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https://doi.org/10.1051/mbcb/2021027

Educational Article

The prevalence of odontogenic maxillary osteitis

at the Cocody University Hospital’s Odontostomatological
Consultation and Treatment Center (CCTOS), Abidjan
(Ivory Coast): clinical and therapeutic aspects
Patrice A. Kouamé1 , Marcellin Ayé2,* , Daniel Amantchi1 , Vazoumana Kouyaté1 ,
Sylvie Koboh N’guessan Atsé1 , Traoré Zié1 , Oheueu S. Saint Honoré1 ,
Jeannette A. Adouko1
1
Département de Chirurgie-Pathologie et Thérapeutique Anesthésiologie Réanimation Radiologie UFR d’Odonto-Stomatologie,
Côte d’Ivoire
2
Département de santé publique UFR d’Odonto-Stomatologie, Université Félix Houphouët Boigny Cocody-Abidjan, Côte d’Ivoire, Côte d’Ivoire

(Received: 13 March 2020, accepted: 16 May 2021)

Keywords: Abstract -- Maxillary osteitis is a bone tissue disease or condition with a dentoalveolar origin. This condition remains
Maxillary bone / a public health concern in most developing countries, particularly in the Ivory Coast. Without appropriate
osteitis / jaw management, it can alter the patient’s overall health owing to aesthetic, functional, and psychological
diseases / tooth complications. This study aimed to provide a better understanding of odontogenic maxillary osteitis to consequently
diseases improve its diagnosis and medical care. Three major etiologies of maxillary osteitis have been reported: infectious,
traumatic, and physicochemical causes. According to the literature, osteitis is grouped into two clinical forms,
namely circumscribed osteitis and diffuse osteitis. Their diagnosis is based on a rigorous clinical examination as well
as radiographic, histological, and bacteriological examinations. At the Cocody University Hospital’s Odontosto-
matological Consultation and Treatment Center (CCTOS), patients with the late stages of the condition present with
significant, disabling, and unsightly osteocutaneous-mucous lesions. Treatment of this osteitis is preventive,
curative, and restorative. Odontogenic maxillary osteitis is encountered frequently and typically at a late stage at the
Cocody University Hospital’s CCTOS. To limit aesthetic and functional damage, raising awareness among African
people about oral hygiene and the need for regular consultations should be encouraged.

Introduction In this article, we describe chronic diffuse osteitis, which is

most frequently encountered at the Cocody University Hospital
Osteitis is an inflammatory condition of the bone tissue [1]. (Ivory Coast). The goal of this educational study is to provide a
With the introduction of antibiotic treatments, improved better understanding of odontogenic maxillary osteitis to
asepsis, and early detection, the prevalence of odontogenic thereby improve its diagnosis and management.
maxillary osteitis has declined considerably in developed
countries [2]. However, in most developing countries and
Etiopathogenesis
particularly in the Ivory Coast, this condition remains a serious
disease with frequent complications [3–6]. The authors have
The maxillary bone is mainly composed of richly
unanimously identified self-treatment as one of the major
vascularized spongy tissue. In contrast, the mandible is
causes, as it usually results in late consultations. More than one
predominantly composed of compact bone with terminal
in three affected patients restore to this practice [7,8], which
vascularization. This difference explains the preferential
explains why >25% of the patients present following the
localization of osteitis in the mandible. Maxillary osteitis
formation of bulky bone sequestra and their associated
typically originates from dentoalveolar infections. Other
aesthetic, functional, and psychological consequences. This
causes, notably traumatic and physicochemical causes, have
consequently results in an impairment of the patient’s overall
also been mentioned. The responsible organisms belong to the
health [3].
saprophytic flora of the oral cavity, among which the major
* Correspondence: [email protected] ones are Staphylococcus, Streptococcus, Enterococcus [9].

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J Oral Med Oral Surg 2021;27:50 P.A. Kouamé et al.

