CHRONIC PERIOSTITIS IN THE MANDIBLE UNDERNEATH ARTIFICIAL DENTURES

Transcription

1 CHRONIC PERIOSTITIS IN THE MANDIBLE UNDERNEATH ARTIFICIAL DENTURES P. H. D. LEWARS, M.B.B.S., B.D.S., F.D.S. Exeter INTRODUCTION FROM time to time patients wearing artificial lower dentures have presented with a swelling in the lower buccal sulcus, implying that a residual root was present in the underlying bone. However, X-ray examination has not confirmed that this is the cause and even when the dentures have been removed the swelling has persisted. Subsequent investigation has shown chronic inflammation of the periosteum--chronic periostitis. Six cases of this type are presented, followed by a description of the features of the condition and the treatment given. CASE REPORTS Case I Mrs. E. B., aged 4 I, a housewife, complained of a swelling in the left buccal sulcus, which had begun eight months previously. It was occasionally very tender and prevented her from wearing a lower denture. Her dental surgeon had altered the denture but this had not brought relief and she had sought further advice from her doctor. She was a healthy woman with no previous relevant medical history. On examination, she was edentulous and wore a full upper and lower denture, which had been made a few months after the teeth were extracted in I958. The lower denture had been cut away from the left molar region in the area where the gum was tender. The upper and lower denture beds were well formed, although the lower buccal sulcus was shallow and a considerable amount of the alveolar bone had been absorbed. The oral mucous membrane was normal. There was an ill-defined diffuse swelling in the left buccal sulcus, extending from the premolar region back to behind the molar triangle. This swelling obliterated the buccal furrow. The swelling was soft and slightly tender. There were no palpable lymphatic glands in the submandibular region. X-rays disclosed normal bone. There were no retained roots or unerupted teeth. A diagnosis of periostitis was made. She was seen again on r5th May and the swelling was found to be considerably reduced, so that surgical treatment was deferred. However, in August, the swelling recurred and she was admitted to hospital. Under a general anaesthetic the periosteum and overlying mucous membrane and a portion of the buccinator muscle fibres were excised, leaving an area of raw bone surface, approximately 2 x 3 cm. This was packed with gauze soaked in Whitehead's Varnish and two weeks later it was removed and the wound healed by granulation. She was seen again in November and subsequently, but in December there was no further swelling. She continued to wear her dentures in comfort. Six months later there was still no evidence of recurrence, but after that visit the patient did not attend hospital. The pathologist reported that there was granulation tissue with many giant cells, and dense areas of fibrosis surrounded by more recent areas of inflammation. This was consistent with chronic periostitis (Fig. I). Case z. x Mr. W. W., aged 4o, a painter and decorator, complained of swelling in the left buccal sulcus. This had first appeared two months previously and his 264

2 CHRONIC PERIOSTITIS IN THE MANDIBLE 265 dentist had told him it was a dental cyst. However, the swelling had only lasted three or four days and then subsided. It had recurred IO days before examination and was again beginning to subside. He had not been able to wear his lower denture, although his dentist had relieved the denture where the swelling had been. The patient appeared to be a healthy man with no previous medical history. On examination, he was a well-built, athletic man and edentulous. His teeth had been extracted seven years previously and the dentures worn were his second set. The denture beds were well formed with good alveolar ridges, and the buccal sulci were deep. The mucous membrane was normal in all respects. There was a swelling on thc buccal aspect of the lower alveolus in the molar area. This was soft, slightly tender, and appeared to be fluctuant. The lymphatic glands under the mandible were not palpable. Radiological examination did not disclose the presence of any dental root or unerupted tooth; nor was there any suggestion of a bone cyst in the area. The Wassermann and Kahn reactions wcre both negative. Blood examination showed a normal blood cell count. By the following week the swelling had subsided and the patient was discharged. He returned, however, on 26th October with an acute swelling forming again in exactly the same area. On i2th lxlovembcr he was admitted to hospital and, under general anaesthesia the area was excised, leaving a raw bone surface of approximately 2 x 2 cm. This was packed with gauze soaked in B.I.P.P., and he continued to attend as an outpatient. On 7th December 1962, the pack was replaced for a further seven days and then removed. The patient did not return to the hospital but attended his dental surgeon, who reported in March of the following year that there had been no further swelling. The pathology report was that the tissue consisted largely of oedematous granulation tissue with many giant cells. In some areas thcre was a sarcoid-like reaction and some endothelial cells. This was consistent with chronic periostitis (Fig. 2). Case 3. November, I963. Miss J. E. B., aged 30, schoolteacher, complained of swelling of the left buccal sulcus, which had begun seven or eight months previously. The swelling was exquisitely painful from time to time and interfered with eating. Her dental surgeon had reduced the size of the lower denture but this had made no lasting difference to the swelling, which had fluctuated, becoming larger and then receding but never going away entirely. She was a healthy woman with no previous medical history. On examination, she was an athletic edentulous female. Her teeth had been extracted I2 years previously and an immediate lower denture fitted. These same dentures had been worn since the clearance. The denture bearing areas were well formed. The mucous membrane was normal. Where the left ascending ramus of the mandible fused into the molar area of the body there was a soft, ill-defined swelling, which extended forwards and largely filled the molar area of the buccal sulcus. In spite of the fact that the denture had continued to be worn there was only a slight indentation to suggest that the denture itself was rubbing and had caused the swelling. On palpation there was a suggestion of local fluctuation and it was tender. There was no regional lymphadenitis. X-rays disclosed normal bone, without retained tooth tissue and a diagnosis of chronic periostitis was made. Under local infiltration anaesthesia an incision made into the periosteum failed to produce either pus or fluid. Two weeks later there was a slight reduction in the size of the swelling. On 6th December, under regional block anaesthesia, the whole area was excised, leaving a raw surface of bone 2 x 2 cm. in diameter. This was packed with gauze soaked in Whitehead's Varnish. The pack was removed after two weeks and the defect subsequently healed satisfactorily. The pathology report indicated an infective lesion with, in addition to the evidence ofpyogenic infection, many giant cells of foreign body type. One section showed a small nerve surrounded by fibrosis. Some sections showed dense fibrous tissue. Other parts of the tissue showed giant cells surrounded by cellular debris (Fig. 3).

