Conservative treatment of children with chronic diffuse sclerosing osteomyelitis/tendoperiostitis of the mandible

Bisphosphonate therapy in the management of diffuse sclerosing osteomyelitis of the mandible: a systematic review and narrative synthesis

Background

Diffuse sclerosing osteomyelitis (DSO) affecting the mandible is an uncommon condition characterised by recurrent pain and functional disturbances. Traditional treatments involving antibiotics, steroids, and analgesics have generally yielded unsatisfactory results. Numerous articles have proposed the utilisation of bisphosphonate therapy as an alternative approach to achieve sustained symptom relief. This study aims to consolidate the available evidence on the effectiveness of bisphosphonate therapy in managing DSO.

Methods

A systematic review protocol was registered with PROSPERO and reported in accordance with the Preferred Reporting for Items for Systematic Reviews and Meta-Analyses. Comprehensive electronic search strategies were devised, and studies were screened based on predefined inclusion and exclusion criteria.

Results

Ten articles met the eligibility criteria, encompassing a total of 135 patients diagnosed with DSO who received bisphosphonate treatment. All included studies consistently reported a reduction in pain levels and swelling, along with a decrease in the cumulative use of analgesics. The majority of patients reported long-lasting symptom improvement with bisphosphonate therapy. Notably, four studies documented improvements in maximal mouth opening, with one study reporting a mean increase of 9.6mm. Furthermore, six studies observed improvements in panoramic radiographs and cone beam computed tomography scans, with one publication describing two patients exhibiting near-normal bone architecture. Importantly, all studies reported the absence of long-term complications.

Conclusions

Bisphosphonate therapy emerges as a promising treatment modality for DSO, exhibiting efficacy in symptom alleviation and radiological enhancement while conferring lasting benefits. Nevertheless, further prospective studies are warranted to refine treatment protocols and substantiate these findings.

Bisphosphonate therapy in chronic diffuse sclerosing osteomyelitis/tendoperiostitis of the mandible: Retrospective case series

This study aims to evaluate short-term and long-term results of bisphosphonate therapy in patients with diffuse sclerosing osteomyelitis/tendoperiostitis (DSO/TP) of the mandible. Eighteen patients (12 female, 6 male) aged 34.8 ± 22.2 years with DSO/TP of the mandible that were treated with bisphosphonates were included. In 16 patients, the bisphosphonate treatment led to remission with decrease of symptoms (pain, swelling of the cheek, trismus, tenderness of masticatory muscles) with a follow-up period of 4.5 (0.8-11.9) years between start of bisphosphonate treatment and latest follow-up consult. Of these, three patients were still in need of regular bisphosphonate therapy. Two patients were lost to follow-up. Bisphosphonate therapy is a treatment option for DSO/TP of the mandible that is associated with a high chance of remission of symptoms. Within the limitations of the study it seems that this treatment might be an effective second step in DSO/TP refractory to conservative treatment.

Is Operative Management Effective for Non-Bacterial Diffuse Sclerosing Osteomyelitis of the Mandible?

PURPOSE

Operative management has been reported to show varying degrees of therapeutic effects for non-bacterial diffuse sclerosing osteomyelitis of the mandible (DSOM). The purpose of this study was to retrospectively analyze and summarize the operative outcomes for non-bacterial DSOM.

METHODS

In this retrospective cohort study, patients with non-bacterial DSOM who received operative treatment were enrolled at the Peking University Hospital of Stomatology between 2012 and 2019. The primary predictor variables were the type of operative treatment and number of operations. The outcome variables were operative outcomes (symptom relief or ineffective) and time to recurrent symptoms after operations. Other study variables were demographics, including sex, age, and non-bacterial DSOM onset time. The χ² test and Kaplan-Meier model were used to evaluate differences.

RESULTS

The sample was composed of 72 patients with a mean age at onset of 26.1 ± 17.8 years and showed a female predilection. Decortication was performed for 68 patients with non-bacterial DSOM, and 4 patients underwent segmental mandibulectomy. Symptom relief was achieved in 37 (54.4%) patients after the first decortication, and the median time to symptom recurrence was 2.0 months. Furthermore, the longest time to symptom recurrence was not more than 6 months in all patients. Among the 4 patients who underwent segmental mandibulectomy, 2 who received fibula repair experienced recurrence of symptoms at 4 and 5 months after the operations, respectively, and their normal mandible and the transplanted fibula also presented with imaging manifestations of osteomyelitis.

CONCLUSIONS

Decortication and segmental mandibulectomy were not effective for non-bacterial DSOM. This finding is consistent with the results of other reports, and this condition may be best managed non-operatively by rheumatologists.

