Possible identity of diffuse sclerosing osteomyelitis and chronic recurrent multifocal osteomyelitis. One entity or two

Chronic Diffuse Sclerosing Osteomyelitis of the Mandible: The Use of Bisphosphonates as a Treatment for a Rare and Challenging Condition

Chronic diffuse sclerosing osteomyelitis is a very rare condition, described as a non-suppurative, inflammatory disease of the bone and characterized by a proliferative endosteal reaction, which clinically reveals itself with cyclic pain of the jaw and swelling. We reported two clinical cases, where patients suffered recurrent swelling and pain at the mandible irradiating to the preauricular area, denying any previous trauma or significant medical history. Odontogenic causes were excluded. An initial treatment with antibiotics and NSAIDs temporarily relieved the symptoms without complete resolution, prompting further investigations. After a comprehensive array of diagnostic tools (X-rays, CT scans, scintigraphy, bone biopsy, serum markers), both patients were diagnosed with chronic diffuse sclerosing osteomyelitis of the mandible. Bisphosphonates (clodronate and zolendronate) with different treatment schemes were used to treat the condition, until a full recovery from symptoms was reported. Bisphosphonates could therefore represent an effective option in managing this rare but impactful condition. Further research is warranted to better understand the underlying mechanisms of the disease and to optimize treatment strategies.

Clinical and therapeutic diversity in adult chronic nonbacterial osteomyelitis (CNO) of the sternocostoclavicular region: a meta-analysis

OBJECTIVES

Chronic nonbacterial osteomyelitis (CNO) is a rare inflammatory bone disease. The distinct CNO subtype that affects the anterior chest wall is descriptively named sternocostoclavicular hyperostosis (SCCH) and mainly occurs in adults. Literature on CNO/SCCH is scattered and lacks diagnostic and therapeutic consensus.

METHODS

Systematic review and meta-analysis aiming to characterize clinical presentation and therapeutic modalities applied in adult CNO/SCCH patients. Untransformed numerical data and double-arcsine transformed proportional data were pooled in a random effects model in R-4.0.5; proportions were reported with 95% CI.

RESULTS

Forty studies were included, containing data on 2030 and 642 patients for aim 1 and 2, respectively. A female predisposition (67%, 95% CI 60, 73) and major diagnostic delay (5 years 95% CI 3, 7) were noted. Clinical presentation included chest pain (89%, 95% CI 79, 96) and swelling (79%, 95% CI 62, 91). Patients suffered from pustulosis palmoplantaris (53%, 95% CI 37, 68), arthritis (24%, 95% CI 11, 39) and acne (8%, 95% CI 4, 13). Inflammatory markers were inconsistently elevated. Autoantibody and HLA-B27 prevalence was normal, and histopathology unspecific. Increased isotope uptake (99%, 95% CI 96, 100) was a consistent imaging finding. Among manifold treatments, pamidronate and biologicals yielded good response in 83%, 95% CI 60, 98 and 56%, 95% CI 26, 85, respectively.

CONCLUSION

CNO/SCCH literature proves heterogeneous regarding diagnostics and treatment. Timely diagnosis is challenging and mainly follows from increased isotope uptake on nuclear examination. Biopsies, autoantibodies and HLA status are non-contributory, and biochemical inflammation only variably detected. Based on reported data, bisphosphonates and biologicals seem reasonably effective, but due to limitations in design and heterogeneity between studies the precise magnitude of their effect is uncertain. Fundamentally, international consensus seems imperative to advance clinical care for CNO/SCCH.

GNAS mutation analysis assists in differentiating chronic diffuse sclerosing osteomyelitis from fibrous dysplasia in the jaw

Chronic diffuse sclerosing osteomyelitis of the mandible (DSOM) and fibrous dysplasia (FD) are distinct lesions with overlapping clinicopathological features that complicate their diagnosis. This study aimed to evaluate the efficacy of GNAS mutation analysis in differentiating between these two conditions. DNA samples from patients with DSOM (n = 35) and FD (n = 29) were collected to analyze the presence of GNAS mutations in exons 8 and 9, the two previously reported hotspot regions, using polymerase chain reaction and direct sequencing. Twenty-four of 29 patients (83%) with FD showed missense mutations in codon 201 in exon 8, whereas no mutation was detected in exon 9. No mutations were found in any of the 35 cases with DSOM. We also identified one case with an uncertain diagnosis due to overlapping clinicopathological features of DSOM and FD. A Q227H mutation was detected in this case, that confirmed the diagnosis of FD. Taken together, the findings indicate that mutational analysis of the GNAS is a reliable approach to differentiate between DSOM and FD of the jaw.