3 266 BRITISH JOURNAL OF ORAL SURGERY The patient remained under observation and, on 22nd May 1964, there was further swelling in the premolar region of the same sulcus. This was smaller but exhibited the same features as had the previous swelling in the molar region. The affected-area was treated by curettage and local excision and thereafter the patient left the district and further follow-up was not feasible. FIG. I FIG. 2 FIG. 3 FIG. 4 Fig. I.--Oedematous granulation tissue with foreign body giant cells, x r5o. Fig. 2.--Sarcoid-like reaction ; some endothelioid ceils with large pink cytoplasm. Haem. & eosin, x 15o. Fig. 3.--Small nerve surrounded by fibrosis and forming giant cells, x I5o. Fig. 4.--Doubly refractile foreign body particles embedded in inflammatory tissue, x 15o. Case Mr. F. P. J., aged 49, quarryman, complained of intermittent swellings over the left side of the face, which had begun six months previously. He declared that the swellings would subside if he took out his lower denture but the gum would still remain tender. He had been edentulous for 17 years and had had two sets of dentures. Six years previously a premolar tooth had been removed from the left lower jaw. There was no relevant medical history. On examination he was a healthy man and edentulous. The denture bearing areas were well formed but there was quite pronounced bone absorption in both the upper and lower alveoli. There was a diffuse, firm, slightly tender swelling in the left buccal

4 CHRONIC PERIOSTITIS IN THE MANDIBLE 267 sulcus. The adjacent lymphatic glands were not palpable. X-ray disclosed normal bone. A diagnosis of chronic periostitis was made. As the dentures were not a good fit, new ones were constructed. The swelling was kept under observation over a period of two months and was found to remain fairly constant until August 1964, when an acute swelling developed, complicated by numbness of the lower lip. In October 1964, he was admitted to hospital and, under a general anaesthetic, the chronically inflamed periosteum was excised. The area of raw bone was covered with a pack soaked in Whitehead's Varnish. The Wassermann and Kahn reactions were negative. Three weeks later the wound had healed and, after a small adjustment, he continued to wear the recently reconstructed dentures. There was no further swelling and he was discharged. He has had no further recurrence of discomfort or swelling since that time to date (September 1967). The pathology report referred to inflammatory tissue with oedema, and irregular thickening of the surface epithelium due to inflammatory changes. There were many foreign body giant cells in the chronically inflamed fibrous tissue. Case Mr. R. M., aged 42, agricultural engineer, complained of a swelling in the lower left buccal sulcus in the area of the molar teeth. This had begun four weeks previously and his dentist had removed part of the lower denture to relieve the area. This had not reduced the size of the swelling. The patient was prone to eat Magnesia tablets and fragments of these could be seen in the mouth. He was a healthy man with no relevant previous medical history. On examination, he was well built and edentulous. His teeth had been extracted nine years previously and he had worn artificial dentures since that time. The dentures, made in I962, had been worn without discomfort until the advent of the present swelling. The denture beds were well formed and the dentures fitted adequately. The swelling extended from the molar region behind the wisdom tooth area to the site of the first premolar. It was very firm and tender on palpation. The adjacent lymphatic glands were not palpable. Radiographs revealed that there was slight, irregular erosion of the bone, compatible with superficial infection in the area of the lower molars. It was not possible to see clearly any retained root, although one area of bone sclerosis suggested the possibility of a fragment. Wassermann and Kahn reactions were negative. Blood examination, which had been conducted six months previously, was normal and was not repeated. He was seen again a month later, on I5th April and there was no improvement in the swelling. He was reluctant to have the area treated by excision but the swelling persisted and, on 2oth September he was admitted to hospital. Under a general anaesthetic the swelling was excised down to bone and the area was packed with gauze soaked in Whitehead's Varnish. A small portion of the buccinator muscle was also excised. His pack was removed after a week and he was seen again on I7th October, when there was a residual slight swelling on the lateral side of the alveolus in the area opposite the second premolar. This was not tender and it was well clear of the denture, which was again being worn comfortably. He was reviewed in January I967, and in May I967. There was no further recurrence of the swelling and he was discharged. The pathology report referred to acutely inflamed fibrous tissue. There was a small abscess, numerous foreign body giant cells and a fair amount of doubly retractile foreign body particles embedded in the tissues along with giant cells (Fig. 4). Case Mr. L. K., aged 29, bus conductor, complained of swelling and pain in the right side of the lower jaw during the previous three or four months. He had been edentulous since the age of 17. His dentist had reduced the size ofthe lower denture but the swelling had persisted. In 1964 he had been investigated for 'blackouts'. These attacks were considered not to be epileptic but probably of psychogenic origin. During