Primary chronic osteomyelitis of the jaw: Rapid improvement after hormonal suppression in a girl with precocious puberty

Primary chronic osteomyelitis (PCO) of the jaw is a non-infectious, inflammatory state of the jawbone of unknown etiology. In recurrent periods, these patients often exhibit swelling of the cheek, impaired ability to open their mouth as well as pain. Available treatments today include anti-inflammatory or antiresorptive drugs, hyperbaric oxygen, surgical decortication or resection followed by reconstruction where none of them have been described to lead to restored anatomy and complete relief of symptoms. We here report the unexpected complete regression of all clinical symptoms of PCO within three months after initiating pubertal suppression therapy with a gonadotropin-releasing hormone analogue in a 9-year-old girl with PCO of the jaw and early onset of pubertal development. Radiology of the jawbone confirmed complete PCO remission when performed 18 months after starting the hormone suppression therapy. To our knowledge, total regression of PCO in such a short period of time has not been described earlier suggesting an effect of the anti-hormonal therapy per se. In this case report, we discuss possible underlying mechanisms and hypothesize that anti-hormonal treatment could be a potential effective treatment in patients with PCO of the jaw.

An Orthodontic Approach for Garre's Sclerosing Osteomyelitis of the Mandible

The nonsuppurative osteomyelitis of the mandible is a rare condition that can occur in children due to low-grade inflammatory processes, dental cavities, periodontal lesions as well as the eruption process of the teeth. We submit a case report involving the orthodontic management of a 9-year-old female patient who presented in our service in the mixed dentition period with diagnosed Garre’s sclerosing osteomyelitis of the entire mandibular body. After a full work-up, the following symptoms and signs were noted: bilateral temporomandibular joint (TMJ) pain, loss of the leeway space, anterior open bite, distalization of the secondary maxillary right canine, nail biting and tongue thrust. Our orthodontic objectives were to relieve the TMJ pain, limit the eruption process of the teeth and to diminish the evolution of the osteomyelitis, reduce the growth of the inferior lower third of the face and to prevent further invasive treatment of the patient. In the first phase of treatment, we established a centric relationship using an orthopedic appliance (occlusal splint) and physiotherapy to deprogram the muscles and the TMJ. Throughout the second phase of treatment, we used orthopedic appliances to inhibit the overeruption of the secondary molars. After another year of treatment, the osteomyelitis lesions were under control with the permanent teeth in final position, good facial esthetic and as a functional result, no root resorption. We can conclude that by using low physiological forces to direct and control the growth pattern, good results could be obtained in stabilizing and controlling the sclerosing osteomyelitis of the mandible.

Do Bisphosphonates Alleviate Pain in Children? A Systematic Review

PURPOSE OF REVIEW

The goal of this systematic review is to analyze the effectiveness of bisphosphonates (BPs) to treat bone pain in children and adolescents who have diseases with skeletal involvement.

RECENT FINDINGS

We included 24 studies (2 randomized controlled trials, 3 non-randomized controlled trials, 10 non-randomized open-label uncontrolled studies, 8 retrospective studies, and 1 study with design not specified). The majority of included studies assessed pain from a unidimensional approach, with pain intensity the most frequently evaluated dimension. Only 38% of studies used validated tools; visual analogue scale was the most frequently employed. BPs were used to alleviate bone pain in a wide variety of pediatrics conditions such as osteogenesis imperfecta, secondary osteoporosis, osteonecrosis related to chemotherapy, chronic non-bacterial osteitis, idiopathic juvenile osteoporosis, unresectable benign bone tumor, and cancer-related pain. Twenty of the 24 studies reported a positive effect of BPs for alleviating pain in different pathologies, but 58% of the studies were categorized as having high risk of bias. Intravenous BPs are helpful in alleviating bone pain in children and adolescents. It is advised that our results be interpreted with caution due to the heterogeneity of the doses used, duration of treatments, and types of pathologies included. In addition, this review shows the paucity of high-quality evidence in the available literature and further research is needed.

TRIAL REGISTRATION

Before the completion of this review, the protocol was registered to PROSPERO (International prospective register of systematic reviews), PROSPERO 2020 ID # CRD42020158316. Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020158316.

Application of pamidronate disodium for the treatment of diffuse sclerosing osteomyelitis of the mandible: A clinical study

OBJECTIVE

This study aimed to assess the clinical effectiveness of using pamidronate disodium to treat patients with diffuse sclerosing osteomyelitis of the mandible (DSOM ).

STUDY DESIGN

Patients with DSOM who were hospitalized in the Department of Oral and Maxillofacial Surgery, Peking University Hospital of Stomatology (Beijing, China), between March 2018 and March 2019 were included. All patients were treated with intravenous administration of pamidronate disodium for 3 days. Pain intensity, mouth opening, blood workup findings, imaging examination findings, and incidence of complications before and after treatment and during the follow-up period, were recorded and compared.

