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References

Mallikarjun K, Kohli A, Kumar A, Tanwar A Chronic suppurative osteomyelitis of the mandible. J Indian Soc Pedod Prev Dent. 2011; 29:176-179
Pell GJ, Shafer WG, Gregory GT Garré’s osteomyelitis of the mandible; report of case. J Oral Surg (Chic). 1955; 13:248-252
Ferreira BA, Barbosa AL Garré’s osteomyelitis: a case report. Int Endod J. 1992; 25:165-168 https://doi.org/10.1111/j.1365-2591.1992.tb00780.x
Shah KM, Karagir A, Adaki S Chronic non-suppurative osteomyelitis with prolifera-tive periostitis or Garré’s osteomyelitis. BMJ Case Rep. 2013; 2013 https://doi.org/10.1136/bcr-2013-009859
Ellis DJ, Winslow JR, Indovina AA Garré’s osteomyelitis of the mandible. Report of a case. Oral Surg Oral Med Oral Pathol. 1977; 44:183-189
Oulis C, Berdousis E, Vadiakas G Garré’s osteomyelitis of an unusual origin in a 8 year old child. A case report. Int J Paediatr Dent. 2000; 10:240-244 https://doi.org/10.1046/j.1365-263x.2000.00199.x
Chang YC, Shieh YS, Lee SP Chronic osteomyelitis with proliferative periostitis in the lower jaw. J Dent Sci. 2015; 10:450-455
Suma R, Vinay C, Shashikanth MC Garré’s sclerosing osteomyelitis. Ind Soc Pedodont Prevent Dent. 2007; (25 Suppl)S30-S33
Brazao-Silva MT, Pinheiro TN The so-called Garré’s osteomyelitis of jaws and the pivotal utility of computed tomography scan. Contemp Clin Dent. 2017; 84:645-646 https://doi.org/10.4103/ccd.ccd_304_17
Kannan SK, Sandhya G, Selvarani R Periostitis ossificans (Garrè’s osteomyelitis) radiographic study of two cases. Int J Paediatr Dent. 2006; 16:59-64 https://doi.org/10.1111/j.1365-263X.2006.00630.x
Hayati MA, Caglayan F, Yilmaz SG, Derindag G Garré’s osteomyelitis of the mandible caused by infected tooth. Case Rep Dent. 2018; 18
Woo SE, Kim YJ, Kim HJ Garré’s osteomyelitis in children. J Korean Acad Pediatr Dent. 2011; 38:413-420
Gumber P, Sharma A, Sharma K Garré’s sclerosing osteomyelitis. A case report. J Adv Med Dent Sci Res. 2016; 4:78-83
Tsai PT, Chen YW Garré’s osteomyelitis at right mandible of a nine-year-old girl. HK J Paediatr. 2016; 21:291-293

Garré's osteomyelitis of the jaw

From Volume 48, Issue 4, April 2021 | Pages 295-297

Authors

Roya Hazara

BDS

Central and North West London NHS Foundation Trust

Articles by Roya Hazara

Elena Pappa

MD, DDS, PhD, FRCS (OMFS), MSc

Oral and Maxillofacial Surgery Consultant, Queens Hospital, Romford

Articles by Elena Pappa

Abstract

The aim of this short review is to update dental professionals on the causes, manifestation and treatment of Garré's osteomyelitis. There are multiple cause of facial swellings and asymmetry arising from dental infections, trauma, or more seriously can be benign or malignant tumours. Garré's osteomyelitis is most commonly seen in children and young adults and persists until the cause is removed. Other lesions such as fibrous dysplasia, sarcoma and chondrosarcoma can manifest in the same manner as Garré's osteomyelitis clinically. Garrés’ osteomyelitis can be result of a chronic infection or trauma. Dentists and dental professionals must be aware of the causes, minvestigations required and provide the appropriate treatment. Information was collected using Medline, Pubmed and Athens to access the journals.

CPD/Clinical Relevance: This article highlights the importance of recognizing Garré's osteomyelitis in children and young adults, identifying the cause and treating them appropriately. It is imperative for dental professionals to know and refer to relevant specialties for further investigation.

