Chronic suppurative osteomyelitis of the mandible after a failed extraction site
52-year-old male
§Chief complaint
Persistent pain, bad taste and pus from the lower jaw for 3 months
§Medical & dental history
- 01Poorly controlled type 2 diabetes, HbA1c 9.4%
- 02Heavy smoker
- 03Extraction of 36 four months ago; socket never healed
§Clinical examination
- 01Intraoral sinus discharging pus at the 36 site with exposed rough bone
- 02Tender thickening of the left mandibular body, mild extraoral swelling
- 03Paraesthesia of the left lower lip
- 04Mouth opening 30 mm; no airway compromise
§Figures
§Differential diagnosis
§Final diagnosis
Chronic suppurative osteomyelitis of the left mandible in an uncontrolled diabetic
Persistent suppuration with sequestrum formation and moth-eaten bone in a poorly controlled diabetic smoker, with no antiresorptive or radiation history and biopsy excluding malignancy, defines chronic suppurative osteomyelitis.
§Investigations
- 01Deep bone biopsy for histology and culture (not just a superficial swab)
- 02HbA1c, full blood count, CRP, ESR
- 03Culture including anaerobes and actinomyces; consider mycobacterial culture
§Radiology
- 01OPG — ill-defined moth-eaten radiolucency with central radiopaque sequestra
- 02CT — cortical destruction, sequestrum with surrounding involucrum, periosteal new bone
§Treatment plan
- 01Metabolic optimisation: diabetic control and smoking cessation
- 02Prolonged culture-directed antibiotics (typically 4-6 weeks, often longer)
- 03Surgical sequestrectomy, saucerisation and decortication
- 04Consider hyperbaric oxygen in refractory disease
§Surgical procedure
- 01Buccal flap, removal of all mobile sequestra, saucerisation to bleeding bone, decortication of the lateral cortex
- 02Copious irrigation; closure over the vascular periosteal bed
§Histopathology report
Necrotic bone with empty lacunae and bacterial colonies, surrounded by acute and chronic inflammatory infiltrate and granulation tissue with reactive new bone. No malignancy. Chronic suppurative osteomyelitis.
§Follow-up & outcome
- 012 weeks — sinus closed, pain reduced
- 026 weeks — antibiotics completed, CRP normalised
- 036 months — bone remodelling on OPG, partial recovery of lip sensation
Outcome: Infection resolved after decortication and prolonged antibiotics; residual mild lip paraesthesia.
§Discussion
- 01Host factors (diabetes, smoking, immunosuppression, malnutrition) matter as much as antibiotics in jaw osteomyelitis.
- 02Dead bone is avascular, so antibiotics cannot sterilise it — surgical removal is essential.
- 03Always biopsy: malignancy can masquerade as non-healing infected bone.
§Clinical pearls / learning points
- 01Take a deep bone specimen for culture, not a sinus swab, which grows contaminants.
- 02A non-healing socket beyond 8 weeks demands imaging and biopsy.
§Viva questions
Define sequestrum and involucrum.
Sequestrum is a fragment of necrotic bone separated from viable bone; involucrum is the shell of new reactive bone formed around it.
Why is decortication used?
Removing the poorly vascularised lateral cortex and applying well-vascularised periosteum and muscle improves blood supply and antibiotic delivery.
§MCQs
Q1Which condition most predisposes to mandibular osteomyelitis?
Q2A moth-eaten radiolucency with a central radiopacity suggests:
§ evidenceReferences & Evidence
Current Classification
WHO Classification of Tumours Online — Head and Neck
IARC / WHO · 2022
Continuously updated online edition of the WHO head and neck tumour classification.
Evidence summary
Highest level of evidence linked to this page: WHO / Official Classification.
- L1 · Classification — 1
- L2 · Guideline — 1
- L6 · Textbook — 3
1 linked source was published from 2024 onwards. Where guidance is limited or contested, rely on the higher-level sources above rather than this summary. Educational use only — not a substitute for clinical judgement.
Content last reviewed
September 2026
Evidence last reviewed
September 2026
Next scheduled review
September 2027
Review status
EVIDENCE REVIEWED
Search latest PubMed evidence
Last literature search: 7 September 2026
Current Classification
IARC / WHO. IARC · 2022
Continuously updated online edition of the WHO head and neck tumour classification.
Baltensperger M, Grätz K, Bruder E et al.. Journal of cranio-maxillo-facial surgery : official publication of the European Association for Cranio-Maxillo-Facial Surgery · 2004 · 32(1):43-50
Zurich classification proposal for primary chronic osteomyelitis of the jaws.
Histopathology References
Barnes L. CRC Press · 2008
Detailed histopathological reference for head and neck diagnostic criteria.
Textbook References
Neville BW, Damm DD, Allen CM et al.. Elsevier · 2024
Standard reference textbook of oral and maxillofacial pathology used throughout this atlas.
Rajendran R, Sivapathasundharam B. Elsevier · 2020
Undergraduate and postgraduate oral pathology textbook widely used in BDS and FCPS curricula.
Additional sources cited on this page
- Baltensperger M, Eyrich G. Osteomyelitis of the Jaws. Springer.
- Hudson JW. Osteomyelitis of the jaws. J Oral Maxillofac Surg.
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