RESULTS

Forty-three patients were treated with pamidronate disodium. Adverse reactions, including fever, hypocalcemia, hypokalemia, and diarrhea, were observed during treatment. Fourteen patients had moderate to severe pain before treatment, and the pain was markedly alleviated after days 2 and 3 of treatment. Pain and swelling were found to have disappeared at the 6-month follow-up in 39 patients (90.7%). Mean mouth opening increased from 28.5 mm to 38.1 mm. Imaging examinations showed that the bone mass in the affected area had markedly improved in 32 patients (74.4%).

CONCLUSIONS

Pamidronate disodium alleviated pain and swelling and improved mouth opening in patients with DSOM. Follow-up after 6 to 18 months demonstrated stable treatment effectiveness.

Non-surgical treatment of adults with chronic diffuse sclerosing osteomyelitis/tendoperiostitis of the mandible

Non-surgical therapy has proved to be effective in chronic diffuse sclerosing osteomyelitis (DSO) of the mandible in children. Therefore we aimed to investigate the effect of non-surgical therapy in adult DSO patients. We included consecutive patients with DSO who received non-surgical therapy in our center. They all received occlusal splint therapy, counselling about the disease, and/or physiotherapy by a specialised team. The use of analgesics, preferably nonsteroidal anti-inflammatory drugs, was advised for symptomatic control during periods of exacerbation. Sixteen patients (11/5 female/male) aged 39.9 ± 15.0 years with DSO of the mandible were included. The mean duration of symptoms was 39.7 ± 26.3 months before referral to our center. Patients were treated with a broad range of treatments before referral. All patients underwent non-surgical treatment. In 12 patients this led to remission. Four patients still had complaints after 12 months of non-surgical therapy and started with intravenous bisphosphonate therapy. In our center, DSO of the mandible was successfully treated with non-surgical therapy, despite a long duration before referral and extensive pre-treatment. Considering this high success rate, we recommend this non-surgical approach as the first treatment option for DSO of the mandible. In case of persistence, alternative treatments such as bisphosphonates should be explored.

Total mandibular reconstruction following diffuse sclerosing osteomyelitis

BACKGROUND

Diffuse sclerosing osteomyelitis (DSO) is a non-purulent chronic recurrent inflammation and affects the mandible in many cases. Belonging to the group of autoinflammatory diseases, in children and in cases with various additional symptoms including synovitis, acne, pustulosis, hyerostosis, and osteitis (SAPHO syndrome), therapy usually consists of non-surgical treatment. Against this background, we present an unusual course of DSO in an adult female patient.

CASE REPORT

A 50-year-old female suffering from DSO without SAPHO syndrome was pretreated for years with conservative drug regimens and local surgery. Previous therapy was not successful, and subsequently, multiple surgical procedures were carried out focused on recurrent acute exacerbations of DSO. Surgery resulted in a total resection and alloplastic and autoplastic reconstruction of the mandible including both temporomandibular joints. Prosthetic rehabilitation was possible after dental implant loading, and the final outcome was very satisfactory.

CONCLUSION

In the event that non-surgical options are not successful in DSO, an extended surgical therapy becomes necessary. Even if surgery results in complete resection of the mandible, a satisfactory rehabilitation can be achieved after complex reconstruction.

Radiographic characteristics of chronic diffuse sclerosing osteomyelitis/tendoperiostitis of the mandible: A comparison with chronic suppurative osteomyelitis and osteoradionecrosis

Diffuse sclerosing osteomyelitis (DSO) of the mandible is a poorly understood chronic disease. It is assumed to be a form of chronic osteomyelitis. Other forms of chronic osteomyelitis are chronic suppurative osteomyelitis (CSO) and osteoradionecrosis (ORN). This study aimed to investigate radiographic characteristics of DSO and compare these findings with the radiographic characteristics of CSO and ORN in order to radiographically distinguish these three diseases. In this retrospective study, 33 patients were clinically diagnosed with DSO (13), CSO (6), or ORN (14). The panoramic radiographs, computed tomography images, and magnetic resonance images of these patients were evaluated. Osseous and soft tissue changes were analysed. Patients with DSO showed extensive cortical and medullary sclerosis combined with subperiosteal bone formation, condylar process deformation, and hypertrophy and oedema of the masseter muscle. DSO patients showed no pathological fractures or sequestra, which were observed in patients with CSO and ORN. The radiographic characteristics that differentiate DSO from CSO and ORN include subperiosteal bone formation, condylar process deformation, masticatory muscle changes, and the absence of sequestra and pathological fractures.