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"Lumpy Jaw" in a 20-year-old Male Resists Treatment

"Lumpy Jaw" in a 20-year-old Male Resists Treatment


  • A Chump with a Lump has them Stumped

  • A 20-year-old male is seen for an infection on the side of his jaw that has been unresponsive to multiple antibiotics; it has been present for 6 months. PMH, non-contributory: no pets, not sexually active, no known congenital lesions, no significant illnesses.

  • Lab tests/results: CBC = normal; comprehensive metabolic panel = normal; throat culture = normal flora; intermediate PPD skin test read as 0 mm of induration.

  • Physical examination:The sole finding is a soft, erythematous nodulocystic, 3 x 3 x 1-cm mass at the jaw line on the left side.

  • Nodulocystic mass overlying the left mandible; measures 3 x 3 x 1 cm.

  • Is the physical examination complete? Are you satisfied with what you've found?

  • An oral examination may prove useful in this case.

  • Finding: A “gum boil” which suggests a periapical abscess that has drained.

  • What's your diagnosis?

  • Answer: Periapical abscess. A thoughtful history and thorough physical examination may also include a good dental assessment.

  • Periapical abscess: Most common cause of cutaneous sinus tracts involving face, neck; odontogenic sinus tracts are often misdiagnosed, mistreated; lesions often misinterpreted as chronic, treatment-resistant pyogenic nodules or granulomas. Early diagnosis may prevent unnecessary and ineffective treatment and reduce possibility of complications (ie, sepsis, osteomyelitis).

  • Treatment: Refer patient with periapical abscess for dental evaluation. Typical course: tooth/teeth removed; antibiotics for deep facial infections, osteomyelitis. Microbiology: Gingival crevice: Bacteroides, Peptostreptococcus; Tongue: Streptococcus salivarius; Tooth surface: Streptococcus sanguinis, Streptococcus mutans

  • Differential diagnosis for periapical abscess:Squamous cell carcinoma; osteomyelitis; pyogenic granuloma; actinomycosis; deep mycosis; foreign body; congenital fistula.

  • Draining sinus from actinomycosis.

  • Characteristic sulfur-laden granule seen from microscopic examination of drainage from patient with actinomycosis (sometimes asked on board exams).

A colleague asks you to see a 20-year-old who has been treated unsuccessfully with a series of antibiotics for a persistent lump along his jawline. Was something overlooked in exam?

Follow the history and take a closer look in the slide show above.

 

Resources

Razavi SM, Kiani S, Khalesi S. Periapical lesions: a review of clinical, radiographic, and histopathologic features. Avicenna J Dental Res. 2015;7: e19435

Brown RS, Jones R, Feimster T, Sam FE. Cutaneous sinus tracts (or emerging sinus tracts) of odontogenic origin: a report of 3 cases. Clin Cosmet Investig Dent. 2010;2:63-67. Print 2010.

Giménez-García R, Martinez-Vera F, Fuentes-Vera L. Cutaneous sinus tracts of odontogenic origin: two case reports. J Am Board Fam Med. 2015 Nov-Dec;28:838-840.

Comments

Thanks for your comments Arnold and Alexander. The bottom line is there is no good excuse for not thinking through a differential diagnosis (and that includes all oral possibilities) and performing a complete physical examination. A primary care doctor, especially in a rural area, is responsible for knowing something about oral/dental lesions and making a responsible consult to his dental/oral surgeon colleague. That is the way I was trained and I will stick to that logic.

Jon Schneider, author.

Jonathan @

Ye gods!! I hate these pontifications. The oral-systemic paradigm has nauseated me to death ever since I first heard it coined. as if the dental profession has finally found something legitimate to stand other other than teeth. . Sorry, but after six years of full-time hospital training and practice, interfacing with docs of all stripe, particularly ENT, Plastics, and Ophthalmology who also have interests in the maxillofacial complex, some really good oral medicine mentors in dental school, plus watching how my own personal MD's those disciplines go about it, I have to say that I've approached my dental career and my patient care from the point of view of a head and neck medicine subspecialist for 38 years until retirement 4 years ago. Suffice it to say that any complete H&P by a physician ought to include an intraoral assessment anterior to the pillars of the fauces. You might just turn up an SSC in a patient who does not have a dental home. Congratulations to all of us. Finally made it to the big leagues. It ain't just teeth after all.

Arnold Rosenstock MSEd, DDS
Boca Raton FL

Dr. Arnold @

Dr. Schneider, it was so pleasant for me to see your case presentation of the periapical abscess. As a strong proponent of the oral-systemic paradigm, I have been promoting a close cooperation between the dental and medical camps. Patients coming for help to dentists must be addressed as a whole body and not just a head or even an oral cavity. Most of the “dental” problems are caused by bacterial infection and an inflammatory process, which affects the entire body. There are literally thousands of studies and articles, presented within last 10 years, to show direct correlation between the chronic periodontal disease and detrimental sequela on many organs and tissues within the system. Therefore, dentists must be paying close attention to the general health of their symptomatic patients and, based on systemic presentations, refer such patients to PCP or medical specialists for further evaluation. At the same time, physicians must be trained to recognize periodontitis or other oral lesions and signs of soft/hard tissue decay, and immediately refer patients with positive findings to dentists for a more thorough evaluation and possible treatment. Knowledgeable and proactive dentists must be treated as another medical subspecialists for the good of our patients. Any missed periodontal, subgingival ulcerations in a diabetic or RA patient is a disaster. And yet, very few physicians are examining their patients’ gums and dentition during routine visits.
The dentists and physicians must work together.
Respectfully,
Dr. Alexander Slepak, MD

Alexander @

note from author - if you click on the first reference, you will find a superb review that is a PDF article that you can download. I suggest that you do. I think it is the best up to date review available to us.
Jon

Jonathan @

Epidermal inclusion Cyst

HERVE @

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