|Year : 2015 | Volume
| Issue : 1 | Page : 143-146
Oral myiasis of maxilla and mandible: A case report
Shruti A Shah1, Sonali G Kadam1, Dimple S Padawe2, Vilas S Takate2
1 Department of Oral Medicine and Radiology, Government Dental College and Hospital, Mumbai, Maharashtra, India
2 Department of Paediatric and Preventive Dentistry, Government Dental College and Hospital, Mumbai, Maharashtra, India
|Date of Submission||26-Nov-2014|
|Date of Acceptance||15-Sep-2015|
|Date of Web Publication||12-Oct-2015|
Shruti A Shah
Room No. 23, Department of Oral Medicine and Radiology, Government Dental College and Hospital, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Oral myiasis is a rare parasitic infestation of the house fly in the oral cavity. It is found in cases of extreme neglect of oral hygiene. Here is a case report of a 24-year-old female patient with history of cerebral palsy since childhood, affected with oral myiasis simultaneously affecting the maxilla as well as mandible. This case reports gives an overview of the clinical features of this distressing disease and also throws light on its treatment with a combination of conventional therapy and new drug Ivermectin.
Keywords: Cerebral palsy, Ivermectin, oral myiasis
|How to cite this article:|
Shah SA, Kadam SG, Padawe DS, Takate VS. Oral myiasis of maxilla and mandible: A case report. J Indian Acad Oral Med Radiol 2015;27:143-6
|How to cite this URL:|
Shah SA, Kadam SG, Padawe DS, Takate VS. Oral myiasis of maxilla and mandible: A case report. J Indian Acad Oral Med Radiol [serial online] 2015 [cited 2020 Nov 26];27:143-6. Available from: https://www.jiaomr.in/text.asp?2015/27/1/143/167139
| Introduction|| |
The word myiasis is derived from the Greek term "Myia," which literally means fly. It is the infestation of the tissues of animals or humans by the larvae of certain Diptherian animals. It is commonly seen in tropical countries. Oral myiasis is a rare disease associated with poor or neglected oral hygienic conditions and in patients having conditions such as cancrum oris,  cerebral palsy, , mouth breathing, neglected mandibular fractures,  patients undergoing mechanical ventilation,  alcoholics, and in those using narcotics. , Oral myiasis is most commonly seen in the anterior maxillary region owing to the easy accessibility of the site to flies. ,, We present a unique case of oral myiasis caused by Chrysomya bezziana involving both maxillary and mandibular arches, in a patient of cerebral palsy. Simultaneous involvement of two anatomic locations is a rare finding and has not been reported yet. The treatment consists of conventional method of manually removing the larvae with a blunt tweezer, followed by a course of Ivermectin.
| Case Report|| |
A 24-year-old female patient was brought to the Department of Oral Medicine and Diagnostic Radiology by her parents with the chief complaint of worms coming out of her mouth since 2 days. According to her previous medical reports, patient had spastic cerebral palsy since childhood. On general examination, patient was unable to walk or communicate on her own and was on wheel chair. On taking further history, parents revealed that they had consulted a private practitioner a day before, who had taken out around 30 worms from the patient's mouth and he referred the case to our institution for better management of the condition.
On extraoral examination, the patient appeared restless, dehydrated, and febrile with continuous drooling of saliva from the mouth. The patient had habit of mouth breathing because of deviated nasal septum and, hence, had incompetent lips [Figure 1]. On intraoral examination, it was seen that the palatal mucosa was separated from underlying bone till the molar region and was hanging in the anterior region. There was a deep invagination with live worms inside [Figure 2]. The worms were also evident in the deep pockets in interdental and lingual regions of the left side of mandibular arch, suggestive of migration of the larvae from primary site to these areas. The intraoral hygiene was poor with marked halitosis and multiple carious teeth were seen.
|Figure 2: Intraoral view showing overhanging palatal tissue with presence of live larvae inside. Poor oral hygiene can also be noted|
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Computed tomography (CT) scan and cone beam computed tomography (CBCT) scan were attempted, but could not be performed as the patient was uncooperative. On the basis of clinical examination, diagnosis of oral myiasis was made. Subsequently, it was decided to remove the worms manually using turpentine oil, which is the conventional treatment for oral myiasis. Mechanical removal of around 55 larvae from both maxillary and mandibular arches was done using turpentine oil over three consecutive days, along with irrigation of the lesion with normal saline. On the second day, all the infected root pieces were also removed from the maxillary and mandibular arches. The worms which were retrieved were collected in a container filled with formalin solution [Figure 3]a and b and were sent for species analysis to a microbiology center, which confirmed it as C. bezziana.