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.

Efficacy of diffusion-weighted magnetic resonance imaging in the diagnosis of osteomyelitis of the mandible

OBJECTIVE

This retrospective cohort study aimed to determine the diagnostic utility of apparent diffusion coefficient (ADC) values in the quantitative evaluation of mandibular osteomyelitis.

METHODS

We analyzed the records of 70 patients aged 30 to 90 years, with and without osteomyelitis, who underwent magnetic resonance imaging at the Nihon University School of Dentistry between April 2017 and March 2019. The mean ADC of bone marrow of patients without osteomyelitis and those with acute and chronic osteomyelitis of the mandible were calculated. Differences in ADC overall and in pair-wise comparisons were analyzed. Correlations with patient age were also calculated.

RESULTS

The mean ADC values in the nonosteomyelitis, acute osteomyelitis, and chronic osteomyelitis groups were 0.87 ± 0.15 × 10^-3, 1.24 ± 0.11 × 10^-3, and 1.07 ± 0.13 × 10^-3 mm²/s, respectively (P < .001 for all pair-wise comparisons). Receiver operating characteristic curve analysis revealed an ADC cut-off of 0.98 for osteomyelitis. Diagnostic values for predicting osteomyelitis were ≥ .81. No correlations of osteomyelitis with age were found.

CONCLUSIONS

The ADC was significantly higher in the osteomyelitis groups than in the nonosteomyelitis group. This suggests that ADC may be a useful parameter for quantitative evaluation of mandibular osteomyelitis.

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.

Effect of bisphosphonates on healing of tooth extraction wounds in infectious osteomyelitis of the jaw

OBJECTIVES

Antiresorptive agent-related osteonecrosis of the jaw (ARONJ) and infectious osteomyelitis of the jaw (OMJ) in antiresorptive-naïve patients are different disease entities. Although osteoclast inhibition is at the center of the pathogenesis of ARONJ, the role of osteoclast inhibition in infectious OMJ is unknown. The objective of this study was to determine the effect of bisphosphonate osteoclast inhibition in infectious OMJ.

METHODS

Osteomyelitis was induced in mice by S. aureus inoculation. The establishment of OMJ was verified by the culture of bone marrow samples obtained from the mandible. Infected animals received either zoledronic acid (ZA) or saline starting at week-2. Treated animals along with non-infected animals underwent tooth extractions at week-4 post-infection. Healing was assessed every week using in vivo micro-computed tomography and intraoral photos. Animals were euthanized at week-8 and cervical lymph nodes were assessed for lymphatic and blood vessels.

RESULTS

Tooth extraction wounds did not heal in animals with OMJ. These wounds were characterized by incomplete soft tissue coverage, sporadic bone fill in the sockets, and inflammatory cell accumulation in the connective tissue at 4 weeks after tooth extractions. Conversely, the majority of tooth extraction wounds in the infected animals treated with ZA had improved healing with better bone fill than even non-infected control animals. Consistently, atrophic lymphatic vessels were noted in the draining lymph nodes in animals with OMJ. However, infected animals treated with ZA had lymphatic vessels that were unaltered and showed a similar appearance to those in non-infected control animals.

CONCLUSION

ZA treatment promoted wound healing in the jaw with infectious osteomyelitis. Clearly, antiresorptive therapy is contraindicated in patients with ARONJ. However, our finding suggests that osteoclast inhibition is potentially an effectual remedy for infectious OMJ in antiresorptive-naïve patients.

