Intermttumal Endodontk Journal (1992) 25^ 165-168

Garre's osteomyelitis: a case report B. A. FERREIRA & A. L. B. BARBOSA Dejjartment of Diagnosis and Surgery, Faculty of Odontology—UNESP, Araraqimra. Sao Paulo, Brazil

Summary This is a case report of Garre's osteomyelitis caused by infection from a lower left molar which was successfully managed by root treatment following several unsuccessful attempts with antibiotic therapy alone. After 18 monlhs there was complete resolution of tbe bony lesion. Keywords: periapical infection, root canal treatment. Introduction Garre's osteomyelitis is named after Carl Garre. who first observed the condition in 1893. He described a massive focal thickening of the periosteum of bones, with peripheral reactive bone as a result of irritation, or attenuated infection (Shafer et al. 1983). The condition was first observed in the tibia, and ^vas most frequently found on the anterior surface. Berger (1948) reported a case of perimandibular ossification with all the features of Garre's osteomyelitis. Correspondence: i)r B. A. Ferreira. Unlversidade Estadual Pauiista. 'Campus' de Araraquara. Facoldade deOdootologia. Rua Humaita, No. 1680. C.P. 3 31. CEP:14,8()()—.^araquara. Sao Paulo. Brazil.

altbough it was Pell el al. (1955) who first reported a case of Garre's osteomyelitis, involving the mandible in a 12-year-old Negro boy, caused by a deep carious lesion in the first molar. Garre's osteomyelitis is defined as a periosteal osteosclerosis, similar to endosteai sclerosis of chronic diffuse and focal scierosing osteomyelitis. Garre's osteomyelitis is known by different names. Including 'ossifying periostitis' and 'noE-suppurative ossifying periostitis'. The main incidence inv'oh'es the mandible, but cases involving the maxilla have been recorded. It has been noted that the highest incidence occurs in individuals under 2 5 yearsofage. Eversole ct al. (1979). in a report of 29 cases, found that tbe median age was 10.9 j'ears (range 2.5-31 years). The causes of Garre's osteomyelitis include dental caries, periodontal defect, miid periodontitis, recent dental extraction or a consequence of infection of the underlying soft tissue that later involved tbe deeper periosteum and. rarely, no causative factor could be found. Lichty et al. (1980), in a report of 22 cases. obser\'ed that the most common cause was a periapical

• - . ' • • ' ' .^;- •fVt Fig. 1. Initial radiograph of ift^sliowing a deiicient root treatment and bone destruction between the roots and around the mesial apex.

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Fig. 2. Initial occlusal radiograph showing focal overgrowth on the outer surface of the

i.

Fig. J. Radiograph 18 months after treatment, showing complete bony repair.

abscess on the first permanent molar. These workers also noted that in no instance did the periosteal proliferation cross the midline or occur on the lingual aspect of the mandible. Tbis lesion is usually found unilaterally, but an unusual case of bilateral incidence has been reported. Garre's osteomyelitis presents with enlargement of the outer bone surface, which may cause facial asymmetry. Despite the use of tbe term 'non-suppurative', there are reported cases which have demonstrated either serum or pus on exploration, and even sinus tracts on the skin.

An occlusal radiograph can verify an excessive focal bony thickening at the outer surface of the cortex, and it may be described as a duplication of the cortical bony layer. The radiographic features are dependent on the duration and degree of calciication of the reactive lesion, as the trabecular pattern on the radiograph may vary. The occlusal radiograph will also show cortical expansion through new bone deposition in successive layers, giving an 'onion skin' appearance. The centre of the lesion may show a radiolucency.

Garre's osteomyelitis: a case report

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J Fig. 4. Occlusa) radiograph 18 months after treatment, showing return to the original contour of the outer surface of the cortex.

Histologically. tbere is considerable new reactive bone subperiostealiy, with osteoblasts surrounding many of tbe trabeculae. which are frequently orientated perpendicular to the cortex. The connective tissue between the trabeculae is fibrous, and contains lymphocytes and plasma ceils eitber in focal areas or dispersed diffusely. Antibiotic therapy and tooth extraction have been performed most frequently, but recently root treatment bas been indicated. Other diseases which can present with similar features to Garre's osteomyelitis are infantile cortical hyperostosis (Caffey's disease), hypervitaminosis A. syphilis. leukaemia. Ewing's sarcoma and metastatic neuroblastoma. The differential diagnosis of osteomyelitis has been re%'iewed by Benca et al. (1987). Case report An 18-year-old Caucasian female patient complained of swelling on the left side of the mandible. Tbe patient reported that, approximately 2 years earlier, root treatment had been performed in the lower left first molar, and the problem had occurred since then. With tbe appearance of the swelling, the patient had attended several different clinics, and in each case bad been prescribed antibiotics. During this time, despite treatment with antibiotics, the swelling increased. Clinically, the lesion was symptomless. even on palpation, the skin was of normal colour, and the patient did not have cervical lymphadenopatby. Intra-oral examination revealed a symptomless and non-mobile

