The So-called Garrè's Osteomyelitis of Jaws and the Pivotal Utility of Computed Tomography Scan

Abstract

The present paper draw the attention of clinicians to investigate multiple slices of the computed tomography (CT) scan looking for a safe diagnosis of the so-called Garrè's osteomyelitis (GO) of jaws, a not uncommon disease characterized by astonishing bone growth. We report a case involving the left mandible of a 12-year-old girl presenting with a bony enlargement at left mandible. Initial examination revealed carious process of tooth 36 with radiographic apical rarefaction. However, we need to take care with this diagnosis because other aggressive diseases may cause bone enlargement mimicking GO. We observed here that careful examination of CT slices must be elucidative. In the present case, we observed the formation of a hypodense channel between periapical disease and the bone growth, through CT, thus supporting the pathophysiologic conditions for GO and allowing a safer decision to make the intervention restricted to tooth.

Introduction

The term Garrè's osteomyelitis of jaws (GO) refers to the diagnosis of proliferative periostitis, a disease characterized by reactive bone expansion after a low-grade chronic infection that usually derived from pulp necrosis. The spread of infection from the nonvital teeth perforating the cortex and becoming attenuated stimulates bone formation by the periosteum.[1,2] On the other hand, a myriad of diseases may also elevate the periosteum from the cortex such as periodontitis, previous dental extraction, trauma and other uncommon causes including cystic lesions, fibro-osseous lesions, benign and malignant tumors, and others.[2,3,4] Although the disease accounts for only 1% of the biopsies,[1] it is supposed that its frequency is higher in clinical practice and not documented since the disease can be resolved with the treatment of the compromised tooth. The goal of this paper is the demonstration of a simple conduct to avoid the misdiagnosis of GO: the investigation of computed tomography (CT) slices. The bone growth related to other lesions, including malignant tumors, must be similar and a compromised tooth is often a coincident and confounding finding.[5,6]

Case Report

A 12-year-old girl presented with a 5-month history of mandible enlargement and odontalgy. Clinically, the facial asymmetry was attributed to a bone expansion on the mandible, and odontalgy to a caries destruction of tooth 36 [Figure 1a and b]. A dental radiography showed a peryapical radiolucency indicating endodontic infection. The CT scan was performed considering the investigation of the diagnosis of chronic osteomyelitis with proliferative periostitis, the so-called GO. An expansion restricted to bone and a hypodense channel showing interrelationship between dental and bone disease was helpful confirming the diagnosis and excluding reminiscent suspicions of other bone diseases [Figure 1c and d]. Her first molar was extracted and an incisional biopsy opportunely made. The histological observation of a fibrous tissue with chronic inflammation and trabeculae of woven bone was confirmative. After 3 months of follow-up, the lesion receded 2 cm.

Figure 1.

(a) Extraoral presentation of expansive asymmetry involving the left mandibular body. (b) Intraoral aspect showing decay in permanent molar and bony growth on vestibular sulcus. (c) Three-dimensional reconstruction of computed tomography scan showing an regular ellipsoid bony expansion on the body of mandible. (d) Oblique slices from computed tomography scan showing a hypodense channel connecting the apical disease with the bone enlargement

Discussion

Although conventional radiography is still considered a suitable method for determining the presence of bone lesions, CT scan has a lot of advantages, representing an excellent tool for assessing the extent and contour of lesions, cortical margins, and involvement of surrounding structures. The increasing commercialization of CT equipment makes the cost of its use in practice increasingly viable as a usual complementary examination. In this case, the CT scan was required and revealed a hypodense communication between the infected tooth and that periosteal reaction, a finding not previously identified using the conventional radiographies. Thus, we highlight that dentomaxillofacial professionals must be able to analyze the CT scan files in their own computer, performing an investigative evaluation of individualized multiplanar reconstructions to properly identify the disease characteristics. In the present report, we show the existence of a communication channel between an infected tooth and the bone expansion as additional criteria to diagnose GO. Other possible important signs include irregular intralesional radiolucencies (single or multiple) and/or osteosclerotic changes.[7]

The pathophysiology of OG is explained by the following theory: the low-grade infection originating from the compromised tooth spreads toward the surface of the bone, resulting in inflammation of the periosteum with formation of granulation tissue and reactive bone. As the new layer of bone is lifted off the cortex, the inner cambium layer of periosteum is stimulated to form a new bone layer below, often resulting in the classic onionskin appearance of GO in conventional radiographies.[2] However, this classical aspect is not always present, and other types of periosteal reaction are included on the GO spectrum.[8] This variability once again draws attention to the need of supplementary examination of cases with CT, as aggressive tumors such osteosarcoma and Ewing's sarcoma may show similar periosteal expansion mimicking an infectious process.[5,6] In this meaning, clinicians must be also attempted to the cortex aspect of the lesion as destructions of cortex are an alert sign of an aggressive and/or malignant process.[9] Although CT images provide an excellent overview of the facial skeleton and teeth, when no obvious correlation between the bone expansion and some evident chronic infection of tooth is clearly suspected, the biopsy is obligatory. We made an incisional biopsy opportunely since a surgical procedure was inevitable to remove that destroyed tooth, but the endodontic therapy is appropriate in teeth with favorable structural remnant.[8] Finally, a close patient follow-up is mandatory, at short intervals at the beginning, making sure that bone growth has ceased and is in the process of regression.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.