Surgical Management of Primary Chronic Osteomyelitis of the Jaws: The Use of Computer-Aided-Design/Computer-Aided Manufacturing Technology for Segmental Mandibular Resection

The term osteomyelitis of the jaws identifies different pathological patterns characterized by the involvement of the cortical bone and bone marrow in osteoarticular infections.At the head and neck level, the segment most affected by osteomyelitis is the mandible and in most of the cases the cause of the infection is bacterial, as a result of pulp or periodontal infections, post-extraction alveolitis, foreign bodies and fractures. The mandibular PCO often presents with an insidious onset, without a striking acute phase, and it is characterized by recurrent episodes of pain, swelling, lockjaw, latero-cervical lymphadenopathy, without signs of suppuration.Three patients have been collected and recorded for the study.The authors believe that in the more advanced cases of PCO in adult patients, in which the mandibular bone appears almost entirely sclerotic and deformed, and that are not responsive to pharmacological therapy or to conservative surgical therapies such as decortication, it is necessary to perform a complete removal of the portion affected by osteomyelitis, with lower alveolar nerve preservation and contextual reconstruction with free microvascular bone flap.Our review aims to describe the clinico-pathological features of a rare pathological entity, propose a surgical treatment algorithm using computer-aided-design/computer-aided manufacturing technology and review the existing literature.

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.

Juvenile Mandibular Chronic Osteomyelitis: Role of Surgical Debridement and Antibiotics

PURPOSE

To document outcomes of management of juvenile mandibular chronic osteomyelitis (JMCO) using a standardized treatment protocol including open biopsy, decortication, microbial culture, and long-term antibiotic therapy.

MATERIALS AND METHODS

This was a retrospective case study of pediatric patients with JMCO treated at Massachusetts General Hospital for Children from 1996 through 2014. Inclusion criteria included age younger than 18 years, diagnosis of JMCO, management by the protocol, adequate clinical and radiographic data in the record, and follow-up of at least 1 year after initial treatment. Inpatient and outpatient records were reviewed for demographics, clinical and radiographic findings, and histologic and laboratory evaluations. The predictor variable was the standardized treatment protocol and the primary outcome variables were disease status at end of treatment and complications of treatment.

RESULTS

Twenty patients (mean age at onset, 10.7 yr; range, 3 to 14 yr) were treated, 12 (11 girls) of whom met the inclusion criteria. Management of all patients consisted of biopsy (extraoral when feasible, n = 9; intraoral, n = 3), decortication, cultures, and long-term antibiotic therapy. Nonsteroidal anti-inflammatory drugs (NSAIDs) were administered only as needed for pain control. There was complete resolution of osteomyelitis with no recurrence in 7 of 12 patients (mean follow-up, 4.3 yr; range, 1 to 11 yr). Five patients had partial responses, with decreased frequency and severity of disease recurrence. These were well controlled with short courses of antibiotics (4 to 12 weeks) with NSAIDs only as needed for pain control (mean follow-up, 1.4 yr; range, 1 to 3 yr). There were no major complications related to antibiotic therapy. Minor complications included rash (n = 2), nausea and vomiting (n = 1), and vaginal candidiasis (n = 1).

CONCLUSION

The results of this study indicate that 58.3% of patients were cured and had no recurrent symptoms (mean follow-up, 4.3 yr). The remaining patients continue on intermittent treatment with antibiotics for recurrent episodes of swelling and pain. Favorable responses to antibiotic therapy support the hypothesis that JMCO is an infectious disease and that negative cultures might represent a failure of standard culture techniques to isolate the responsible organisms.

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.

Nonbacterial osteitis in children: data of a German Incidence Surveillance Study

AIM

To analyse the incidence, clinical presentation, laboratory and radiological findings, as well as diagnostic approaches and therapeutic procedures in paediatric patients suffering from nonbacterial osteitis.

METHODS

A nationwide incidence survey was conducted from 2006 to 2008 through monthly contacts with all German paediatric and paediatric-orthopaedic hospitals. Children with osteomyelitic bone lesions newly diagnosed as suffering from nonbacterial osteitis were identified. Cases were assessed using a questionnaire to be filled in by the treating physician containing information on time since first symptoms, associated diseases, diagnostic procedures, localization of lesions, complications, laboratory and histological results, and treatment.

RESULTS

Nonbacterial osteitis was newly reported in 148 children. The annual incidence was estimated at 0.4 per 100,000 children. Mean manifestation age was 11.4 years (SD 3.2); 99 children (67%) were girls. Palmoplantar pustulosis was observed in 8 (6%). Unifocal manifestations were seen in 50 (34%) patients. Of all patients with vertebral involvement (15%), 9% suffered from vertebral fractures. Bone biopsies were taken in 79 (53%) patients.

