Initial results of the treatment of diffuse sclerosing osteomyelitis of the mandible with bisphosphonates

Abstract

Objective

Diffuse sclerosing osteomyelitis (DSO) of the mandible is characterised by recurrent pain, swelling of the cheek and trismus. Treatment is difficult and symptoms often recur. Recently case reports and small series have reported good results after treatment with bisphosphonates.

Study design

Seven patients suffering from treatment resistant DSO were treated with intravenous bisphosphonates. Diagnosis was based on clinical, radiological and histopathological examination. Symptoms had been present for between 20 and 167 months (mean 78). Patients were admitted, laboratory tests and Technetium-scans were performed. Pamidronate was administered intravenously up to four times a year. Follow-up varied from 18 to 46 months (mean 30).

Results

In all patients, symptoms and the need for analgesic drugs diminished considerably. One patient remained free of symptoms after one treatment. In two patients a switch in bisphosphonate was made based on a decreased response. All patients showed a decrease in uptake in the DSO-area on the Tc-scans when comparing pre- and post-treatment. One patient was lost to follow-up.

Conclusion

In therapy-resistant DSO bisphosphonate treatment may be a good option.

Introduction

Chronic diffuse sclerosing osteomyelitis (DSO) is characterised by recurrent pain, swelling of the cheek and trismus, without suppuration or formation of sequestra (Merkesteyn et al., 1988, Merkesteyn et al., 1990). Panoramic radiographs (Fig. 1) and CT-scans show areas of sclerosis and occasionally osteolysis, and Technetium-scans (Tc-scans) show increased uptake in the area of the lesion due to increased bone turnover.

The aetiology of DSO remains controversial. Some authors believe it is a response to a microbial stimulus (Jacobsson, 1984). Others have introduced chronic periostitis as a new concept of its aetiology (Merkesteyn et al., 1988, Merkesteyn et al., 1990, Groot et al., 1992a, Groot et al., 1992b).

The management of DSO can be quite challenging. Several strategies are often used, including long-term analgesic medication, antibiotics, and surgical interventions, for example decortication. In most cases these treatments do not succeed in achieving a long-lasting reduction of the recurrent pain, trismus and swelling. Some patients benefit from corticosteroids, but often this is only a temporary improvement.

Since the beginning of the current century several articles have been published concerning the treatment of DSO with bisphosphonates (Montonen et al., 2001, Soubrier et al., 2001, Sugata et al., 2003, Kopterides et al., 2004, Hino et al., 2005, Compeyrot-Lacassagne et al., 2007, Yamazaki et al., 2007). In most cases the bisphosphonate (pamidronate, clodronate or zoledronate) was given once. Follow-up extended to a maximum of 2 years. A remarkable decrease in complaints was noted in most patients. However, most articles are case reports. In this article a series of seven patients are reported.