Year : 2007 | Volume
: 25 | Issue : 5 | Page : 30--33
Garre's sclerosing osteomyelitis
R Suma1, C Vinay1, MC Shashikanth2, VV Subba Reddy1,
1 Department of Pediatric Dentistry, College of Dental Sciences and Hospital, Davangere - 577 004, Karnataka, India
2 Department of Oral Medicine and Radiology, College of Dental Sciences and Hospital, Davangere - 577 004, Karnataka, India
Department of Pediatric Dentistry, College of Dental Sciences and Hospital, Davangere - 577 004
Garre«SQ»s sclerosing osteomyelitis is a specific type of chronic osteomyelitis that mainly affects children and young adults. This disease entity is well-described in dental literature and is commonly associated with an odontogenic infection resulting from dental caries. This paper describes a case of Garre«SQ»s osteomyelitis in a 10-year-old boy, in whom the condition arose following pulpoperiapical infection in relation to permanent mandibular right first molar. Clinically the patient presented with bony hard, non-tender swelling and the occlusal radiograph revealed pathognomic feature of «DQ»onion skin«DQ» appearance. The elimination of periapical infection was achieved by endodontic therapy and the complete bone remodeling was seen radiographically after three months follow-up.
|How to cite this article:|
Suma R, Vinay C, Shashikanth M C, Subba Reddy V V. Garre's sclerosing osteomyelitis.J Indian Soc Pedod Prev Dent 2007;25:30-33
|How to cite this URL:|
Suma R, Vinay C, Shashikanth M C, Subba Reddy V V. Garre's sclerosing osteomyelitis. J Indian Soc Pedod Prev Dent [serial online] 2007 [cited 2020 Nov 30 ];25:30-33
Available from: https://www.jisppd.com/text.asp?2007/25/5/30/34744
Garre's sclerosing osteomyelitis is a specific type of chronic osteomyelitis that primarily affects children and adolescents.  It is also known as chronic non-suppurative sclerosing osteomyelitis, chronic osteomyelitis with proliferative periostitis and periostitis ossificans. 
This disease entity was first described by Carl Garre in 1893 as irritation induced focal thickening of periosteum and cortical bone of tibia. It is a non-suppurative inflammatory process, where there is peripheral subperiosteal bone deposition caused by mild irritation and infection. This condition is seen exclusively in children or young adults.
The mandible is more often affected than the maxilla. When it affects the jaw, this generally originates from an infection of low virulence, such as dental decay, mild periodontitis, dental eruption or previous dental extraction in the lesion area.
Clinically, this reactive process accounts for the hard swelling of the jaw and the subsequent facial asymmetry with which patients may present. The lesion is usually asymptomatic with no accompanying general and local signs of inflammation, although the clinical picture may vary widely. Garre's osteomyelitis presents a characteristic radiographic feature, especially in occlusal radiograph showing new periosteal proliferation located in successive layers to the condensed cortical bone. This is the typical radiographic feature of Garre's osteomyelitis and is well known as "onion skin" appearance. 
A 10-year-old boy reported with the complaint of pain in the left lower back tooth region and extra-oral swelling in the right inferior border of the mandible. Extra-oral examination of right side revealed a diffuse non-tender swelling which was hard in consistency with no lymphadenopathy and the skin color was normal [Figure 1]. Intra-oral examination disclosed the extensive carious lesion in relation to 36 and 46 [Figure 2]. No mobility or tenderness was evident in relation to 46, however 36 was tender on percussion. A provisional diagnosis of chronic alveolar abscess was made in relation to 36 and 46. Intra-oral periapical radiographs of involved teeth revealed the presence of chronic periapical abscess in relation to 36 and 46 [Figure 3]. Occlusal radiograph of mandible was taken which showed 'onion skin' appearance representing the peripheral sub-periosteal bone deposition on the right side [Figure 4]. Patient's oral hygiene was poor with deep caries in relation to 64, 65 and arrested caries in relation to 16 and 26.
