, loose interstitial fibrous tissue, and a low-grade inflammatory cell infiltration.

CONCLUSION

Gross periostitis ossificans of type B or type C may be a specific form of mandibular osteomyelitis without demonstrable cause.

Radiographic investigation of mandibular periostitis ossificans in 55 cases

The radiographic and clinical features of periostitis ossificans in 55 patients with mandibular osteomyelitis were studied. On the basis of whether the original mandibular contour was preserved or not, the lesions could be classified radiographically into two major types, each with two subtypes. Type I lesions were of shorter duration than Type II. Type 1-2 and Type II-1 periostitis ossificans were characteristically observed in patients under 25 years of age. Extraction of the lower third molar with pericoronitis was the most frequent cause of periostitis ossificans. An unerupted third molar tooth bud was found in close proximity to the area of periostitis ossificans in six patients. With adequate treatment there can be complete resolution of periostitis ossificans in Type I cases; however, when there has been loss of mandibular contour (Type II cases), mandibular deformity remains even when normal bony architecture has been restored.

Periodontal infection leading to periostitis ossificans ("Garrè's osteomyelitis") of the mandible. Report of a case

Periostitis ossifications ("Garrè's osteomyelitis") of the mandible is a rather rare pathology that occurs as a hard swelling at the mandibular angle, persists for a long period, and is mostly painful on palpation. Clinical signs of infection are rarely noted. The etiological factor is generally a carious first permanent molar with a periapical infection or a fracture of the jaw. In this case, a 10 year-old girl showed a fixed painful swelling of the right mandibular angle. This revealed to be periostitis ossificans, although none of the classical causes were present. The symptoms were evoked by a periodontal infection: there was an osseous crater and a probing pocket depth of more than 10 mm disto-lingually of the first right permanent molar of the mandible. This was likely the etiological factor. Extraction of the first and second permanent right molar, curettage of the corresponding alveoli, and antibiotic treatment resulted in complete healing, clinically and radiologically, after 9 months.

An infected dentigerous cyst complicated by periostitis ossificans. Case report

Periostitis ossificans is a rare condition which has not been previously reported arising from an infected dentigerous cyst. This paper reports such a case in a twelve-year-old boy, and reviews the literature concerning periostitis ossificans.

Gentamicin impregnated polymethylmethacrylate (PMMA) beads in the treatment of primary chronic osteomyelitis of the mandible

Primary chronic osteomyelitis (chronic diffuse sclerosing osteomyelitis) of the mandible is an uncommon condition, probably arising as a consequence of infection with bacteria of low virulence, in which bone deposition rather than bone resorption occurs. These bacteria are most likely derived from skin or oral mucosa gaining access to bone from the periodontium or through the circulation. Furthermore, delayed hypersensitivity and ischaemic changes within bone may contribute to the inflammatory response, which once initiated is very difficult to eradicate. When the likely aetiological factors are considered a logical approach to management includes the surgical removal of affected bone and the topical application of a broad spectrum antibiotic to the resultant surgical bed.

Sclerosing osteomyelitis of Garrè (periostitis ossificans)

The diagnosis of sclerosing osteomyelitis of Garrè, or periostitis ossificans, is suggested by a history of hard swelling of the mandible accompanied by a carious dentition. Computed tomography, nuclear medicine scanning, and pantomography are used to illustrate the appearance of this condition arising in a 25-year-old woman. The differential diagnosis of mandibular thickening and associated bony sclerosis is discussed.

Periostitis ossificans versus Garrè's osteomyelitis. Part II: Radiologic analysis of 93 cases in the jaws

Ninety-three clinically and radiologically diagnosed cases of periostitis ossificans were gathered over a 13-year period. Histologic specimens were available in 19 cases. The predominant age, race, and gender were determined. The position of the periosteal reaction, its average length and width, and radiographs required to best demonstrate it were also established. Sequestra were present in two thirds of the cases. Radiographic features and associated clinical findings are described.