Osteomyelitisfrom ChronicPeriodontalInfectionin apatientwithuncontrolled DiabetesMellitus:CaseReport

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1 OLGU SUNUMU Osteomyelitisfrom ChronicPeriodontalInfectionin apatientwithuncontrolled DiabetesMellitus:CaseReport Hilal UslU Toygar, a Esra güzeldemir, a Nebil Bal, b Ülkem CİlasUN c departments of a Periodontology b Pathology, c oral and maxillofacial surgery, Baskent University, Faculty of medicine, ankara ge liş Ta ri hi/received: Ka bul Ta ri hi/accepted: Thiscasereportwaspresentedby Dr.EsraGuzeldemirinSCOR2006, Minia,Egypt. ya zış ma ad re si/correspondence: Hilal UslU Toygar Baskent University adana Practice and research Hospital, Clinics of dentistry, adana, TÜrKİyE/TUrKEy usluhilaladana@yahoo.com ABSTRACTWeaimedtopresenttheeffectsofuncontrolledTypeIIdiabetesmellitusonchronic periodontitisandcomplicationsofdm.a45-year-old-malepatientappliedfortreatmentofperiodontalabscessandpain.duringperiodontalsurgery,adeepinfrabonydefectbetweenteeth#33 and#34whichencircledtheteethalongtherootandreachedthementalforamenandmandibular canalwasseen.teethwereextractedandthetissuespecimensweresentforhistopathologicexamination.histologicalexaminationindicatedosteomyelitis.hewasreferredtoaphysicianforinvestigationofhismedicalhealthandidentificationofthecauseofosteomyelitis.thepatientwas diagnosedasdm.woundhealingwasuneventful.uncontrolled/poorglycemicconditionisarisk factorforperiodontaldiseaseandperiodontaldiseasemayaffectthediabeticcondition.patients withuncontrolleddmandsevereperiodontitishavebeenshowntohaveamuchgreaterincidence ofmacrovascularcomplicationsandsecondaryinfections. KeyWords:Diabetesmellitus,periodontitis,osteomyelitis ÖZETBuolgusunumuilekontrolsüzTipIIdiabetesmellitusun,kronikperiodontitisüzerine etkilerivenedenolduğukomplikasyonlarınsunulmasıamaçlanmaktadır.kırkbeşyaşındaerkek hastaperiodontalabseninveağrılarınıngiderilmesiisteğiilekliniğimizebaşvurmuştur.periodontal cerrahisırasında,33ve34no ludişlerinkökleriarasındanmentalforamenvemandibülerkanala ulaşankemikiçidefektgörüldü.budişlerçekildi,bölgedentoplanandokuvekemikörnekleri histopatolojikincelemeyegönderildi.değerlendirmesonucuosteomiyelitigöstermekteydi.hasta, osteomiyelit gelişiminin nedeninin anlaşılabilmesi amacıyla, ileri medikal değerlendirme için yönlendirildi.incelemesonucundahastanıntipiidiabetesmellitusuolduğuanlaşıldı.buolgu, herhangi bir komplikasyon görülmeden iyileşti. Kontrolsüz veya yetersiz glisemik durum, periodontalhastalıkoluşumuaçısındanriskoluşturduğugibi,periodontalhastalıklardadiyabetik kontrolü etkileyebilmektedir. Kontrolsüz diabetes mellitus ve ileri periodontitis hastaları, makrovaskülerveikincilenfeksiyonlaradahayatkındır. AnahtarKelimeler: Diyabet,periodontitis,osteomiyelit : Cop yright 2009 by Tür ki ye Kli nik le ri eriodontaldisease,characterizedbyadestructiveinflammatoryprocessthataffectsthesupportingtissuesoftheteeth,affectsmanypeople worldwide. 1-5 The progression and severity of periodontal diseasearedeterminedbyriskfactors(immunologic,microbiologic,environmental,andgeneticfactors)andbythepatient sage,sex,race,smoking history.therearealsosomeadditionalfactors,eachhavinganeffectonthe 144