Infectious causes are the result of the following Clinical forms of maxillary osteitis
– Pulpo-periodontal complications or alveolar traumas. The
The literature reports several clinical forms of odontogenic
pulpar or periodontal infection reaches the periapex, spreads
maxillary osteitis. They can be grouped into two types:
to the periosteum, and settles there forming a granuloma or a
circumscribed osteitis and diffuse osteitis.
cyst, showing a radiolucent, unigeodesic, and oval or
rounded mass appended to the apex of the necrotic tooth
Circumscribed osteitis
on X-ray imaging. The bacterial dissemination progresses
either asymptomatically or symptomatically with its conse- It is localized osteitis on the one hand and osteoperiostitis
quence being inflammatory signs. on the other.
– The pericoronitis of an inferior third molar, most often in In terms of localized osteitis, the following are observed:
disimpaction with a possible superinfection in the peri- – Alveolar osteitis following complications of dental extrac-
coronal cap or the follicular sac, which may lead to osteitis. tions.
– Central osteitis developing from a granuloma or a cyst.
Traumatic causes – Cortical osteitis resulting from an infection of the mucous
membrane surrounding the dental socket.
– Maxillo-facial: Any trauma that may or may not have caused
In case of osteoperiostitis, the following are observed:
an open maxillo-mandibular fracture is likely to subsequently
– Serous osteoperiostitis or suppurative or chronic AXHAUSEN
cause maxillary osteitis. This results from bacterial inocula-
osteoperiostitis, which is characterized by the inflammation
tion of the fractured site, improper care of the teeth at the
of periodontal ligament.
fractured site, or poor osteosynthesis following bone fracture
– Suppurative osteoperiostitis or subperiosteal abscess clini-
[10].
cally characterized by a submucosal abscess.
– Oral healthcare: The friction generated by the use of
– Chronic osteoperiostitis or GARDE osteoperiostitis most
rotary instruments during dental extractions may cause the
often localized in the mandible and related to endocanalar
bone tissue to heat up. Significant heating without effective
treatment.
cooling can lead to the burning of the alveolar bone–a
source of post-extraction osteitis. Similarly, damage may be
involuntarily caused by practitioners who leave permanent Diffuse osteitis
alveolar-dental debris in the sockets of alveolar fractures.
The extension of an initially circumscribed process. Diffuse
Finally, the use of a vasoconstrictor during intraseptal osteitis affects both the bone and the periosteum, with a
anesthesia may disrupt blood clot formation, thereby trigger- tendency toward necrosis of the bone segments, thereby
ing osteitis [11]. leading to more or less extensive sequestration. This type of
osteitis is more frequently observed in Africa and is particularly
Physicochemical causes common in the Ivory Coast [4,7,8].
The chief physicochemical cause of induced osteitis is
osteoradionecrosis. This refers to the occurrence of osteitis Diagnosing odontogenic maxillary osteitis
following the radiation treatment of a malignant cervico-facial Positive diagnosis
tumor. According to Marx, there are three associated
mechanisms [12]: reduction in oxygen intake known as Diagnosing odontogenic maxillary osteitis requires a
hypoxia, severe damage to arteries known as hypovasculaiza- meticulous clinical examination in addition to X-ray examina-
tion, and damage to metabolic bone units (osteocytes, tions (panoramic X-ray, cone beam computed tomography, and
osteoblasts, and osteoclasts) known as hypocellularity. scanner). In case of doubt, histological and bacteriological
Osteoradionecrosis is still relevant. At the maxillo-mandibular examinations are conducted.
level, with the exception of spontaneous osteoradionecrosis, By interviewing the patient, it is possible to highlight the
the most common point of origin is eroded bone, which becomes signs of either neglecting toothache or managing it improperly
superinfected and results in somewhat significant sequestration. from the patient’s history. The symptomatology depends on the
Together with osteoradionecrosis, arsenical bone necrosis pathological stage.
should also be mentioned. This results from faulty therapeutic – At onset, periodontitis with paroxysmal algia, especially at
practices involving the periodontal passage of arsenic applied night, which may or may not be linked to mobility, is
as an intersession dressing during pulpectomy. This is why observed around the infected tooth. Trismus may also be
several countries including France have prohibited its use in present.
dental practice. Furthermore, antiresorptive therapies – At the established stage, the general signs include fever,
(bisphosphonates, raloxifene, strontium, and denosumab) asthenia, and insomnia. Acute, pulsating, continuous,
predispose the patient to maxillary osteitis [13]. irradiating pain resistant to pain medication may also be

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J Oral Med Oral Surg 2021;27:50 P.A. Kouamé et al.