lower left first molar, which did not respond to percussion testing, and was restored with a cast crown. Radiographic examination revealed a deficient root treatment in the lower left irst molar, together with the presence of a separated instrument in one mesial canal. There was a radiolucent area betiveen the roots of the lower left first molar and a circular radiopaque area over the second premolar. On the mesial root of the lower first molar there was an apical area of bone loss (Fig. 1). A bony oi'ergrowth on the buccal aspect of the mandible o\'er the roots of the lower first molar was seen (Fig. 2). The radiograpbic feature of this excessive focal bony growth on the outer cortical surface was a smooth and ivell-calcifled bony mass, with a thin, well-defined margin. Root treatment was performed using rotary instruments and ultrasonic instrumentation, and obturated by tbe lateral condensation technique. No antibiotic therapy was prescribed because of the lack of general symptoms. The patient was reviewed periodically, and after 18 months there was clinical and radiographic evidence of complete healing {Figs 3 and 4). At that stage a new restoration was placed. Discussion Periosteal bony proliferation may occur in many conditions besides Garre's osteomyelitis, and a biopsy may be required for differential diagnosis. In the present case biopsy was not undertaken because of the obvious

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cause, a chronic periapical abscess; the radiographic appearance in the occlusal view was not fully characteristic of an onion skin. The unsatisfactory previous root treatment aided diagnosis, but if the lesion had not responded to treatment, a biopsy would then have been performed. In the past, treatment of Garre's osteomyelitis has often been by antibiotics and extraction of the causative tootb (lichty et al. 1980), In view of the value of a first molar tooth and the efficacy of root treatment, the authors considered that root treatment was the correct choice. Many authors have recommended remodelling surgery of the mandible. However, McWaiter and Schaberg (1984) demonstrated that such surgery is not necessary, as bone returns to its original contour after elimination of the causative factor. Among the features of Garre's osteomyelitis there is a paradox: bony destruction around the root apex, but bone apposition on the outer surface of the mandible. The authors believe that, in the case described here, the most important part of therapy was the effective root treatment, and this confirms the report of McWaiter and Schaberg (1984), These findings, together with the recent report of Arcari and Aquino (1989), appear to be the only recorded cases of Garre's osteomyelitis treated by root treatment rather than by dental extraction.

Conclusions This report demonstrate the successful treatment of Garre's osteomyelitis by root treatment, without the need for surgical intervention. Rrferraices ARCARI G.M. & AQUINO R.G. (1989) Osteomyelitis de Garre da mandibula. Regressao apos terapia endodoutica. Revista daucha de Cdontologica, 3 7 , 1 2 8 - 1 3 2 . BENCA P.G., MOSTOFI R. & Kuo P.C. (1987) Proliferative periostitis (Garre's osteomyelitis). Orai Surgery, Oral Medicine and Oral Pathology, 6 3 , 258-260. BERGEB A . (1948) Perimandibular ossification of possible traumatic origin: report of case. Journal of Oral Surgery, 6 , 3 5 3 - 3 5 6 . EvERSOLE L.R., LEIDER A.S.. CoRWiNj.O. & KARIAN B.K. (1979) Proliferative periostitis of Garre: its differentiation from other neoperiostoses. Journal of Oral Surgery, 37(10), 7 2 5 - 7 3 1 . UcHTY G.. LANGLAIS R.P. & AnFDEMORTE T. (1980) Garre's osteomyelitis, literature review and case report. Oral Surgery, Oral Medicine and Oral Pathology, 50, 309-313. McWALTER G.M. & SCHABESG SJ. (1984) Garre's osteomyelitis of the mandible resolved by endodontic treatment. Journal of the American Dental Association, 1 0 8 , 1 9 3 - 1 9 5 . PELL G.J., SHAFER W.G.,

GREGORY G.T.,

PING R.S. & SPEAR L.B. (1955)

Garre's osteomyelitis of the mandible: report of case. Journal of Oral

Surgery, ii, 248-2S2. SHAFER W.G.. HINE M.K. & LEVY B.M. (1983) A Textbook of Oral Pathology, 4th edn. Saunders. Philadelphia.