Remarkable response of juvenile diffuse sclerosing osteomyelitis of mandible to pamidronate

Chronic non-bacterial osteomyelitis (CNO) and chronic recurrent multifocal osteomyelitis (CRMO) with a focus on pamidronate therapy

Chronic recurrent multifocal osteomyelitis (CRMO), also called chronic nonbacterial osteomyelitis (CNO) or nonbacterial osteomyelitis (NBO), is a rare autoinflammatory bone disease of unknown etiology. However, the number of patients properly diagnosed would increase with better knowledge of the disease. In this regard, whole-body magnetic resonance imaging (WB MRI) has been found to be a better predictor of active lesions than clinical examination. Importantly, the RINBO index (radiologic index for NBO) quantifies the involvement based on the WB MRI. Further, a chronic nonbacterial osteomyelitis MRI scoring (CROMRIS) has been developed as an online tool for assessing WB MRI. The therapy consists of non-steroidal anti-inflammatory drugs (NSAIDs), bisphosphonates (pamidronate, zoledronate, etc.) and other drugs, including biologics. Pamidronate is an appropriate and safe therapy. The first pilot prospective randomised controlled trial (RCT) on pamidronate vs. placebo was carried out in adults. No RCT has been done in children yet. Besides RCTs, there are a number of issues to be explored in future, i.e. predictors of therapy effect, optimal therapy duration, predictors of therapy discontinuation and evaluation of optimal therapy protocol. Recently, the CNO clinical disease activity score (CDAS) was constructed and validated but the classification criteria are still being developed. As collaboration on this rare disease is essential, a prospective Chronic Nonbacterial Osteomyelitis International Registry (CHOIR) was established to generate future comparative effectiveness research data.

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.

Diagnostic Efficacy of Diffusion-weighted Imaging in Distinguishing Chronic Diffuse Sclerosing Osteomyelitis from Suppurative Osteomyelitis of the Mandible

PURPOSE

Chronic diffuse sclerosing osteomyelitis (CDSO) is a non-suppurative inflammatory bone disease diagnosed based on combined clinical, histopathological, and radiological findings. Accurate diagnosis is important since CDSO is more refractory to treatment than suppurative osteomyelitis. The purpose of this study was to determine the diagnostic efficacy of diffusion-weighted imaging (DWI) in the quantitative assessment of CDSO to distinguish it from acute suppurative osteomyelitis (ASO) and chronic suppurative osteomyelitis (CSO) of the mandible.

METHODS

Using a retrospective cohort study design, we analyzed MRI data of 6 patients with CDSO and 34 patients with ASO and CSO. The mean apparent diffusion coefficient (ADC) values of the three groups (CDSO, ASO, and CSO groups) were calculated, and differences were analyzed using Kruskal-Wallis and post-hoc Mann-Whitney tests with Bonferroni adjustments. We performed a receiver operating characteristic (ROC) curve analysis to evaluate the ability of the ADC to predict CDSO. P < 0.05 was considered statistically significant.

RESULTS

The mean ADCs in the CDSO, ASO, and CSO groups were 1.22 ± 0.04 × 10-3 mm2/s, 1.28 ± 0.08 × 10-3 mm2/s, and 1.06 ± 0.09 × 10-3 mm2/s, respectively. Significant differences were observed between the ASO and CSO groups (P < 0.001) and CSO and CDSO groups (P < 0.01). However, there was no significant difference between the ASO and CDSO groups (P = 0.21). The ROC analysis revealed a cut-off ADC value of 1.19 for distinguishing the CSO group from the CDSO group. Sensitivity, specificity, accuracy, and area under the ROC curve were 1.0, 0.92, 0, 95, and 0.94, respectively.

CONCLUSION

The results suggest that ADC may be useful in distinguishing CDSO from mandibular suppurative osteomyelitis.

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.

