Primary chronic osteomyelitis (PCO) of the jaw is a rare condition of unknown etiology with severe pain and/or facial swelling. In this article, a 63-year-old man whose severe pain caused by PCO of the mandible was treated with intravenous administration of lidocaine and magnesium is described. At the first visit, paresthesia on the right lower lip and chin was noted in an extraoral examination, and the results of an intraoral examination and laboratory examination were normal. Radiographic findings showed a ground glass-like opaque image and a bone resorption image on the right mandible. The patient was clinically diagnosed as having PCO. Pain control was difficult with conventional treatment, but successful pain control was achieved with intravenous administration of lidocaine and magnesium. The results suggested that intravenous administration of lidocaine and magnesium could be a new therapy for refractory PCO of the jaw.
Primary chronic osteomyelitis (PCO) of the jaw is a rare inflammatory condition of unknown etiology with severe pain.
In patients with PCO, pain control is often difficult.
Good pain control was obtained by intravenous administration of lidocaine and magnesium for intractable chronic pain.
Primary chronic osteomyelitis (PCO) of the jaw is a rare inflammatory disease of unknown etiology and is characterized by nonsuppurative chronic inflammation of the jaw bones with recurrent pain, trismus and swelling and without pus formation, extra- or intraoral fistula, or sequestration [ , ]. PCO can cause intense pain. NSAIDs are commonly used to control the pain, but pain control is often difficult. It has recently been reported that intravenous administration of low concentrations of lidocaine and magnesium has a reliable analgesic effect and can be safely used in patients with intractable chronic pain [ , ]. In this paper, a case of PCO in which good pain control was obtained by intravenous administration of lidocaine and magnesium for intractable chronic pain is described.
Presentation of case
A 63-year-old man who had severe pain in his right mandible and paresthesia in his right lower lip for 3 months was referred to our clinic. The patient had become edentulous 10 years ago and never had any symptoms. His medical history was only hypertension. The patient had severe pain according to subjective evaluation methods with a pain catastrophizing scale (PCS) score of 42 points and painDETECT questionnaire (PD-Q) score of 23 points. Extraoral examination revealed paresthesia on the right lower lip and chin and no swelling of the face or submandibular lymph nodes ( Fig. 1 A). Intraoral examination showed no abnormality in the oral mucosa and no pain-inducing findings ( Fig. 1 B). Radiographic imaging revealed a ground glass-like sclerotic appearance of the entire mandible and a focal bone resorption of the right mandibular molar region, but there was no periosteal reaction ( Fig. 2 ). Laboratory findings were normal. Based on these findings, a diagnosis of PCO of the right mandible was made. The patient was first treated with antimicrobials and analgesics but subsequently developed allodynia in the mandibular branch (V3) of trigeminal. Trigeminal nerve block had no effect on the allodynia and the pain gradually worsened. Decortication of the right mandible was performed and hyperbaric oxygen (HBO) therapy was given for 2 weeks ( Fig. 3 ). In bacterial cultures on bone marrow, only alpha-Streptococcus was isolated. The patient’s recovery was good, but symptoms recurred one month after surgery. Therefore, the patient was given intravenous infusion of lidocaine at 100 mg (1.4 mg/kg) and Mg at 0.5 mEq (magnesium sulphate at 30 mg/kg) dissolved in 100 ml of saline over a period of 15 minutes twice a day under inpatient management. After administration of lidocaine and Mg, his pain gradually improved and complete pain relief without any side effects was finally achieved ( Fig. 4 ). The results of a quantitative sensory test were normal at 17 months after treatment, and there was no recurrence of pain because the PCS score was 0 and the PD-Q was 10 at 19 months after treatment.