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Neonatal osteomyelitis: An unusual complication of natal tooth extraction

Article  in  Journal of Indian Society of Pedodontics and Preventive Dentistry · January 2018

DOI: 10.4103/JISPPD.JISPPD_363_16

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Case Report
Neonatal osteomyelitis: An unusual complication of
natal tooth extraction
Esha Chandresh Vora, Jasmin Winnier, Rupinder Bhatia
Department of Pediatric and Preventive Dentistry, D.Y. Patil University, School of Dentistry, Navi Mumbai, Maharashtra, India
ABSTRACT
Osteomyelitis of mandible, if it affects the neonate
presents as a diagnostic and therapeutic challenge
to the clinician. Symptoms and signs are often non-
specific, and the consequences of a missed diagnosis
could lead to long-lasting functional limitations. A
rare case of a 52 days old infant with osteomyelitis
of the mandible following natal tooth extraction is
presented in this report. The diagnosis, pathogenesis
and management have been explained. The
accompanying review briefly summarizes the main
clinical, pathophysiological and radiological aspects
of the condition and gives an update on the treatment.
KEYWORDS: Mandible, natal tooth, neonatal
osteomyelitis
Introduction
Osteomyelitis is an uncommon but important neonatal
infection with recognized morbidity and mortality.
Douglas, in British Medical Journal 1898, reported the
first case of osteomyelitis in infants.[1] The incidence
of neonatal osteomyelitis is 1–7 per 1000 hospital
admissions.[2] However, with the advent of modern
antibiotics and better health‑care protocols, it is rarely
encountered nowadays.
The following report is of a 52‑day‑old infant with
osteomyelitis of the mandible following natal tooth
extraction which presented as a diagnostic challenge
due to its rarity.
Case Report
A 52‑day‑old female infant was referred by a
pediatrician to the department of pedodontics and
preventive dentistry with a complaint of painful
swelling and abscess in the lower anterior region of
the jaw for 1  month  [Figure  1]. Prenatal history was
noncontributory. The child was delivered in another
hospital through normal delivery, at 32‑week gestation.
The birth weight was 1.5 kgs, and the baby was
© 2018 Journal of Indian Society of Pedodontics and Preventive Dentistry | Published by Wolters Kluwer - Medknow
Address for correspondence:
Dr. Rupinder Bhatia,
Department of Pediatric and Preventive Dentistry,
D.Y. Patil University, School of Dentistry, Sector 7,
Nerul, Navi Mumbai ‑ 400 706, Maharashtra, India.
E‑mail: bhatia.rupinder@gmail.com
Access this article online
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DOI:
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admitted in the Neonatal intensive care unit  (NICU)
for 10  days. At birth, a natal tooth was observed in
the lower anterior region which was extracted on the
11th day in the same hospital.
From the 12th day onwards, parents gave a history of
difficulty in suckling, intermittent fever, inflammation,
and pus discharge from the extraction site which
relieved on medications but recurred. The intraoral
examination revealed inflammation in the lower
anterior region with a pointing abscess of about
2 mm × 2 mm in size [Figure 2]. A provisional diagnosis
of infected extraction socket and a differential diagnosis
of osteomyelitis were made. The patient was started
on amoxicillin 125 mg thrice daily and metronidazole
100  mg thrice daily. Blood investigations computed
axial tomography  (CT) scan, and culture tests were
advised, the patient was recalled the next day.
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How to cite this article: Vora EC, Winnier J, Bhatia R. Neonatal
osteomyelitis: An unusual complication of natal tooth extraction.
J Indian Soc Pedod Prev Dent 2018;36:97-100.
97
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Vora, et al.: Neonatal osteomyelitis
At 24  h recall, the condition of the infant worsened.
The CT scan revealed destruction of the bone involving
right inferior border of the mandible without signs
of pathologic fracture. Blood investigations revealed
elevated erythrocyte sedimentation rate  (ESR) and
C‑reactive protein  (CRP). Blood and pus culture
revealed Staphylococcus  aureus. Based on the reports,
a final diagnosis of chronic suppurative osteomyelitis
was made. The patient was hospitalized and
Vancomycin 15  mg/kg/day intravenous  (IV) was
administered 12 hourly.
Over the next 24  h, the child developed an extraoral
draining sinus in the lower anterior border of the
mandible and presented with respiratory depression
[Figure  3]. Vancomycin 15  mg/kg IV was now
administered 6 hourly. After 3 weeks of medications,
extraoral and intraoral healing was satisfactory
[Figure 4]. As per the recommendations[3] and clinical
considerations in the present case, IV Vancomycin was
continued for another 1  week and then orally for a
week.
Figure 1: Extraoral picture at the 52nd day of birth
Figure 3: Intraoral picture at 55th day of birth showing draining sinus
98 Journal of Indian Society of Pedodontics and Preventive Dentistry | Volume 36 | Issue 1 | January-March 2018 |
Postdischarge, parents were advised quarterly recall
and to report immediately if any signs of recurrence
were observed. They were educated to look for early
signs of ankylosis. The possibility of future facial
deformity was also discussed.
Discussion
The neonatal period is susceptible to osteomyelitis due
to several iatrogenic predisposing factors. However,
there are no cases till date reported in the literature
wherein, the etiology is natal tooth extraction.
The pathogenesis of osteomyelitis in infants could be
hematogenous or contiguous focus. Hematogenous
osteomyelitis occurs due to bacterial seeding from
the bloodstream, and contiguous focus occurs due to
direct inoculation of microorganisms into the bone at
the time of trauma.[4] In our case, the osteomyelitis was
considered to be of the contiguous focus type as the
infant had suffered trauma at the time of natal tooth
extraction. Trauma to tissues leads to decrease in blood