Pediatric chronic nonbacterial osteomyelitis of the mandible: Seattle Children's hospital 22-patient experience

BACKGROUND

Studies evaluating treatment responses for chronic nonbacterial osteomyelitis (CNO) are lacking. We aimed to measure and compare response rates of medical treatments, time to response of medical treatments among patients with CNO of the mandible, and describe bacterial contamination rates from biopsy.

METHODS

We conducted a retrospective chart review of all patients diagnosed with CNO of mandible between 2003 and 2017 and extracted demographic, clinical, laboratory, imaging and surgical data. Detailed medication use and response to medications were recorded. The primary outcome was response to medical treatments defined as improvement of presenting symptoms, inflammatory markers, and imaging if available. Medical treatments included nonsteroidal anti-inflammatory drugs (NSAIDs), glucocorticoids, disease modifying anti rheumatic drugs (DMARDs), anti-tumor necrosis factor (TNF) therapy, and pamidronate. Descriptive analysis was performed when appropriate. Multivariable logistic regression and Kaplan-Meier curves were applied to compare the responses to medical treatments and time to full response.

RESULTS

We identified 22 patients with a median age of 11 and 36% were female. Four patients (18%) had multifocal bone lesions. CT findings (n = 21) showed lytic lesions (62%) and sclerosis (90%). MRI (n = 14) revealed hyperintensity within bone marrow (100%), soft tissue (71%) and bony expansion (71%). Non-antibiotic treatments including NSAIDs (n = 18), glucocorticoids (n = 10), DMARDs (n = 9), anti-TNF therapy (n = 5) and pamidronate (n = 6) were applied. Rates of full responses to anti-TNF therapy (60%) and pamidronate (67%) were higher than that to NSAIDs (11%) (p < 0.05). Patients receiving pamidronate responded more rapidly than those receiving anti-TNF therapy (median two vs 17 months, p = 0.01) when there was a full response. All had bone biopsies. Intraoral biopsy was performed in 12 of 13 operated in our center and the most common contaminants were Neisseria spp and Streptococcus viridians.

CONCLUSION

Both anti-TNF and pamidronate appeared superior to NSAIDs alone in treating mandibular CNO. Patients receiving pamidronate responded faster than those receiving anti-TNF therapy.

Diagnostic Challenge and Clinical Management of Juvenile Mandibular Chronic Osteomyelitis

Juvenile mandibular chronic osteomyelitis (JMCO) is a rare, idiopathic disease of chronic bone inflammation without suppuration, sinus tract formation, or sequestration. As the name suggests, this condition predominately affects children. The few cases of JMCO reported in the literature describe different treatments, and thus a standard therapy protocol has not yet been established. The aim of this paper is to report a clinical case in a 9-year-old girl that was misdiagnosed and unsuccessfully treated for 1 year. After experiencing persistent symptoms, a correct diagnosis was subsequently rendered based on the physical and radiographic examination as well as successful treatment with non-steroidal anti-inflammatory drugs (NSAIDs). The patient received drug therapy followed by periods of remission over a 4 year follow-up period. Diagnosis and treatment of JMCO is a challenge given the rarity and nonspecific signs and symptoms of this condition. Treatment with NSAIDs and regular follow-up is a conservative option for these patients.

Treatment of diffuse sclerosing osteomyelitis of the jaw with denosumab shows remarkable results-A report of two cases

Denosumab may play a central role in the treatment of diffuse sclerosing osteomyelitis of the mandible. This report describes two patients who had been treated unsuccessfully with antibiotics and steroids for several years. After denosumab treatment, both patients became pain-free and the radiological examination showed less severe osteomyelitis.

Denosumab as a potential treatment alternative for patients suffering from diffuse sclerosing osteomyelitis of the mandible-A rapid communication

PURPOSE

Diffuse sclerosing osteomyelitis (DSO) is a rare disease of the jaw bone. Its treatment is challenging. Different medical and surgical treatment protocols have been proposed; however, none of these treatment protocols produce reliable results. Recently, ibandronate administration has been attempted as a treatment alternative in acute cases of DSO. Due to the similar antiresorptive effect, we sought to explore the application of the human monoclonal antibody to the receptor activator of nuclear factor kappaB ligand (RANKL), denosumab, in the treatment of DSO.

