Oral Tuberculous Osteomyelitis Mimicking Chronic Jaw Infection: Role of Empirical Treatment in Diagnosis

REPORTthe patient underwent extraction of the right side mandibular primary second molar at some private clinic.Since then, the patient has been experiencing pain in that region.Soft necrotic bone at the site of extraction on the buccal aspect was revealed on intraoral examination (Fig. 1).The area was curetted, and betadine irrigation was done.For symptomatic relief, antibiotics and analgesics were prescribed.On follow-up visit, again a necrotic bone sequestrum was apparently projecting from the buccal surface, which was coming out as small fragments.Cone beam computed tomography (CBCT) was advised, which revealed ill-defined, irregular areas of osteolysis involving the right side of the mandible between the distal surface of the right deciduous primary first molar, extending posteriorly and superiorly up to the mandibular notch.Scattered, diffuse, radio-opaque foci of IntroductIonTuberculous osteomyelitis is a granulomatous infectious disease that is commonly seen in developing countries like India, affecting persons of all ages.Tuberculosis (TB) is more prevalent in India due to poor air quality index, poor nutrition, and low socioeconomic status. 1 According to WHO estimates, around seven million people are affected with TB annually all over the world, and 9% of those cases are seen in children.TB mainly affects the lungs and, less commonly, involves other sites, called extrapulmonary TB (EPTB), which is observed more in children.Mycobacterium tuberculosis is the main causative agent for both pulmonary and EPTB.EPTB accounts for about 2% of cases of skeletal TB, involving the vertebrae and the long bones, commonly and rarely the mandible. 2The clinical presentation of oral tuberculous osteomyelitis varies from pain to swelling at the site of the lesion to pus discharge from the involved site.Diagnosing TB in children is challenging, as less than 10% of sputum tests yield positive results, and only 30% of patients have a positive bacteriological culture.Although a thorax X-ray is the primary diagnostic tool, 15% of all TB patients can have normal radiological results. 3Due to this nonspecific presentation of the symptoms, these cases often mislead the dentist and may delay the timely detection of TB.Since there is no diagnostic test that is 100% accurate, management of suspected cases of TB should not be delayed, and diagnostic tests should be correlated clinically. 3So, our case highlights the difficulties encountered in establishing the diagnosis based on clinical presentation and management of osteomyelitis of the mandible through empirical antituberculosis treatment (ATT) when conventional diagnostic methods yield inconclusive results. case descrIptIonA 5-year-old child reported to our department with the chief complaint of an irregular hard tissue projecting from the buccal mucosa in the lower right back region, which was perceived as a remnant of a tooth by the parents of the child.Two months back,