supply resulting in necrotic areas where bacteria bind
Figure 2: Intraoral picture at the 52nd‑day showing abscess formation
Figure 4: Healing seen at the 3rd week of admission
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and infection begins its course. The severity of tissue
injury and inherent susceptibility of the patient should
also be considered since the presence of bacteria in a
wound alone is not sufficient to cause osteomyelitis.[5]
Initially, the clinical signs and symptoms are nonspecific
and mild, including temperature instability and feeding
intolerance.[2] Majority of children are unwell, but a few
remain surprisingly well despite the disease progression.
These children will present with irregular temperature,
frequent convulsions, marked anorexia and will have
difficulty in nursing due to the pus in the nostril. As the
disease progresses, more specific signs maybe present
such as, disability, local swellings or erythema.[1] Due
to the presence of these nonspecific symptoms, we had
started the patient on empirical antibiotics.
Early diagnosis of neonatal osteomyelitis is often
challenging, and radiography may not be helpful
since destructive bone changes do not appear until
7–14 days of disease.[6] CT was a more practical option
in our case since it would help us to localize and study
the extent of the lesion.[7] Other methods for diagnosis
of acute osteomyelitis are ultrasound, which detects
lesions earlier than radiographs, magnetic resonance
imaging, which detects within 3 to 5  days after
onset of infection and the three‑phase bone imaging,
which allows detection within 24–48  h after onset of
symptoms.[4] Laboratory findings frequently show
normal leukocytic count, ESR, and elevated CRP in the
first few days.[8] Although laboratory findings are not
helpful in diagnosis, they assist to monitor response
to therapy or identify complications. Blood cultures
are recommended when osteomyelitis is suspected,
though they are often negative except in cases of
hematogenous osteomyelitis. If patient presents with
ulcers or draining wounds, it should be cultured.[9]
Differential diagnosis of chronic osteomyelitis mainly
consists of neoplasms such as, Ewing’s sarcoma,
Langerhans cell histiocytosis, bone metastases, and
chronic recurrent multifocal osteomyelitis.[8]
On confirmation of the diagnosis of osteomyelitis,
antimicrobial therapy should be administered against
the most common bacterial isolates responsible
depending on the age group. In infants, the
predominant pathogen is Staphylococcus species,[10]
hence it is recommended to begin a regimen that
includes antistaphylococcal agent.[11] For neonates
and infants at risk for hospital‑acquired infection
(methicillin‑resistant S. aureus  [MRSA]), vancomycin
instead of amoxicillin should be preferred. Intravenous
drug administration is recommended for 2–3  weeks
followed by oral medication.[2]
Delay in therapy and presence of MRSA infection
increases the risk for complications including
pathologic fractures, temporomandibular joint
disorders and if systemic complications persist, it leads
to death.[12]
Journal of Indian Society of Pedodontics and Preventive Dentistry | Volume 36 | Issue 1 | January-March 2018 |
Vora, et al.: Neonatal osteomyelitis
In the present case also, the infant had the history of
swelling and abscess formation for 1  month which
was undiagnosed. Late presentation and presence of
hospital‑acquired infection were probably the reasons
why patients did not respond to initial antibiotics, and
extraoral draining sinus was encountered in spite of
appropriate antibiotics; and thus, a more aggressive
therapy was administered with which the patient
showed satisfactory recovery.
Conclusion
Neonatal osteomyelitis is a rare complication that offers
a diagnostic and therapeutic challenge. Osteomyelitis
should be considered in infants with clinical signs of
sepsis, but no obvious focus, to facilitate early diagnosis
and initiation of appropriate therapy. There is no single
test that can confirm or rule out osteomyelitis thus, a
combination of careful history, physical examination,
imaging, laboratory tests, and aspiration or biopsy is
required to make a definitive diagnosis and an accurate
treatment plan.
Declaration of patient consent
The authors certify that they have obtained all
appropriate patient consent forms. In the form the
patient(s) has/have given his/her/their consent for
his/her/their images and other clinical information
to be reported in the journal. The patients understand
that their names and initials will not be published and
due efforts will be made to conceal their identity, but
anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
1. Wilensky AO. Osteomyelitis of the jaws in nurslings and
infants. Ann Surg 1932;95:33‑45.
2. Kiechl‑Kohlendorfer U, Griesmaier E. Neonatal Osteomyelitis,
Neonatal Bacterial Infection; 2013. Available from: http://
www.intechopen.com/books/neonatal‑bacterial‑infection/
neonatal‑osteomyelitis. [Last accessed on 2017 Aug 20].
3. Castellazzi L, Mantero M, Esposito S. Update on the
management of pediatric acute osteomyelitis and septic
arthritis. Int J Mol Sci 2016;17:855.
4. Brook I. Microbiology and management of joint and
bone infections due to anaerobic bacteria. J Orthop Sci
2008;13:160‑9.
5. Brady RA, Leid JG, Calhoun JH, Costerton JW, Shirtliff ME.
Osteomyelitis and the role of biofilms in chronic infection.
FEMS Immunol Med Microbiol 2008;52:13‑22.
6. Blickman JG, van Die CE, de Rooy JW. Current
imaging concepts in pediatric osteomyelitis. Eur Radiol
2004;14 Suppl 4:L55‑64.
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Vora, et al.: Neonatal osteomyelitis

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8. Schuppen J, Van Doom M, van Rijn R. Childhood
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12. Dodwell E. Osteomyelitis and Septic Arthritis in Children:
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100 Journal of Indian Society of Pedodontics and Preventive Dentistry | Volume 36 | Issue 1 | January-March 2018 |

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