MATERIALS AND METHODS

One female patient with histologically verified DSO received subcutaneous injections of denosumab (Prolia^® 60 mg). The further course of the disease was followed clinically and by radiography and scintigraphy.

RESULTS

In this case, the use of denosumab displayed promising results in aiding pain relief and reducing inflammatory activity.

CONCLUSION

We suggest that antiresorptive treatment with denosumab can be considered as an alternative treatment for patients suffering from DSO. However further studies, with respect to clarifying the mechanisms of action and defining the necessary medication dose as well as application intervals, have to be conducted.

Osteomyelitis of the jaws: A retrospective series of 40 patients

INTRODUCTION

The caseload of jaw osteomyelitis seem to have decreased considerably over the last fifty years thanks to the progress of oral hygiene, the appearance and the use of antibiotics, and early screening. 'Limited osteitis' remains frequent in general practice (alveolitis after dental extraction), but osteomyelitis is much rarer as evidenced by the lack of current literature and the low number of reported patients in the published series. The aim of this study was to analyze retrospectively all the cases of maxillo-mandibular osteomyelitis treated in a large academic department of Stomatology and Maxillofacial Surgery over a period of 6 years and to compare the results to data from the literature.

MATERIAL AND METHOD

All patients diagnosed with maxillo-mandibular osteomyelitis by one of the staff surgeons between January 2009 and December 2015 was included. An epidemiological record (sex, age, ethnic background, risk factors, clinical, origin of disease, imaging and biology, treatments and progression) were collected for each patient. Osteomyelitis cases were classified according to the Zurich Classification System. Results were compared to data from the literature.

RESULTS

Forty patients were retained. Three presented acute osteomyelitis, 26 secondary chronic osteomyelitis and 11 a primary chronic osteomyelitis. Osteomyelitis affected predominantly the mandible (87%). Dental origin was found in 90% of cases. Nine patients (22.5%) recovered and 29 (90%) were clinically improved. Ten of the 11 patients with primary chronic osteomyelitis were improved.

DISCUSSION

This cohort study is one of the largest series currently available and presents results comparable to those of the literature of the last 25 years.

Pediatric Chronic Nonbacterial Osteomyelitis of the Jaw: Clinical, Radiographic, and Histopathologic Features

PURPOSE

Chronic nonbacterial osteomyelitis (CNO) is a focal sterile inflammatory osteitis in children that most commonly develops in the long bones, but can occur in any bone. The disease course is variable, ranging from acute and self-resolving isolated lesions to chronic recurrent multifocal osteomyelitis (CRMO), which is frequently associated with extraosseous inflammatory disease. The purpose of this study was to present our clinical experience with CNO of the mandible in children. The specific aims were to 1) document the clinical characteristics, radiographic findings, and histologic features of CNO and 2) determine the percentage of our sample with multifocal disease (CRMO).

MATERIALS AND METHODS

This is a retrospective case series of patients with mandibular CNO. To be included, patients had to have a mandibular lesion radiographically consistent with osteomyelitis without infection, onset before aged 18 years, and complete records. Medical records were reviewed for history, clinical features, imaging, and pathology. Descriptive data were summarized.

RESULTS

The sample included 22 patients (13 female and 9 male patients) with disease onset at a mean age of 9.05 ± 2.4 years. On presentation, all patients reported mandibular pain and swelling, and 45% had trismus. All had clinical and/or radiographic findings of multifocal intraosseous disease and/or extraosseous inflammatory lesions. Of the patients, 12 (54%) had a documented family history of autoimmune or autoinflammatory disease and 15 (68%) had elevated erythrocyte sedimentation rates during a flare. Computed tomography scans typically showed expansion of the affected mandible with sclerosis of the medullary space, small foci of poorly defined lytic destruction with a lamellated periosteal reaction, and swollen muscles of mastication. Four distinct histologic features were noted including parallel and interconnected osteoid seams, atypical osteoid, areas of woven bone and hypocellular fibroblastic stroma resembling fibrous dysplasia, and patchy nodular fibrosis.