2 OSTEOMyElITISFROMCHRONICPERIODONTAlINFECTIONINAPATIENTWITHUNCONTROllED... HilalUSlUTOyGARetal otherdiabetesmellitusandage,cardiovasculardiseasesandage,andsmokingandheartdisease. 2,6-12 Diabetesmellitus(DM)isachronicmetabolic disordercharacterizedbyanabnormalregulation ofglucosemetabolism.diabetes-relatedmorbidity andprematuremortalityimposeasizeableburden onindividualswiththisdiseaseandonsociety,representingamajorpublichealthconcern. 13 DMaffects9%oftheadultAmericanpopulationand6 millionoftheseindividualshavethediseasebut undiagnosed. 14,15 DMandimpairedglucosetolerancearealsocommoninTurkey. 16,17 Theprevalence of diabetes in the Turkish population is 7.2%. 13 Multipleperiodontalabscessesthatleadtorapid destruction of periodontal support are often identifiedinpeoplewithundiagnosedorpoorly controlleddm. 18 UncontrolledDMisassociated withseveralchroniccomplicationsincludingretinopathy, 19 nephropathy,neuropathy,cerebrovascularandcardiovasculardiseases, 20 anincreased susceptibilitytoinfection, 21 andalteredwoundhealing.dmisamodifiableriskfactorforperiodontaldisease,whichisthesixthcomplicationofdm. The prevalence of DM is increasing worldwide; thus,thenumberofcomplicationsofthisdiseaseis increasingaswell. 22 Areviewoftheliteratureby Kinane and Chessnutt showed considerable evidencetosuggestthatdmandperiodontitishavea directrelationship. 23 InareviewbyVanDykeand Sheilesh,theassociationbetweenpoorglycemic controlandperiodontaldiseasewaswellsummarized. 24 TheAmericanDiabetesAssociationhasofficiallystatedthatperiodontaldiseaseiscommonin patientswithdiabetes,andthestandardsofcareestablishedbytheorganizationincludedobtaining eachdiabeticpatient shistoryofcurrentorpast dentalinfectionsasapartoftheclinicalexamination. Periodontitishasbeenshowntoprecedethe worseningofglycemiccontrol.uetaandcoworkersstatedthatdmisapredisposingfactorforperiodontaldisease. 25 Periodontalinfectioninindividualswithasystemicdiseasecouldbeatriggerforosteomyelitis, whichinvolvesinflammationoftheboneandbo- nemarrow,andsclerosingintramedullarybonein- fectioncausedbyoralanaerobessuchasanacti- nomyces species and Eikenella corrodens. 26 The hallmarkofmandibularosteomyelitisispersistent, intensepainthatwaxesandwanes,mildexpansion ofthemandible,andoccasionalsofttissueswelling duringexacerbationsofthedisease.mandibularregions-mostlyinthebodythenintheangle,andramus-areinvolved.maxillaryosteomyelitishasalso beennoted,butinamuchlowerincidencethan themandibularform.inpatientswithmandibular osteomyelitis,themandiblemaybetendertopalpationparticularlyatthebuccalcortex.nosuppuration or drainage can be noted and the radiographicimageismottled.sclerosisofthetissuetypicallyoccursovertime.theclinicalprogressionoforofacialosteomyelitisvariesaccording tothepatient sresistancetoandthevirulenceof themicroorganisminvolved. Inthiscasereport,wedescribea45-year-old diabeticmanwithmandibularosteomyelitiscausedbyperiodontalinfection. Ca se re PorT A45-year-oldmanwasadmittedtotheBaskent University Adana Medical and Research Center OralandDentalHealthClinicsin2005becauseof aperiodontalabscessandpainwhilechewing.accordingtohisself-reportedmedicalhistory,hehad nomedicaldisorder.afterhisdetaileddentalexaminationandobtaininginformedconsentfrompatient,rootcanaltherapytotheleftlowercanine (#33)andthefirstpremolar(#34)wereperformed. Thenhewasreferredtoperiodontaltreatment.He describedpainaroundteeth#33and#34.thepanoramicradiographrevealedcommonverticalbone resorptionwithradiolucentareas(figure1)that werebetweenthementalforamenandthemesial rootofthefirstmolarbilaterally.duringthepatient sinitialperiodontalexamination,10mmperiodontalpocketsweredetectedintheregionsofteeth #33and#34.Theclinicaldiagnosiswaschronicperiodontitis.Subgingivalcurettagewasperformed duringthepatient sinitialperiodontalvisit.toeliminatelocalpathogenicfactorsandthedeepperiodontalpocket,periodontalsurgerywasplanned. 145