Article

Osteomyelitis refers to the infection of the medullary part of the bone, most commonly caused by bacteria. The inflammation of the bone can be both acute or chronic largely dependent on the clinical manifestation.1 Garré's osteomyelitis was first described by Carl Garré in 1893 in relation to the thickening of a periosteum of the tibia and was first mentioned in dental literature by Pell et al in 1955.2,3 It is a type of chronic non-suppurating osteomyelitis that is associated with increased thickening of the periosteum of the bones, and peripheral reactive bone deposition resulting from trauma or infections, commonly seen in children and young people.4 The mandible is frequently affected due to its poor blood supply.5 Dentists should be aware of a multitude of causes of facial swelling, and must be vigilant of swellings that can mimic other conditions, especially benign or malignant tumours. Primary care dentists and dental professionals should refer these cases to the relevant specialties for a second opinion. The aim of this article is to review Garré's osteomyelitis and present a case report to update the knowledge of dental professionals.

Electronic databases including Medline and Pubmed were searched for articles on osteomyelitis and Garré's osteomyelitis. Other references were manually searched from articles or bibliographies.

Case presentation

A 13-year-old boy presented in accident and emergency with a 3-week history of left-sided facial swelling. The presenting symptoms were pain, and trismus with a 20-mm interincisal distance mouth opening recorded. He was medically fit and well with no allergies. In the first instance, an orthopantomagraph (OPG) was taken for dental assessment (Figure 1). Clinical examination showed no obvious intra-oral swelling and no tenderness to percussion of any teeth on the left side. The OPG revealed no dental cause, but bony expansion of the left mandible was evident. There was no history of recent trauma, but his parents could not rule out trauma or a fall in the past. An urgent ultrasound scan was carried out, indicating thickening of the left masseter muscle, which was suggestive of inflammation. There were also some subtle cortical irregularities within the outer cortex of the mandible. The patient was given IV co-amoxiclav and metronidazole as well as analgesics. The swelling reduced and the symptoms subsided after 2 days of IV antibiotics.

Figure 1. Orthopantomograph (OPG) showing expansion of bone on the left angle of the mandible. There is no obvious dental cause or infection.

The patient returned after a couple of months complaining of swelling and pain from left mandible. A biopsy of this area was taken under general anaesthetic. The histology confirmed reactive bone. A subsequent CT scan was performed. The CT revealed a subperiosteal reaction, which was seen buccally along the mandible extending from the region of the left mental foramen to the left neck of the condyle and left coronoid process (Figures 2 and 3). There was also loss of the appearance of the trabecular bone within the mandible from the LL5 region posteriorly to the ascending ramps, with widespread replacement by sclerotic bone. With the CT scan, the histological findings of reactive bone and given patient's age, it was concluded that the diagnosis was most likely to be sclerosing osteomyelitis of Garré. The swelling gradually reduced in size following treatment with IV antibiotics, but did not resolve completely. The cause of the bony expansion was not established; however, the patient was monitored regularly.

Figure 2. (a, b) 3D-reformatted CT scan, showing subperiosteal reaction along the mandible extending from the region of the left mental foreman to the left neck of the condyle and left coronoid process.
Figure 3. CT scan showing bony expansion of left mandible.

Findings

Garré's osteomyelitis normally arises as a result of dental infection or trauma. Other causes of Garré's osteomyelitis have been reported in relation to dental extraction, mild periodontitis and trauma.6 The swelling typically appears in the molar or premolar region.7 Patients present with hard bony swelling of the mandible, resulting in facial asymmetry.8 Dental infection is caused by tooth decay, which, if left untreated, can develop into a chronic infection leading to pulp necrosis. The infection extends to the bone, which in turn stimulates bony proliferation by the periosteum.9,10 Pain is not usually a complaint, but if the lesion is secondarily infected, then severe pain is a common characteristic.11

Radiographic examinations such as OPG or CT are important diagnostic tools in determining a diagnosis of Garré's osteomyelitis. CT scans show the presence of bony lamellae parallel to each other outside the cortex of the bone involved.5 Scans also show an ‘onion skin’ appearance of new periosteal proliferation located in successive layers parallel to condensed cortical bone.7,12 Kannan et al concluded that the radiographic appearance of Garré's osteomyelitis may determine the duration, progression and the mode of healing of the disease process.10

Garré's osteomyelitis could mimic the appearance of fibrous dysplasia and, therefore, must be investigated thoroughly. Osteoblastic osteosarcoma, Ewing's sarcoma and other benign and malignant tumours must not be ruled out until a definitive diagnosis is reached.3