Fig. 1. Diffuse odontogenic mandibular osteitis fistulized below the chin (a). Frontal view of the voluminous swelling (b) and concealment
of the swelling (c).

Fig. 2. Voluminous swelling owing to odontogenic maxillary osteitis in a child (a). Intraoral view of the bone sequestrum (b) and operative
specimen after sequestrectomy (c).

present. The patient presents with a facial deformity owing to – During the repair stage, the newly formed bone fills the bone
the development of bone swelling and hypoesthesia of the deficits. The sequelae and complications resulting from bone
lower lip and chin. This swelling of the bone is the major sign and tooth loss cause aesthetic and functional problems (Fig. 3).
indicating a need for consultation [3]. Mouth opening is
somewhat reduced, thereby limiting intraoral examinations.
The patient presents with halitosis and hypersalivation. The Differential diagnosis
radiographic examination is generally extraoral and does not
reveal any particular signs. In the absence of treatment, The differential diagnosis of odontogenic maxillary osteitis
osteitis progresses to the stage of sequestration with can be made based on osteocondensing or osteolytic tumor
suppuration, becomes fluctuant, and then fistulizes in one or diseases or on the presence of certain mutilating oral infectious
more cutaneous or mucosal locations (Fig. 1). diseases.
– During the sequestration stage, the general signs and pain Osteocondensing tumor diseases:
– Fibrous dysplasia characterized by dermatological and
disappear. The inflammation subsides but the swelling
persists. At this stage, radiopaque images surrounded by a neurological lesions.
– Cementoma revealed by X-ray images showing radiculo-
radiolucent area defining the bone sequestra are observed.
These sequestra can be spontaneously or surgically removed, dental osteocondensation.
with or without the teeth entrapped in the sequestrum. The Osteolytic tumor diseases:
suppuration then dries up and the fistulas close up, marking – Ameloblastoma characterized by its honeycomb-like appear-
the beginning of the repair stage (Fig. 2). ance on X-ray.

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J Oral Med Oral Surg 2021;27:50 P.A. Kouamé et al.

Fig. 3. Sequela of odontogenic mandibular osteitis: facial asymmetry (a) and unsightly scarring from the mandibular angle (b).

Fig. 4. Simple ablation of bulky sequestra (pulled out) and prosthetic rehabilitation. Right facial asymmetry (a). Intraoral view of the
sequestrum (b) and after sequestrectomy (c). Prosthesis in place (d).

– Osteoradionecrosis of the maxillae with signs of radiation Conclusion

therapy.
Mutilating oral infectious diseases like noma, which mainly Odontogenic maxillary osteitis is an inflammatory and
affects children suffering from malnutrition, combined with infectious bone disease that most often follows an untreated or
poor oral hygiene. poorly treated tooth infection. The preventive treatment of
odontogenic maxillary osteitis involves the effective manage-
Management ment of infected oral sites. When they occur, early treatment is
required to limit the complications and aesthetic and
The management of odontogenic maxillary osteitis is functional sequelae. Unfortunately, these sequelae are quite
preventive, curative, and restorative. Prevention involves common in African countries owing to the low socioeconomic
recommending regular odontostomatological consultations status of the population and the remoteness of health
and adopting a good oral hygiene routine. The curative aspect infrastructure. Today, the epidemiological profile of patients
comprises the earliest possible management (medical or presenting with this pathology have brought the effects of late
medico-surgical treatment) to prevent progression to the consultation and poor oral hygiene to the forefront. Patients
formation of bone sequestra and other complications. Curative present to the first consultation during the stage involving the
antibiotic therapy that complies with the best practice formation of significant bone sequestra requiring surgical
recommendations of the working group of the National Agency excision and removal of a significant portion of the alveolar
for the Safety of Medicines and Health Products (ANSM) is bone and teeth. The treatment of sequelae involves recon-
administered [14]. Subsequently, surgical and restorative structive surgical procedures supplemented by dental pros-
management is performed, which comprises sequestrectomy thetics. Hence, awareness of oral hygiene and regular
followed by prosthetic rehabilitation (Fig. 4). In our clinical consultations may guarantee of the prevention of maxillary
setting, >15% of the patients present with aesthetic and osteitis, which remains a cause for concern in some developing
functional complications [3]. countries.

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J Oral Med Oral Surg 2021;27:50 P.A. Kouamé et al.

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