3 HilalUSlUTOyGARetalOSTEOMyElITISFROMCHRONICPERIODONTAlINFECTIONINAPATIENTWITHUNCONTROllED... FIGURE 1: Preoperative panoramic radiograph. FIGURE 2: reflected periodontal flap. Threemonthsaftertheinitialtreatment,periodontalsurgerywasperformed.Followingadequatelocalanestheticadministration(lidocaine2% with 1: epinephrine), a sulcular incision wasmadeand theperiodontalflapwasreflected fromthemesialsideoftooth#33tothedistalside of#34(figure2).therewasadeepinfrabonycombineddefectbetweenteeth#33and#34whichencircledtheteethalongtherootperiapicallyand reachedthementalforamenandmandibularcanal betweentheteeth.teeth#33and#34wereextracted,andthegranulationtissuewasremoved(figure 3). Specimens of granulation tissue and bone weresentforhistopathologicalexamination.the defect was expanded to the upper border of the mandibularcanalandthementalforamen,andthe mandibularandmentalnerveswereexposed.the defect,whichwasborderedwithbuccalandlingualcorticalbone,continuedtotheposteriormandibularsideundertheperiapicalsidesofthesecond premolar(#35)andthefirstmolar(#36).teeth#35 and#36werealsoextracted;thegranulationtissue wasremoved(figure4),andtissuespecimenswereobtainedfromthatregionforhistologicalexamination. Toenablehaemostasisandinfectioncontrol, anabsorbablehaemostaticagent(surgicel.oxidisedregeneratedcellulose2005johnson&johnson, NorthyorkshireBD233RX,UK)wasplacedaroundteeth#35and#36.Toprotectthemandible fromfractureandtoensurealveolarbonevolume forfutureprosthesisconstruction,theregionaroundteeth#33and#34wasaugmentedwithademineralized bone matrix (Grafton DBM Putty, FIGURE 3: after the extraction of teeth #33 and #34, the granulation tissue was removed. FIGURE 4: after the extraction of teeth #35 and #36, the granulation tissue was removed; cavity border was reached to the mandibular canal. 146

4 OSTEOMyElITISFROMCHRONICPERIODONTAlINFECTIONINAPATIENTWITHUNCONTROllED... HilalUSlUTOyGARetal FIGURE 5: The absorbable hemostat around teeth #35 and #36 and augmentation with demineralized bone matrix around teeth #33 and #34. OsteotechInc.Cedec2-France).Thecompleteflap closure was performed with continuous sutures with4/0silksutures(doğsan,turkey)(figure5). Chemicalplaquecontrolwitha0.2%chlorhexidinegluconate(KlorhexGargara,Drogsan,Turkey) wasperformedfor2weeks.postsurgicalmedications included amoxicillin 500 mg(largopen 500 mg,bilim,turkey)twicedailyfor7daysandflurbiprofen 100 mg (Majezik 100 mg, Sanovel, Turkey)twicedaily. Twodaysafterthesurgery,thepatientwas referredtotheradiologydepartmenttoundergo postsurgical evaluation with computerized tomographyandmagneticresonanceimagescanning.thefindingsofhistologicalandradiological studiesindicatedosteomyelitis(figure6-10). Thisclinicalcourseofthediseaseandthepresentationofthelesionidentifiedinourpatientdes- cribed,arenotcommon.toourknowledge,there arenopublishedreportsofchronicperiodontalinflammationresultingwithosteomyelitis. Chronicperiodontitisisaverycommondisease;howeverwethoughtthatclinicalpresentation ofthiscasewithoutanunderliningmedicaldisorder would be unexpected. Although he claimed thathehadnomedicalproblems,hewasreferred toageneralphysicianforinvestigationofhismedicalhealthindetailsothatthecauseofosteomyelitiscouldbeidentified. Allsutureswereremovedafter10days.The