Infections, Injury to Bone and Maxillary Sinus Disorders
249
or infection characterised by a localised, hard, non-
tender, unilateral bony swelling. The disease occurs
primarily in children and young adults and occa-
sionally in older individuals.
The swelling of several weeks duration is situated
on the lateral and inferior aspects of the mandibular
molar and bicuspid regions. The skin overlying the
lesion is normal. Lymphadenopathy, fever and leu-
kocytosis usually do not occur.
Proliferative periostitis is commonly associated
with a carious lower first molar tooth and a past
history of toothache. Occasionally, no dental cause
is detectable (Table 15.1).
RADIOGRAPHIC FEATURES
Radiograph shows a
focal, well-calcified area of the bone without radio-
lucent border. Radiolucency may be associated with
the apices of the teeth.
In occlusal radiograph, the lesion appears as an
area of radiopacity with thin layers of new bone for-
mation giving an onion-skin appearance (Table 15.1).
DIFFERENTIAL DIAGNOSIS
The condition has to
be differentiated from syphilis (gumma of the bone
in tertiary syphilis), congenital syphilis (irregular
thickening of the sternal head of the clavicle in 30%
of cases and sabre skin in 4% cases), leukaemia,
hypervitaminosis A (fragmentation of the distal fib-
ular epiphysis and marked periosteal thickening),
fracture (callus) and infantile cortical hyperostosis
(asymmetric and multifocal periosteal new bone).
HISTOPATHOLOGIC FEATURES
The tissue is com-
posed of new bone, osteoid with many trabeculae
bordered by osteoblasts. Most trabeculae are arranged
parallel to each other and at right angle to the cortex
separated by fibrous connective tissue.
TREATMENT
The lesion does not require treat-
ment generally.When required, treatment is directed
towards the eradication of identifiable sources of
inflammation. When the affected tooth is not restor-
able, extraction is indicated.
Chronic Sclerosing Osteomyelitis
The two distinct types are chronic diffuse sclerosing
osteomyelitis which affects only the mandible and
Figure 15.3
A panoramic radiograph mottled
radiopacity indicating chronic suppurative
osteomyelitis of the right body of the mandible
with pathological fracture (arrow).
Regimen I:
For hospitalised/medically com-
promised patient or when IV therapy is
indicated
• Aqueous penicillin, 2 million IV every
4 hours, plus metronidazole 500mg every
6 hours
• On improvement, for 48–72 hours switch
over to
– Penicillin V 500mg PO every 4 hours,
plus metronidazole 500mg PO every
6 hours, for an additional 4–6 weeks or
– Ampicillin/sublactam (unasyn), 1.5–3.0g
IV every 6 hours
• On further improvement, for 48–72 hours
switch over to
– Amoxicillin clavulanate (augmentin),
875/125mg two times a day, 4–6 weeks
or more
Regimen II:
For outpatient treatment
• Penicillin V 2 g plus metronidazole 0.5 PO
every 8 hours, for 2–4 weeks after last
sequestrum has been removed and the
patient is without symptoms or
• Clindamycin 600–900mg IV every
6 hours, then clindamycin 300–450mg
PO every 6 hours or
• Cefoxitin (mefoxin) 1g IV every 8 hours or
2g IMor IV every 4 hours until no symptoms
present, then switch over to cephalexin
500mg PO every 6 hours, for 2–4 weeks.
Box 15.1 Antibiotic regimen for
osteomyelitis of jaws
is also known as
Garre’s chronic non-suppurative
sclerosing osteomyelitis
or
periostitis ossificans
.
CLINICAL FEATURES
Chronic osteomyelitis with
proliferative periostitis is a response to mild irritation
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