CONCLUSION

Pediatric CNO of the mandible has characteristic radiographic and pathologic features and is usually found as one of multiple disease foci in CRMO rather than as an isolated lesion.

Primary Chronic Osteomyelitis of the Jaws in Children: An Update on Pathophysiology, Radiological Findings, Treatment Strategies, and Prospective Analysis of Two Cases

Objective. Primary chronic osteomyelitis (PCO) of the jaws in children is associated with pain, trismus, and swelling. In children, temporomandibular joint involvement is rare and few studies have been published due to the relatively low incidence. This paper presents two cases of mandibular PCO in children with the involvement of the collum mandibulae. In addition, a review of the literature regarding demographic data, histological, radiological, and laboratory findings, and treatment strategies of PCO was also performed. Material and Methods. Prospective analyses of two PCO cases. A PubMed search was used and the articles were sorted according to their corresponding key area of focus. Results. Review of the literature revealed twenty-four cases of PCO with two cases of mandibular condyle involvement. The mean age was 18 years; the male to female ratio was 1 : 3. Most of the patients were treated with anti-inflammatory drugs in combination with decortication. Clinical recurrence was seen in 7 cases. Conclusion. A combination of anti-inflammatory drugs and surgical intervention appears to be the first choice of treatment. However, surgical removal of necrotic tissue adjacent to collum mandibulae has its limitations in children. Further investigations are of utmost importance in order to increase our knowledge and understanding of this disease.

Preclinical evidence of potential craniofacial adverse effect of zoledronic acid in pediatric patients with bone malignancies

High doses of zoledronic acid (ZOL), one of the most potent inhibitors of bone resorption, are currently evaluated in phase III clinical trials in Europe for the treatment of malignant pediatric primary bone tumors. The impact of such an intensive treatment on the craniofacial skeleton growth is a critical question in the context of patients with actively growing skeleton; in particular, in light of our previous studies evidencing that endochondral bone formation was transiently disturbed by high doses of ZOL. Two protocols adapted from pediatric treatments were developed for newborn mice (a total of 5 or 10 injections of ZOL 50μg/kg every two days). Their impact on skull bones and teeth growth was analyzed by X-rays, microCT and histology up to 3months after the last injection. ZOL administrations induced a transient delay of skull bone growth and an irreversible delay in incisor, first molar eruption and root elongation. Other teeth were affected, but most were erupted by 3months. Root histogenesis was severely impacted for all molars and massive odontogenic tumor-like structures were observed in all mandibular incisors. High doses of ZOL irreversibly disturbed teeth eruption and elongation, and delayed skull bone formation. These preclinical observations are essential for the follow-up of onco-pediatric patients treated with ZOL.

Chronic recurrent multifocal osteomyelitis

Chronic recurrent multifocal osteomyelitis (CRMO) is an autoinflammatory bone disease occurring primarily in children and adolescents. Episodes of systemic inflammation occur due to immune dysregulation without autoantibodies, pathogens or antigen-specific T cells. CRMO is characterised by the insidious onset of pain with swelling and tenderness over the affected bones. Clavicular involvement was the classical description; however, the metaphyses and epiphyses of long bones are frequently affected. Lesions may occur in any bone, including vertebrae. Characteristic imaging includes bone oedema, lytic areas, periosteal reaction and soft tissue reaction. Biopsies from affected areas display polymorphonuclear leucocytes with osteoclasts and necrosis in the early stages. Subsequently, lymphocytes and plasma cells predominate followed by fibrosis and signs of reactive new bone forming around the inflammation. Diagnosis is facilitated by the use of STIR MRI scanning, potentially obviating the need for biopsy and unnecessary long-term antibiotics due to incorrect diagnosis. Treatment options include non-steroidal anti-inflammatory drugs and bisphosphonates. Biologics have been tried in resistant cases with promising initial results. Gene identification has not proved easy although research in this area continues. Early descriptions of the disease suggested a benign course; however, longer-term follow up shows that it can cause significant morbidity and longer-term disability. Although it has always been thought of as very rare, the prevalence is likely to be vastly underestimated due to poor recognition of the disease.

