Journal of Indian Society of Pedodontics and Preventive Dentistry
Journal of Indian Society of Pedodontics and Preventive Dentistry
                                                   Official journal of the Indian Society of Pedodontics and Preventive Dentistry                           
Year : 2018  |  Volume : 36  |  Issue : 1  |  Page : 97--100

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

Correspondence Address:
Dr. Rupinder Bhatia
Department of Pediatric and Preventive Dentistry, D.Y. Patil University, School of Dentistry, Sector 7, Nerul, Navi Mumbai - 400 706, Maharashtra


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.

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

How to cite this URL:
Vora EC, Winnier J, Bhatia R. Neonatal osteomyelitis: An unusual complication of natal tooth extraction. J Indian Soc Pedod Prev Dent [serial online] 2018 [cited 2020 Sep 26 ];36:97-100
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Full Text


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 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.{Figure 1}

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.{Figure 2}

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 3}{Figure 4}

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.


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 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]

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.


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.

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Conflicts of interest

There are no conflicts of interest.


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