5 268 BRITISH JOURNAL OF ORAL SURGERY investigations he was found to have choroido-retinitis due to congenital syphilis; but apart from this there was no other relevant medical history. On examination he was a tall, healthy man wearing full dentures. The mucous membrane was normal and the denture beds were well-formed except that there was a diffuse swelling in the right buccal sulcus (Fig. 5). extending over the molar and premolar areas. This was tender. The lymphatic glands were not palpable. Radiographs showed normal bone but there was a shadow, suggesting thickening of the periosteum over the molar region on the right side of the mandible. The Wassermann reaction was negative. A diagnosis of chronic periostitis was made. FIG. 5 Swelling seen in the right buccal sulcus. Case 6. On 22nd September, under a general anaesthetic, the periosteum of the right buccal sulcus was excised, and an area of exposed bone measuring 1.5 x 3 cm. was packed with gauze soaked in Whitehead's Varnish. Two weeks later the pack was removed and the wound subsequently healed. There was no recurrence of the swelling and new artificial dentures were fitted. The pathology report suggested that the findings were compatible with a foreign body reaction. Near the deeper margin of the tissues there was some pigmentation and chronic inflammatory cellular infiltration, including giant cells. The clinical features of the six cases described show remarkably close similarity. Each of the patients was a vigorous denture user and had worn a lower denture for several years. The appliances themselves, in each case, were well constructed and could not be said to be 'digging' into the adjacent soft tissues and causing either ulceration or chronic irritation. When the swelling appeared the denture may have been responsible for ulceration on the surface, but after removing the denture for a period and allowing the ulcer to heal the swelling persisted. Oedematous tissue simulated fluctuation and led to unproductive and ineffective incisions. Pathological examination may eventually reveal the aefiology of this condition. In each case there is the presence of chronic inflammatory cells, sometimes plasma

6 CHRONIC PERIOSTITIS IN THE MANDIBLE 269 cells, but always, somewhere in the section, multinucleated giant cells of the foreign body type. In at least one case foreign material was seen. It is possible that minute food particles are impounded on the mucous membrane and driven into the submucous tissue of the periosteum, where they provoke a foreign body reaction which in turn gives rise to the clinical picture observed. One or two of the earlier cases encountered, but not included in above series, were treated, in the first instance, by incision. This was followed by a slight reduction in the swelling, which, however, always recurred. Failure to effect a cure by incision alone led to exploration to uncover suspected foreign material. However, when the tissues were opened, foreign material could not be seen except under the microscope. It has seemed to the author that excision is the only appropriate method of treatment, and the clinical results support this view. If the sides of the wound had been approximated and closed after excision of the periosteum there would have been loss of the buccal sulcus; and for this reason the wound is packed open and allowed to granulate. The extent of the excision is not easy to judge. The edges of the swelling are not clearly defined and in one case at least, after what seemed quite an adequate excision, recurrence of a swelling at the margin took place. This indicated that there was additional foreign material which had escaped excision at operation. Operation under general anaesthesia is preferable because a local anaesthetic injection tends to obscure the extent of the swelling, so that the excision may be incomplete. In three instances where local anaesthesia was employed a recurrence occurred and a further operation became necessary. ACKNOWLEDGEMENT I am indebted to Dr. George Stewart-Smith, Devon and Exeter Clinical Area Consultant Pathologist, for the interpretation of pathological findings and micro-photographs.