Pediatric chronic nonbacterial osteomyelitis

BACKGROUND AND OBJECTIVES

Little information is available concerning the natural history and optimal treatment of chronic nonbacterial osteomyelitis (CNO). We conducted a retrospective review to assess the clinical characteristics and treatment responses of a large cohort of pediatric CNO patients.

METHODS

Children diagnosed with CNO at 3 tertiary care centers in the United States between 1985 and 2009 were identified. Their charts were reviewed, and clinical, laboratory, histopathologic, and radiologic data were extracted.

RESULTS

Seventy children with CNO (67% female patients) were identified. Median age at onset was 9.6 years (range 3-17), and median follow-up was 1.8 years (range 0-13). Half of the patients had comorbid autoimmune diseases, and 49% had a family history of autoimmunity. Patients with comorbid autoimmune diseases had more bone lesions (P < .001), higher erythrocyte sedimentation rate (P < .05), and higher use of second line therapy (P = .02). Treatment response to nonsteroidal antiinflammatory drugs (NSAIDs), sulfasalazine, methotrexate, tumor necrosis factor α inhibitors, and corticosteroids was evaluated. The only significant predictor of a positive treatment response was the agent used (P < .0001). Estimated probability of response was 57% for NSAIDs, 66% for sulfasalazine, 91% for methotrexate, 91% for tumor necrosis factor α inhibitors, and 95% for corticosteroids.

CONCLUSIONS

In a US cohort of 70 children with CNO, coexisting autoimmunity was a risk factor for multifocal involvement and treatment with immunosuppressive agents. Disease-modifying antirheumatic drugs and biologics were more likely to lead to clinical improvement than NSAIDs.

Current understanding of the pathogenesis and management of chronic recurrent multifocal osteomyelitis

Chronic recurrent multifocal osteomyelitis (CRMO) is an inflammatory disorder that primarily affects children. Its hallmark is recurring episodes of sterile osteomyelitis. The clinical presentation is insidious onset of bone pain with or without fever. Laboratory studies typically reveal nonspecific evidence of inflammation. Radiologic imaging and histologic appearance resemble those of infectious osteomyelitis. There is a strong association with inflammatory disorders of the skin and intestinal tract in affected individuals and their close relatives, suggesting a shared pathophysiology and supporting a genetic component to disease susceptibility. Two genetic syndromes have CRMO as a prominent phenotype-Majeed syndrome and deficiency of the interleukin-1 receptor antagonist-and suggest that interleukin-1 may be a key cytokine in disease pathogenesis. This review briefly summarizes the main clinical and radiologic aspects of the disease and then focuses on genetics and pathophysiology and provides an update on treatment.

Diffuse sclerosing osteomyelitis of the mandible successfully treated with pamidronate: a long-term follow-up report

Diffuse sclerosing osteomyelitis of the mandible (DSOM) is an uncommon chronic inflammatory disease of bone that is refractory to conventional treatments, such as antibiotics, nonsteroidal anti-inflammatory drugs, and decortication. We report a case of chronic DSOM of 15 years' duration in a 61-year-old woman that was successfully treated with a single infusion of pamidronate. Persistent, intractable pain resolved 3 days after infusion. Intense accumulation on (99m)Tc scintigraphy decreased 2 months after infusion, and almost disappeared after 3 years. Panoramic radiography demonstrated a clear decrease in pathologic changes, close to that of normal bone architecture, which has not been reported in DSOM treated with bisphosphonates.

