Chronic jaw pain with pus discharge and a sinus tract

§Chief complaint

Persistent pain and bad-tasting discharge from the lower jaw for 3 months

§Medical & dental history

• 01Poorly controlled diabetes, HbA1c 10.2 percent
• 02Heavy smoker
• 03Extraction of 46 four months ago; socket never healed

§Clinical examination

• 01Extraoral sinus tract discharging pus over the right mandibular body
• 02Tender, thickened mandible with intraoral exposed necrotic bone at the 46 site
• 03Paraesthesia of the right lower lip (Vincent sign)
• 04Mouth opening 25 mm; low-grade fever

§Figures

§Differential diagnosis

§Final diagnosis

Chronic suppurative osteomyelitis of the right mandible in an uncontrolled diabetic

The combination of prior odontogenic infection, no antiresorptive or radiation history, sequestrum formation and a moth-eaten radiographic pattern establishes suppurative osteomyelitis. Vincent sign indicates inferior alveolar nerve involvement.

§Investigations

• 01OPG — moth-eaten radiolucency with central sequestra and periosteal new bone
• 02CT — cortical destruction and sequestrum formation
• 03Deep bone biopsy for culture and sensitivity plus histology (excludes malignancy)
• 04FBC, CRP, ESR, HbA1c

§Treatment plan

• 01Optimise glycaemic control and stop smoking
• 02Culture-directed prolonged antibiotics (initially IV, then oral for 6 weeks or more)
• 03Surgical sequestrectomy, saucerisation and decortication
• 04Consider hyperbaric oxygen for refractory disease

§Surgical procedure

• 01Intraoral degloving, removal of all sequestra
• 02Decortication of the buccal plate to expose vascular medullary bone
• 03Irrigation and primary closure over a drain
• 04Load-sharing reconstruction plate applied to prevent pathological fracture

§Histopathology report

Necrotic bone with empty lacunae and bacterial colonies, surrounded by acute and chronic inflammatory cells and granulation tissue. No malignancy. Culture: mixed anaerobes and Streptococcus species.

§Follow-up & outcome

• 01Sinus closed at 4 weeks; CRP normalised
• 02HbA1c 7.4 percent at 6 months
• 03Radiographic bone remodelling at 9 months; no pathological fracture

§Clinical pearls / learning points

• 01Always biopsy chronic osteomyelitis — malignancy and MRONJ mimic it.
• 02Antibiotics without removal of necrotic bone will not cure osteomyelitis.
• 03Vincent sign (lip numbness) signals significant medullary involvement.

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