patientwasthenplacedonaroutinemaintenance scheduletohisindividualneeds.healingoftheextractionsocketswasuneventfully. Tendaysafterthesurgery,thebiochemicalexaminationrevealedthatthepatient sbloodglucoselevelwas420mg/dl.therearenodataabouthis pastglucoselevelsandhismedicalcondition.the treatment of DM began immediately and three months later his blood glucose level was under control(278mg/dl).anoralexaminationshowed thattherewasnopathologictissueformationinthe operationarea(figure11). FIGURE 6: Post-operative computer tomography image. FIGURE 7: Post-operative magnetic resonance imaging. 147

5 HilalUSlUTOyGARetalOSTEOMyElITISFROMCHRONICPERIODONTAlINFECTIONINAPATIENTWITHUNCONTROllED... FIGURE 8: Histologic view of fibrous tissue between the bone specules (H&E 100). FIGURE 9: Histologic view of mixed inflammatory cell infiltration includes PmN between bone specules (H&E 200). dis CUs si on Thiscaseillustratestheimportanceoftheaccurateassessmentofapatient ssystemichealth,theunexpectedmedicalsituationsthatfacephysiciansin clinicalpractice,andthelimitationsof2-dimensionaldentalradiographs.anotheraimofthiscase reportistopointthepossibledestructiveeffects evenresultingwithjawfractures,ofthiscommon metabolicdiseaseonperiodontalstatusandtooth loss. DMincreasestheriskandseverityofperiodontaldisease. 27 Hyperglycemiaistheprimaryfactor responsible for the development of diabetic complications.anincreasedlevelofglucoseinthe gingivalcrevicularfluidcouldmodifythequantity andspeciesofthebacteriaintheoralmicroflora. DMdoesnotresultingingivitisorperiodontaldefects,perse,butitalterstheresponseoftheperiodontaltissuestolocalpathogenicfactors,causinga reductionindefensemechanisms,andanincreasedsusceptibilitytoinfection.itcanbesuggested thatthemetaboliccontrolmayaffectthestatusof periodontaldisease. Although some investigators suggested that theperiodontaltreatmenthavenoeffectonmetaboliccontrol, 28,29 manystudiesaffirmedthatthe stateofinflammationmayinfluencethestateofinsulinresistanceandthisresultconducetheriskof poorglycemiccontrolindiabeticpatients. 30,31 FIGURE 10: after the surgery (a) and 4 months later (b), in panoramic radiographs. StudieshaveshownthatpatientswithDMare atgreaterriskforongoingperiodontaldestruction thanarenon-diabeticindividuals. 32 AlthoughpeoplewithpoorlycontrolledoruncontrolledDMrespondlesssuccessfullytoperiodontaltherapythan dothosewithwell-controlleddmornon-diabetic individuals, 24,32,33 Promsudthiandcoworkersshowedthatmechanicalperiodontaltherapywithadjunctivesystemicantimicrobialtreatmentimprovedtheperiodontalstatusofthepatientswithun- 148

6 OSTEOMyElITISFROMCHRONICPERIODONTAlINFECTIONINAPATIENTWITHUNCONTROllED... HilalUSlUTOyGARetal FIGURE 11: Intraoral view 4 months after the operation. controlleddm. 34 Kiranandcoworkersdemonstratedthatnonsurgicalperiodontaltreatmentwasassociated with improved glycemic control in individualswithdm; 31 however,promsudthiand colleaguesfoundnosuchcorrelation. 30 UetaandcolleaguesshowedthatDMisapredisposingfactorfor periodontalandperiapicalabscessformationbecauseneutrophilfunctionissuppressedindiabeticindividuals. 25 Preferansowetal.reportedthatuncontrolleddiabeteswasthecrucialcauseofperiodontal changesand,toalargeextent,influencedthefunctionofthemasticatoryorganinpatient. 