CONCLUSIONS

Nonbacterial osteitis is an auto-inflammatory disorder resulting in at least 60 new paediatric cases/year in Germany. Spinal lesions and complications are frequently observed, even at first diagnosis.

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.

Effectiveness of sinus lift procedures for dental implant rehabilitation: a Cochrane systematic review

CONFLICT-OF-INTEREST STATEMENT

Marco Esposito, Pietro Felice and Paul Coulthard are among the authors of four of the included trials, however, they were not involved in the quality assessment of these trials. This review is based on a Cochrane systematic review entitled 'Interventions for replacing missing teeth: augmentation procedures of the maxillary sinus' published in The Cochrane Library (see http:// www.cochrane.org/ for information). Cochrane systematic reviews are regularly updated to include new research and in response to comments and criticisms from readers. If you wish to comment on this review, please send your comments to the Cochrane website or to Marco Esposito. The Cochrane Library should be consulted for the most recent version of the review. The results of a Cochrane Review can be interpreted differently, depending on people's perspectives and circumstances. Please consider the conclusions presented carefully. They are the opinions of the review authors, and are not necessarily shared by the Cochrane Collaboration.

BACKGROUND

Insufficient bone volume is a common problem encountered in the rehabilitation of the edentulous posterior maxillae with implant supported prostheses. Bone volume is limited by the presence of the maxillary sinus together with loss of alveolar bone height. Sinus lift procedures increase bone volume by augmenting the sinus cavity with autogenous bone and/or commercially available biomaterials.

OBJECTIVES

To test whether and when augmentation of the maxillary sinus is necessary and which are the most effective augmentation techniques for rehabilitating patients with implant-supported prostheses.

SEARCH METHODS

The Cochrane Oral Health Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE were searched. Several dental journals were hand searched. The bibliographies of review articles were checked, and personal references were searched. More than 55 implant manufacturing companies were also contacted. The last electronic search was conducted on 7th January 2010.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of different techniques and materials for augmenting the maxillary sinus for rehabilitation with dental implants reporting the outcome of implant therapy at least to abutment connection.

DATA COLLECTION AND ANALYSIS

Screening of eligible studies, assessment of the methodological quality of the trials and data extraction were conducted independently and in duplicate. Authors were contacted for any missing information. Results were expressed as random-effects models using mean differences for continuous outcomes and odds ratios for dichotomous outcomes with 95% confidence intervals. The statistical unit of the analysis was the patient.

RESULTS

Ten RCTs out of 29 potentially eligible trials were suitable for inclusion. One trial including 15 patients, evaluated whether 5-mm-long implants with a diameter of 6 mm could be an alternative to sinus lift in bone having a residual height of 4 to 6 mm. Nine trials with 235 patients compared different sinus lift techniques and, of these, four trials (114 patients) evaluated the efficacy of platelet-rich plasma (PRP). Since different techniques were evaluated in different trials, only two meta-analyses evaluating the efficacy of PRP could be performed for implant failures (two trials) and complications (three trials). No statistically significant difference was observed for any of the evaluated interventions.

CONCLUSIONS

Conclusions are based on few trials, usually underpowered, having short follow-ups, and often judged to be at high risk of bias, therefore they should be viewed as preliminary and interpreted with great caution. It is still unclear when sinus lift procedures are needed. Short implants (5 mm) can be successfully loaded in maxillary bone with a residual height of 4 to 6 mm, but their long-term prognosis is unknown. Elevating the sinus lining in the presence of 1 to 5 mm of residual bone height without the addition of a bone graft may be sufficient to regenerate new bone to allow rehabilitation with implant-supported prostheses. Bone substitutes might be successfully used as replacements for autogenous bone. If the residual alveolar bone height is 3 to 6 mm, a crestal approach to lifting the sinus lining and placing 8 mm implants may lead to less complications than a lateral window approach and placing implants at least 10 mm long. PRP treatment does not seem to improve the clinical outcome of sinus lift procedures with autogenous bone or bone substitutes.

