Osteonecrosis of jaw bones: A complication of severe dengue
The present case has been reported in the Journal of Indian Academy of Oral Medicine and Radiology.

A 24 year-old male reported with a chief complaint of multiple draining sinuses in the oral cavity for 2 months. The patient's medical history was significant for dengue fever which required hospitalization for 3 months. During the course of treatment, the patient noticed locking of jaws.

Later on, on recovery from dengue, the patient developed diffuse swelling on the left side of the face and multiple draining sinuses from the left buccal vestibule. The patient had no history of deleterious oral habits, trauma, or any systemic disease before contacting dengue fever. There was no history of any drug allergies.

On extraoral examination, there was extensive diffuse erythematous swelling of the left side of the face. Intraoral examination revealed good oral hygiene with no carious teeth. No evidence of gingival swelling, gingival recession, mobility, or attachment loss on periodontal probing was seen. There was slight obliteration of buccal vestibule extending from 38 till 43 region with multiple draining sinuses.

Panoramic radiograph revealed multiple small irregular osteolytic areas involving the left body of mandible from 38 to 43 regions extending to left ramus, coronoid, and condylar regions giving moth-eaten appearance. Interdental vertical and horizontal pattern of bone loss was evident from 38 to 43 regions.

Advanced imaging such as contrast-enhanced computed tomography and cone-beam computed tomography was carried out which showed evidence of diffuse osteolysis with intermingled area of sclerosis. Multifocal areas of cortical break in left coronoid, condylar process, and ramus extended up to symphysis menti and involved the right half of the body of mandible.

Erythrocyte sedimentation rate was raised to 94 mm/1st h. Other test results such as complete blood count, hemoglobin, and blood sugar levels (fasting and PP) were within normal limits. The patient was nonreactive to HIV and hepatitis. Aspirated material did not show any evidence of acid-fast bacilli with Gram staining and was negative to fungal growth. Histopathological examination of necrosed hard tissue sample at 40× magnification revealed cancellous bone with empty lacunae. Lacunae indicating acellular marrow space infiltrated with chronic inflammatory cell with superadded secondary infection.

Based on history, clinical findings, and radiological examination, diagnosis of ONJ secondary to dengue fever was made. Osteomyelitis was ruled out as there was neither odontogenic infection nor primary periodontal infection. The only suitable diagnosis that could be made was ONJs.

The patient was on conservative management with oral amoxicillin with combination of potassium clavulanate (625 mg) and analgesic thrice in a day for 15 days. For maintenance of oral hygiene, the patient was advised with 0.2% chlorhexidine oral rinse twice daily for 3 months along with desensitizing toothpaste. The patient had signs of improvement in 3 months and is on regular follow-up.

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