Syphilitic Osteomyelitis of Mandible - A Case Report

SB Sakarde*, RM Borle**

Abstract
Syphilis is a chronic infectious disease which shows generalised involvement of body tissues and organs. It is usually sexually transmitted but this can also be via contact with the organisms. Since many a times since the lips and oral mucosa are primarily involved it is very important that the dentist recognizes the signs of the disease and initiates treatment. Tertiary involvement of the oral cavity causing gummatous necrosis is rare and in rare cases syphilitis osteomyelitis is seen as reported in this case. Penicillin is still the most effective agent in its treatment. A case of syphilitic osteomyelitis of mandible is reported. Although, the case was not treated, it is reported because of its rarity which can be judged from the relative paucity of literature. Key Words : Syphilis, Gummatous leion, Osteomyelitis, Mandible

INTRODUCTION

yphilis is an infectious veneral disease with protean manifestatiojns and is caused by Treponema pallidum, a delicate Spirochaete. Oslar called syphilis as a Great imitator, because of its protean manifestations.After a primary lesion at the site of entrance of T. Pallidum is formed, in the due course the disease becomes generalized. In the tertiary stage there is wide spread involvement of skin mucous membrane, cardiovascular system, liver, spleen, testis, nervous system and bones and hence it is said that if one knows syphilis in all of its manifestations one will know all branches of medicine. Following the spirochaetamia, the treponema cause inflammatory reactions in the perivascular lymphatics of terminal vessels with sub-sequent obliterative endartitis, tissue necrosis and fibrosis i.e gumma formation. The gumma is syphilitic hypersensitivity reaction. The bones most commonly in-volved in the tertiary syphilis are tibia cranial bones, shoulder girdle, femur humerus and bones of forearm. Involvement of jaw bones is relativily rare.1,2 In the present article a case of syphilitic-osteomylitis of mandible is reported.

CASE REPORT
A 45 year old male patient reported to the department with the complaint of pain swelling and extraoral pusdischarging sinus over the right mandibular region since two years. In the beginning the patient was hesitant to give precise past medical history. But, careful probing revealed that the patient was chronic bidi smoker since thirty years. He was hospitalized four years before, at Medical College Hospital, Nagpur for some respiratory problem. The patient had repeated sexual exposure since
*Lecturer; **PG Student, Dept. of Oral Medicine & Radiology, Government Dental College, Nagpur. 222

long. He was treated for a painful bol on the penis three years back by a medical practitioner. But the patient did not pay much attention to the medical advice and did not seek complete treatment. This history was suggestive of a venereal disease, probably syphillis. General examination did not reveal any abnormality; except the mandibular swelling on right side. Local examination showed a hard tender, non-adherent inflammatory swelling extending from right mandibular canine to the gonial region. There was sinus in the right submandibular area with the necrosed tissue. The pus discharge was not pronounced. The bilateral submandibular lymphadenopathy was evident and the lymph nodes were firm, discrete and tender. Intraorally, an expansion of buccal cortex was noticed on the right side of mandible. Crackling was elicited on palpation in the premolar region with slight pus discharge. The remaining teeth were mobile and oral hygiene of patient was extremely poor. Lateral right oblique view of mandible revealed a large sequestrum in the molar region. Provisional diagnosis of chronic 'Syphilitic' osteomylitis was made. The patient was hospitalized for further investigations and treatment. The laboratory values of

Fig. 1 : Ortho pan tomograph. JIDA, Vol. 5, No. 2, February 2011

all the routine investigations (Haemogram, Urine analysis, X-ray of long bones, K.F.T., L.F.T., Blood Sugar, B.T. and C.T., P.S.) were within normal range. However K.T., V.D.R.L. reaction was strongly reactive and x-ray chest showed changes suggestive of chronic bronchitis. The case was referred to the physician and syphilitic involvement of C.V.S. Nervous system and other organs was ruled out. The pulmonary function tests were carried out and diagnosis of COAD (Chronic obstructive airway disease) was made by the physician. Sequestrectomy was planned under general anesthesia but unfortunately the patient refused to undergo any surgery and took discharge against medical advice and hence he was lost to further followup.

Serological testing is a must before the diagnosis and primary and secondary carcinoma of jaws, chronic pyogenic osteomyelitis, tuberculous osteomyelitis, myeloma and eosinophilic granuloma should be considered. In addition detection of the spirochetes in the exudates is also essential to label the particular lesion as syphilitic osteomyelitis. The lesion can be missed clinically because of the decreasing incidence of syphilis and the fact that the patients suffering from sexually transmitted diseases are generally reluctant to volunteer the information about their afflictions.

CONCLUSION
Syphilitic osteomyelitis is a rare manifestation and since it causes severe destruction of the jaw bone, pain and sequestration the lesion should be diagnosed as early as possible and treated with specific antibiotics and surgical drainage.

DISCUSSION
The gummatous changes in the facial bones are generally found in the anterior part of hard palate arising either from nasal or oral surfaces and often causing perforation. The gummatous lesions of the palate have been reported by Wideman (1948) and Ganguli (1949). Chan (1942) reported a case of gumma at the lower border of mandible.3,4,7 Syphilitic osteomyelitis is a chronic disease characterized by pain, suppuration and sequestration.5,6 It mimics pyogenic osteomyelitis but is distinguished from it by a more progressive course, and lack of clinical improvement following standard treatment and dramatic improvement following antisyphilitic treatment.8 Most of the cases reported in the literature were diagnosed after failure of the preliminary treatment with antibiotics and drainage of pus surgically. There was dramatic improvement following the anti-syphilitic treatment.

REFERENCES
1. Bhende YM, Deodhar and Kelkar SS. Spirochetal infections in General Pathology. First Edn. 1969 Published by Bombay Popular Publications, PP.376 Burkit. Oral Medicine 7th Edn. 1977: 508-18. Cahn CR. Gumma of Mandible. Am Dent J 1942; 10 : 77. Ganguli A. Syphilitic manifestations of Oral Cavity. Indian Med Garetto 1949; 84 : 335. Heslop IH. Syphilitic Osteomyelitis of Mandle. Br J of Oral Surgical 1943: 59. Nathan AS, Lawson W. Syphilitic Osteomyelitis of Mandble. O Surg O Med O Path 1964; 17 : 284. Thoma KH, Goldman HM. Oral Pathology 5th Edn. 1960. St. Lousie mosby pub. PP 1.728 Yusuf H, Bhattacharya MM. Syphilitic osteomylitis of mandible. Br J of Oral Surgery 1982; 20 : 122-28.

2. 3. 4. 5. 6. 7. 8.

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