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.

Chronic recurrent multifocal osteomyelitis presenting as acute scoliosis: a case report and review of literature

Chronic relapsing multifocal osteomyelitis (CRMO) is a rare condition. It commonly affects the clavicle and pelvis. Rarely it can affect the spine. Spinal deformity due to CRMO is rare. We report a case of acute scoliosis due to CRMO. A 10-year-old girl with CRMO presented with acute painful scoliosis of her spine. She was neurologically intact. Imaging suggested a neoplastic process involving T10, L2 and L3. Further imaging and subsequent biopsy was performed and a diagnosis of CRMO was established. Spinal involvement with deformity is uncommon. It is commonly misdiagnosed as infection or a neoplasm and unnecessary aggressive surgical and antibiotic therapy instituted. A high index of suspicion is needed to diagnose this disease and thus manage it appropriately. This patient with a previously normal spine had a long right sided thoracic scoliosis. We think that the particular pattern of scoliosis was a protective mechanism to offload the right sided T10 vertebral pedicle. Prognosis is generally good although the disease can relapse and remit over many years. At 9 months follow up, the lesions were resolving and the deformity had resolved. CRMO presenting as acute scoliosis is rare and to our knowledge this is the second recognised case in the reported world literature.

Remarkable response of juvenile diffuse sclerosing osteomyelitis of mandible to pamidronate

We report a juvenile case of diffuse sclerosing osteomyelitis of the mandible that showed a favorable response to pamidronate, a bisphosphonate derivative. Although conventional treatments had been ineffective for 5 years, pamidronate administration brought about conspicuous improvement both clinically and radiographically. Severe adverse reaction was not found except for low-grade fever and lassitude on the day following administration. During the course of the treatment, however, nonsuppurative osteomyelitis of the right humerus also occurred, leading to the established diagnosis of chronic recurrent multifocal osteomyelitis. Pamidronate therapy was again performed successfully with near disappearance of clinical symptoms. Both bone-specific alkaline phosphatase (bone formation marker) and pyridinoline cross-linked carboxyterminal telopeptide of type I collagen (bone resorption marker) showed a marked decrease with pamidronate therapy, suggesting that pamidronate is useful for the treatment of chronic recurrent multifocal osteomyelitis with inhibitory effect on bone turnover.

Chronic Recurrent Multifocal Osteomyelitis Mimicking Osteosarcoma

We report a case of an adolescent female who had an initial outside clinical and imaging presentation that was considered highly suspicious for metastatic osteosarcoma. Extensive evaluation led to the diagnosis of chronic recurrent multifocal osteomyelitis. If this etiology had been considered earlier in the patient's clinical course, her diagnostic evaluation may have been less involved and treatment could have commenced sooner. When this entity is a diagnostic possibility along with neoplasm, strong consideration should be given to proceeding directly to open surgical biopsy due to the difficulty in diagnosing this lesion from small percutaneously-obtained biopsy samples.

Chronic recurrent multifocal osteomyelitis of the spine and mandible: case report and review of the literature

At initial presentation, chronic recurrent multifocal osteomyelitis may mimic acute hematogenous osteomyelitis; however, cultures of affected bone are sterile. Nuclear scintigraphy identifies additional foci of involvement that present concurrently or sequentially. Unlike acute bacterial osteomyelitis, chronic recurrent multifocal osteomyelitis seems unaffected by antibiotic therapy and typically responds to treatment with antiinflammatory drugs. Surgical decortication has been reported for refractory cases. The case presented here illustrates the rare involvement of the mandible after initial presentation in the spine of a 4-year-old girl and the refractory nature of the disease over 6 years despite treatment with various medical and surgical therapies.

Is primary chronic osteomyelitis a uniform disease? Proposal of a classification based on a retrospective analysis of patients treated in the past 30 years

INTRODUCTION

Primary chronic osteomyelitis of the jaw is a rare, non-suppurative, chronic inflammatory disease of unknown aetiology. To date, classification is confusing due to a non-uniform terminology. The aim of this study was to establish a simple (clinical) classification based on patient data from our clinic.

METHODS

Retrospective analysis revealed 30 cases of which clinical course, radiology, pathology, therapy and outcome were analysed.