[Diffuse sclerosing osteomyelitis of the mandible and SAPHO]

Diffuse sclerosing osteomyelitis of the mandible may be the presenting manifestation of synovitis, acne, pustulosis, hyperostosis and osteitis (SAPHO) syndrome. We report an additional case of such a presentation.

Clinical care of children with sterile bone inflammation

PURPOSE OF REVIEW

To review the current literature of sterile bone inflammation in childhood and to evaluate the evidence for clinical care including diagnostic methods and treatment.

RECENT FINDINGS

Chronic noninfectious osteomyelitis includes several different entities marked by sterile bone inflammation associated with histologic evidence of a predominant neutrophil infiltration in the absence of autoantibodies and autoreactive T cells, some of which are associated with a genetic mutation. Whole body MRI is helpful in detecting asymptomatic lesions. Initial treatment with NSAIDs is usually sufficient to control symptoms as the bone heals. However, if the lesions persist and do not respond to first-line treatment, or involve the spine or hip, treatment with bisphosphonate will usually lead to a resolution of symptoms. Rarely, treatment with anti-TNF agents is required.

SUMMARY

This review summarizes recent information on diagnosis, treatment and prognosis of disorders involving sterile bone inflammation in childhood. It also addresses the evolving differential diagnosis for autoinflammatory disorders that include sterile bone inflammation and presents a treatment algorithm for management.

Chronic multifocal osteomyelitis: is infectious causation a moot point?

Chronic multifocal osteomyelitis (CMO) is an uncommon disease entity with descriptions possibly emanating from the medical literature over one century ago, and there are numerous disease entities which have been historically detailed and which are probably synonymous. The illness is one of chronicity with exacerbating and remitting focal bony lesions. The differential diagnosis for a bony lesion which ultimately proves to be CMO is initially quite broad. There is no absolute pathognomonic clinical finding, and the diagnosis is highly dependent on clinical course, histopathology, and an absence of microbial infection. Recent studies have focused on immune dysfunction or dysregulation, and there are now many other diseases which are inflammatory in nature and which have been diagnosed among patients with CMO. Despite the aforementioned, the potential for direct infectious causation or indirect causation by infectious stimulation of immunity cannot be entirely excluded. Infection as a mechanism for pathogenesis must continue to be entertained. Multi-centre studies are key to future research.

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.

Hemimandibulectomy after bisphosphonate treatment for complex regional pain syndrome: a case report and review on the prevention and treatment of bisphosphonate-related osteonecrosis of the jaw

BACKGROUND

The increase in reported cases of osteonecrosis of the jaw has increased the clinical significance of bisphosphonate therapeutic agents in the dentistry field.

METHODS

We present a rare and severe case of bisphosphonate-related osteonecrosis of the jaw caused by medicamentous treatment of complex regional pain syndrome. This article reviews the current international prevention and treatment guidelines with regard to bisphosphonate treatment.

RESULTS

Even rare indications for bisphosphonate treatment may lead to devastating effects on the patient.

CONCLUSIONS

Dentists and physicians who prescribe bisphosphonates should be familiar with the side effects of these drugs and the management of these side effects. To prevent negative outcomes, it is important that there be a close collaboration among the doctors involved and that a thorough medical history is obtained; this is especially true because the range of indications for bisphosphonate treatment increases every year.

Surgical management of primary chronic osteomyelitis of the jaws in children: a prospective analysis of five cases and review of the literature

INTRODUCTION

Primary chronic osteomyelitis (PCO) of the jaws is an uncommon non-suppurative inflammatory disease of unknown origin. Although the disease is not age-specific, only sparse cases with onset during childhood or adolescence have been reported in the literature.

PURPOSE

This study seeks to present five cases of maxillofacial PCO in children and to evaluate the effectiveness of the applied therapeutic protocol. A review of the literature concerning diagnosis and treatment of PCO with special emphasis on surgical therapy is also performed.