In the first visit root canal opening was done and open dressing was given in 36 and 46 followed by antibiotic and analgesic therapy. Three days later the root canals of 46 and 36 were irrigated with mixture of metronidazole and gentamycin infusion solutions, then canals were dried and closed dressing was given. The root canal dressing was changed in 46 on weekly basis for three weeks, till the hard swelling subsided completely, [Figure 5] then the canals were obturated [Figure 6] and access cavity was restored with silver amalgam. The stainless steel crown was cemented after two weeks as a semi-permanent restoration [Figure 7]. In subsequent visits 16 and 26 were restored with composite resin, 64 and 65 were extracted. After three months on recall visit, the occlusal radiograph and intraoral periapical radiograph showed complete remodeling of bone [Figure 8],[Figure 9].
The Garre's osteomyelitis is a well-described pathologic entity in the dental literature. The difficulties in the diagnosis and classification of mandibular osteomyelitis have prevented clinicians and researchers from developing an improved understanding of this inflammatory condition, this has resulted in dilemmas for planning treatment strategies. Terms like Garres osteomyelitis and osteomyelitis with periostitis are used to identify lesions with a large amount of periosteal reaction. But periosteal reaction can be seen in any type of osteomyelitis lesion, the amount of periosteal reaction depends on the activity of the osteoblastic cells in the periosteum. The degree and duration of the symptoms depend on various factors such as the virulence of the causative organisms, the presence of underlying diseases and the immune status of the host. 
The most important differential diagnosis is Fibrous dysplasia. The signs and symptoms of Fibrous dysplasia and Garre's osteomyelitis may be clinically indistinguishable. Based on the characteristic radiographic feature of "onion skin" due to periosteal new bone formation, it is differentiated from fibrous dysplasia. Similar proliferation of sub-periosteal new bone may be seen in Infantile cortical hyperostosis, Syphilitic osteomyelitis, Fracture callus and Ewing's sarcoma. In the present case, both clinical and radiographic evidences were in accordance with diagnostic features of Garre's osteomyelitis and the biopsy was not taken because of obvious cause that is pulpo-periapical pathology in relation to 46.
The main treatment goal for Garre's osteomyelitis is to eliminate the etiologic factor, most frequently by extraction of the causative tooth. Though the role of endodontic therapy in the management of Garre's osteomyelitis is questionable, Batcheldor et al. suggested the possible efficacy of endodontic intervention. , In our present case we considered endodontic therapy since the tooth was restorable and the patient's parents were hesitant for surgical extraction.
This disease entity is rare in occurrence because its development depends on the occurrence of a set of critically integrated conditions; that is chronic infection in a young individual, with a periosteum capable of vigorous osteoblastic activity and an equilibrium between the virulence of the infectious agents and the resistance of the host.  Since the occurrence of Garre's osteomyelitis is confined to younger age group, whenever the clinical situation permits, endodontic therapy should be considered as the main treatment goal.
|1||Oulis C, Berdousis E, Vadiakas G, Goumenos G. Garres osteomyelitis of an unusual origin in a 8 year old child: A case report. Int J Pediatr Dent 2000;10:240-4|
|2||Neelima M. Osteomyelitis and osteo radionecrosis of the jaw bones. Textbook Oral Maxillofac Surg 608-11|
|3||Eswar N. Garres Osteomyelitis: A case report. J Indian Soc Pedo Prev Dent 2001;19:157-9|
|4||Suei Y, Taguchi A, Tanimoto K. Diagnosis and classification of mandibular osteomyelitis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;100:207-14|
|5||Gonclaves M, Oliveira DP, Oya EO. Garres Ostoemyelitis associated with a fistula: A case report. J Clin Pediatr Dent 2002;26:311-4|
|6||Batcheldor GD, Giansanti JS, Hibbard ED, Waldron CA. Garre's osteomyelitis of the jaws: A review and report of two cases. J Am Dent Assoc 1973;87:892-7|
|7||Felsberg GJ, Gore RL, Schweitzer ME, Jui V. Sclerosing osteomyelitis of Garre (periostitis ossificans). Oral Surg Oral Med Oral Pathol 1990;70:117-20|