35 Theeffects ofdmonthehostresponseofdm(andinparticularneutrophilfunction)mayaccountforthisfinding. Inourpatient,toeliminatetheriskofinfectioncausedbyendodonticinfection,rootcanaltreatments were performed before periodontal treatment.becauseofthelabialpositionofthecanineoutsidethedentalarchinourpatient,impactedfoodmighthavecausedachronicperiodontal infectionandthesubsequentformationofaperiodontalabscess.weconcludedthatourpatientdemonstrated a combined abscess (periapical and periodontal)formation.treatmentofmandibular osteomyelitisinvolvesremovalofthediseasedtooth(orteeth)androotalongwithdebridementof theinvolvedmandibularbone. 33 Clinicians must remember that most of the systemicdisordershaveoralmanifestationsandpatientswithsuchdisordersmaynotbeawareoftheir medical conditions. DM is a modifiable risk factorfor(butnotacauseof)periodontaldisease. AlthoughDMcannotbecured,itcanbecontrolled.Uncontrolledsystemicdiseasesoftencontributetothedevelopmentofmorecomplicatedand advanceddisordersthataffectthepatient squality anddurationoflife. Conflictofinterestandsourceoffundingstatement:Theauthorsdeclarethattheyhavenoconflictofinterests.Thispaperwaspreparedwithout anysourcesoffinancialsupport. 1. of fen bac her s. Pe ri o don tal di se a ses: pat ho - ge ne sis. ann Pe ri o don tol 1996;1(1): Hart TC, Korn man Ks. ge ne tic fac tors in the pat ho ge ne sis of pe ri o don ti tis. Pe ri o don tol ;14(1): oka da H, mu ra ka mi s. Cyto ki ne ex pres si on in pe ri o don tal he alth and di se a se. Crit rev oral Bi ol med 1998;9(3): gra ves dt, Coc hran d. The con tri bu ti on of inter le u kin-1 and tu mor nec ro sis fac tor to pe ri o - don tal tis su e des truc ti on. J Pe ri o don tol 2003; 74(3): Fass mann a, Hol la li, Buc ko va d, Vas ku a, zno jil V, Va nek J. Poly morp hisms in the +252(a/g) lympho to xin-alp ha and the - 308(a/g) tu mor nec ro sis fac tor-alp ha ge nes and sus cep ti bi lity to chro nic pe ri o don ti tis in a Czech po pu la ti on. J Pe ri o don tal res 2003; 38(4): references 6. gen co rj, slots J. Host res pon ses in pe ri o - don tal di se a ses. J dent res 1984;63(3): Van dyke TE, schwe i neb ra ten m, Ci an ci o la lj, of fen bac her s, gen co rj. Ne ut rop hil che - mo ta xis in fa mi li es with lo ca li zed ju ve ni le peri o don ti tis. J Pe ri o don tal res 1985;20(5): gen co rj, Van dyke TE, le vi ne mj, Nel son rd, Wil son me Kres ho ver lec tu re. mole cu lar fac tors inf lu en cing ne ut rop hil de fects in pe ri o don tal di se a se. J dent res 1986; 65(12): Haf fa je e ad, soc ransky ss. mic ro bi al eti o lo - gi cal agents of des truc ti ve pe ri o don tal di se a - ses. Pe ri o don tol ;5: mic ha lo wicz Bs. ge ne tic and he ri tab le risk fac tors in pe ri o don tal di se a se. J Pe ri o don tol 1994;65(5 suppl): Hod ge P, mic ha lo wicz B. ge ne tic pre dis po si - ti on to pe ri o don ti tis in chil dren and yo ung adults. Pe ri o don tol ;26(1): Na res s. The ge ne tic re la ti ons hip to pe ri o - don tal di se a se. Pe ri o don tol ;32(1): akin ci F, yil di rim a, go zu H, sar gin H, or bay E, sar gin m. as sess ment of he alth-re la ted qu - a lity of li fe (HrQol) of pa ti ents with type 2 dia be tes in Tur key. di a be tes res Clin Pract 2008;79(1): mok dad ah, Ford Es, Bow man Ba, Nel son de, En gel ga u mm, Vi ni cor F, et al. The con ti - nu ing in cre a se of di a be tes in the Us. di a be tes Ca re 2001;24(2): Cen ters for di se a se Con trol and Pre ven ti on. Na ti o nal di a be tes Fact she et. gov/di a be tes/pubs/pdf/ ndfs_2005.pdf 149

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