PATIENTS AND METHODS

Demographic data, clinical, radiographic and histopathologic findings, blood tests results, and the treatment protocol applied to five young patients suffering from PCO and referred to the Department of Oral and Maxillofacial Surgery at "A. & P. Kyriakou Children's Hospital" over the past 5 years are presented. Decortication and contouring of the affected bone were performed; antibiotics were administered for a short period of time and the patients remained under follow-up evaluation.

RESULTS

The posterior mandible was affected in four cases and the maxilla-zygomatic bone in one case. All patients showed remission of signs and symptoms after surgical treatment. The postsurgical clinical course was uneventful in all cases. However, recurrences have been noted, as reported in the literature.

CONCLUSION

PCO of the jaws is a complex clinical entity, presenting both a diagnostic and therapeutic challenge, especially in young patients. Surgical treatment in conjunction with antibiotics and non-steroid anti-inflammatory drugs proved to be beneficial and to improve considerably the patients' quality of life. Nevertheless, exacerbation of the disease may appear and regular follow-up of the patients is required.

Initial results of the treatment of diffuse sclerosing osteomyelitis of the mandible with bisphosphonates

OBJECTIVE

Diffuse sclerosing osteomyelitis (DSO) of the mandible is characterised by recurrent pain, swelling of the cheek and trismus. Treatment is difficult and symptoms often recur. Recently case reports and small series have reported good results after treatment with bisphosphonates.

STUDY DESIGN

Seven patients suffering from treatment resistant DSO were treated with intravenous bisphosphonates. Diagnosis was based on clinical, radiological and histopathological examination. Symptoms had been present for between 20 and 167 months (mean 78). Patients were admitted, laboratory tests and Technetium-scans were performed. Pamidronate was administered intravenously up to four times a year. Follow-up varied from 18 to 46 months (mean 30).

RESULTS

In all patients, symptoms and the need for analgesic drugs diminished considerably. One patient remained free of symptoms after one treatment. In two patients a switch in bisphosphonate was made based on a decreased response. All patients showed a decrease in uptake in the DSO-area on the Tc-scans when comparing pre- and post-treatment. One patient was lost to follow-up.

CONCLUSION

In therapy-resistant DSO bisphosphonate treatment may be a good option.

Alternative indications for bisphosphonate therapy

Bisphosphonates are currently used in the treatment of osteoporosis (postmenopausal and steroid-induced), hypercalcemia of malignancy, Paget's disease of bone, multiple myeloma, and skeletally related events associated with metastatic bone disease in breast, prostate, lung, and other cancers. There are, however, numerous other conditions where a decrease in bone remodeling by bisphosphonates might aid in disease management. The focus of this review will be to discuss a select group of conditions for which bisphosphonate therapy may be efficacious. In this review we present several cases where bisphosphonates have been used as a primary or adjunctive treatment for giant cell lesions of the jaws. Use of bisphosphonate therapy for giant cell tumors of the appendicular skeleton, pediatric osteogenesis imperfecta, fibrous dysplasia, Gaucher's disease, and osteomyelitis will be discussed. Finally, we will review previous in vivo studies on the use of bisphosphonates to augment integration and to treat osteolysis surrounding failing orthopedic implants.

Bisphosphonate treatment in chronic recurrent multifocal osteomyelitis

OBJECTIVE

To test the safety and efficacy of biphosphonates in chronic recurrent multifocal osteomyelitis (CRMO).

STUDY DESIGN

Five patients with CRMO, all of whom had ongoing pain and loss of function despite conventional treatment with non-steroidal anti-inflammatory agents, were treated with pamidronate (1 mg/kg/dose with a dosing frequency of 2 to 4 monthly for a total treatment duration of 12 to 42 months).

RESULTS

Pain decreased after the first infusion for 4 of 5 patients, with symptomatic improvement maintained with time. Significant improvement was seen in radiological lesions for these 4 patients.

CONCLUSION

Bisphosphonates appear to be a useful and safe adjunctive treatment in CRMO when simple therapies such as anti-inflammatory agents fail to control symptoms or cases in which lesion expansion continues.