There are numerous case reports in literature that support development of Garré's osteomyelitis following a dental abscess. In one case4 of a 5 year old, the patient presented with slowly progressive right-sided hard bony swelling of the mandible. An OPG showed a typical periosteal reaction of the inferior cortex of the mandible associated with the infected deciduous mandibular second molar. The patient was treated with antibiotics and removal of the offending tooth. The swelling regressed and resolved over a period of time. Similarly, in another report,9 a 12-year-old girl presented with a 5-month history of left mandibular expansion. Dental radiograph had confirmed the presence of infection associated with the lower left first molar. In this case, a subsequent CT scan was performed to exclude other potential causes. The tooth was extracted and a biopsy was taken. The swelling had gradually subsided by a 3-month review.

In the case8 of a 10-year old boy who presented with pain from the lower left region and extra-oral swelling on the right inferior border of the mandible, extra-oral examination of the right mandible revealed a diffuse hard non-tender swelling with normal skin colour. Intra-oral examination revealed carious lesions related to LR6 and LL6. LR6 was tender to percussion. Occlusal radiographs of the mandible had shown an ‘onion skin’ appearance in relation to peripheral sub-periosteal bone deposition on the right side. Eventually LR6 and LL6 were root-canal treated with intra-canal antibiotics. The canals were irrigated with mixture of metronidazole and gentamicin. After 3 weeks, the swelling had completely subsided and at the 3-month recall, the occlusal radiograph and intra-oral peri-apical radiograph showed complete remodelling of the bone.8

In the literature, a number cases have been presented where pericoronitis has been reported to encourage harbouring of bacteria, which can eventually lead to infection and osteomyelitis.6,13 This highlights the possibility of periodontal involvement in the development of Garré's osteomyelitis in the absence of abscess secondary to dental caries, although it is rare. In a case14 of a 9-year old girl who presented with a 1-month history of painless, bony hard swelling of the right lower face, the patient had developed swelling after being hit by a seesaw. The swelling increased over time. An OPG and occlusal film showed radio-opaque formation without cortical involvement and confirmed an ‘onion ring’ appearance. CT scan further confirmed these findings. Bone scans indicated a high bone remodelling activity of the right mandible and a biopsy confirmed Garré's osteomyelitis. The patient was treated with 2 weeks of antibiotics and non-steroidal anti-inflammatory drugs. The facial asymmetry had shown improvement by the 4-week follow-up appointment.

Discussion

Garré's osteomyelitis is almost exclusively found in children and young adults and is caused by chronic dental infection, trauma or, rarely, can be idiopathic. In our case report, a cause was not established. We could neither rule out previous trauma to the left side of the face nor an idiopathic cause. Treatment with antibiotics seemed to resolve the swelling. However, the patient did return with a similar swelling several mouths later. Further treatment with antibiotics and analgesics helped settle the symptoms and the swelling gradually decreased. The response to antibiotic treatment indicated a bacterial cause, which was not fully identified. As the evidence suggests, effective treatment of Garré's osteomyelitis involves identifying the cause. In some cases, antibiotic therapy and extraction of the offending tooth resolve the symptoms and swelling. The success of endodontics to treat the infection is questionable and needs to be explored further. However, given that this disease is most common in young people, where possible, endodontic treatment should be considered.

The difficulties of diagnosing Garré's osteomyelitis have been attributed to its clinical manifestation, which mimics other fibro-osseous lesions, such as fibrous dysplasia, osteosarcoma and Ewing's sarcoma. Radiographic examination can distinguish Garré's osteomyelitis from other lesions, aiding diagnosis and identifying the cause. A dental radiograph or a CT scan is usually sufficient, but in rare cases a biopsy is required to confirm diagnosis. Fibrous dysplasia is a condition that is most similar to Garré's osteomyelitis clinically, and also tends to manifest in younger patients. Radiographically it is distinguishable due to its ‘ground glass’ appearance. Osteosarcoma presents as a hard bone mass and radiographically shows a ‘sun ray’ appearance. Ewing's sarcoma also presents with a ‘sun ray’ appearance radiographically, but is distinguished clinically by its rapid increase in size, and facial neuralgia and paraesthesia.10

Conclusion

Although Garré's osteomyelitis is not very common, sufficient knowledge of the condition is important for dental professionals. Facial swellings with many different causes present to dentists and dental professionals on a daily basis. A thorough history and investigation is required for the correct diagnosis and appropriate referral.