RESULTS

Both sexes were equally represented. The mean age at onset of disease was 35 years (range 5-76 years). Onset of disease revealed two peaks of incidence, one in adolescence and one after age 50 years. While clinical symptoms were similar in all cases, an increased intensity of these symptoms was noted in younger individuals as well as in the early stages of the disease. Five adults and one adolescent presented with additional non facial bone, joint and skin manifestations consistent with the diagnosis of SAPHO (synovitis, acne, pustulosis, hyperostosis, osteitis) syndrome, or chronic recurrent multifocal osteomyelitis. Radiology demonstrated sclerosis, osteolysis and periosteal reaction in variable stages in all cases. However, findings were more extensive in younger patients. Histology revealed different stages of chronic inflammation in all cases. Microabscess formation was noted in 11 cases, six of which were children/adolescents. Therapy consisted mainly of surgery, antibiotics and hyperbaric oxygen therapy. At the end of the follow up period, 11 patients demonstrated complete remission, while in 14 cases amelioration and in 5 no significant improvement was noted.

CONCLUSION

Based on differences in age at presentation, clinical appearance and course, radiology and histology, a subclassification into early and adult onset primary chronic osteomyelitis has been established. Cases with purely mandibular involvement should further be distinguished from cases associated with other syndromes.

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.

Acne with chronic recurrent multifocal osteomyelitis involving the mandible as part of the SAPHO syndrome: case report

For 12 years, a 26-year-old man had acne conglobata and a non-suppurative diffuse sclerosing osteomyelitis of the mandible as part of a chronic recurrent multifocal osteomyelitis of the sternum, the pelvic bones, and the femoral head, and aseptic arthritis of the knee, the fibulotalar, and the sternoclavicular joints. This fulfills the formal criteria of the SAPHO syndrome. Repeated surgical and antibiotic treatment combined with hyperbaric oxygen caused partial improvement. Complete relief and partial disappearance of the scintigraphic lesions was achieved with long-term corticosteroids, non-steroidal anti-inflammatory drugs, minocycline, and isotretinoin.

Radiographic evaluation of possible etiology of diffuse sclerosing osteomyelitis of the mandible

To examine the cause and site of origin of diffuse sclerosing osteomyelitis of the mandible, we compared various radiographic findings for the mandibular lesions in 20 patients with diffuse sclerosing osteomyelitis with those in 48 patients with osteomyelitis caused by bacterial infection. In osteomyelitis of infectious origin, a typical radiographic feature was a radiolucent lesion spreading in the cancellous bone, with cortical bone perforation and lamellated periosteal reaction. In diffuse sclerosing osteomyelitis, intermingled sclerotic and osteolytic lesions with solid periosteal reaction or external bone resorption were a common finding, and in some patients the cortical bone was initially affected by the fresh or recurrent lesion. Based on these distinct differences, we suggest that the cause of diffuse sclerosing osteomyelitis is not bacterial infection and that the site of origin is not in the bone but in the periosteum.

Chronic recurrent multifocal osteomyelitis involving both jaws: report of a case including magnetic resonance correlation

A case of chronic recurrent multifocal osteomyelitis in a 14-year-old girl is presented. The disease had an initial aggressive osteolytic appearance involving both the maxilla and the mandible. Conservative treatment with minimal surgical intervention has been successful in this case during a 2-year follow-up period. The value of magnetic resonance imaging and bone scintigraphy in this case and the cause of chronic recurrent multifocal osteomyelitis is discussed.

Diffuse sclerosing osteomyelitis of the mandible: its characteristics and possible relationship to synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO) syndrome

PURPOSE

This article reports on the possible relationship of diffuse sclerosing osteomyelitis (DSO) of the mandible to synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO) syndrome.

PATIENTS AND METHODS

The pathologic features in 12 new DSO patients and those in previously reported cases were reviewed and compared with those of SAPHO syndrome.

RESULTS

Many similarities were noted between the two entities in terms of the clinical, radiographic, and histologic features. Furthermore, multiple bone lesions and skin lesions (palmoplantar pustulosis and psoriasis) were observed not only in SAPHO syndrome but also in DSO patients.

CONCLUSION

DSO is concluded to be one manifestation of SAPHO syndrome.