|Figure 3: (a) Larvae removed on the fi rst day. (b) Larvae removed on the second day|
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Patient was then prescribed a single dose of Ivermectin 6 mg. Patient was also prescribed Cap Amoxycillin 500 mg TDS for 5 days, Tab Paracetamol 400 mg TDS for 5 days, and Tab A to Z 1 OD for 15 days as a nutritional supplement. The patient's mother was advised to clean the wound areas twice daily with betadine 2% solution as a home care method. The patient was recalled after 5 days. She was afebrile and healthier than before as she could take proper nutrition after the initial treatment. The extraction socket as well as the palatal tissue showed evidence of healing [Figure 4]. The affected areas were inspected thoroughly for presence of any residual larvae and were irrigated adequately with betadine solution and normal saline to clean the wound. No further medications were prescribed and patient was again recalled after 15 days. On subsequent recall, the palatal defect was almost healed except for the central region where the wound was still in healing phase [Figure 5]a and b. Again the remaining wound was cleaned with betadine and patient was recalled after 15 days. The patient did not come for follow-up thereafter.
|Figure 4: Picture showing healing lesion on fi rst recall after removal of all larvae|
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|Figure 5: (a) Picture showing almost complete healing of maxillary arch on second recall. (b) Picture showing almost complete healing healing of mandibular arch on second recall|
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| Discussion|| |
Oral myiasis was first described in literature in 1909.  It is a disease of tropical countries as the housefly responsible for the disease is a habitant of the tropical region. Body myiasis is well recognized in animals, but is rare in humans and is associated with poor personal hygiene. The body cavities such as ears, nostrils and, occasionally, the oral cavity can be involved.  Infestation in humans may occur in two ways, either accidently with direct inoculation by the fly or by ingestion of infected material.  The location of lesion in the present case suggests direct inoculation by the fly in the maxillary anterior region. Local factors such as halitosis caused by necrotic suppurating tissues must have attracted the flies, as the patient had cerebral palsy and was unable to maintain proper oral hygiene.
Intraorally, myiasis is more commonly reported to occur anteriorly around gingival crevices or extraction sites. , In our case, it was associated with palatal gingiva in the anterior region. This patient had incompetent lips coupled with poor oral hygiene, which would have facilitated the entry of flies to lay eggs behind the maxillary anterior teeth. Oral myiasis affecting mandibular arch is less frequently seen. In 1996, Lata et al. reported a case of oral myiasis in a patient with fractured mandible. Patient was unable to close his mouth due to fracture, which might have been the reason for the flies to infect the lesion.  On the contrary, in our case, maxillary palatal area was the primary site, but the maggots were also found in mandibular gingiva suggesting the possibility of progression of infection to other susceptible areas.
In 2004, Shinohara et al. reported a case of myiasis involving maxillary anterior region in a patient having cerebral palsy. In our case, similar presentation was seen in the maxilla, along with mandibular arch involvement. Simultaneous involvement of both arches is a rare entity and probably the first reported case. CT scan of the patient was performed by Shinohara et al., which showed the extent of tissue destruction and gas bubbles were seen in the soft tissue in the anterior maxilla.  Radiological investigation is very important to define the extent of tissue damage, but could not be done in our case as the patient was uncooperative.
The organism involved in our case as confirmed by the entomologist was C. bezziana which is the larva of housefly. C. bezziana is one of the causative organisms for obligatory myiasis. The species is found to be widely distributed throughout South-East Asia, China, the Indian subcontinent, and tropical Africa.  Diagnosis of myiasis is based on clinical identification of maggots/larvae and treatment consists of removal of maggots. Local application of iodoform, ethyl chloride, mercuric chloride, creosote, and turpentine oil and systemic butazolidin and thiabendazole have been used. ,, In our case, local application of turpentine oil was done, which acts as an asphyxiating agent for the larvae. It helps in removal of deep located maggots, as they come out due to asphyxia.
Ivermectin is a semi-synthetic macrolide antibiotic, isolated from Streptomyces avermitilis, and its use is well documented in large animals for the control of gastrointestinal and pulmonary parasitosis. Ivermectin blocks the nerve impulses on the ending nerve through the release of gamma aminobutyric acid (GABA), linking to the receptors, and causing palsy and death of the parasite.  Ivermectin was used in our case and proved to be useful. Both the treatment modalities, i.e. manual removal of the larvae and Ivermectin therapy, are well documented in the literature. Hence, we decided to combine the treatment modalities with the intention of providing faster relief to the patient, complete removal of the larvae, and increasing the rate of healing of the wound. Broad-spectrum antibiotics were given initially to treat superficial infection due to poor oral hygiene. Nutritional supplements were started to improve the general health of the patient.
| Conclusion|| |
As prevention is better than cure, we conclude that proper oral hygiene maintenance is the prime requisite for the prevention of oral myiasis in susceptible patients such as those with cerebral palsy. So, extra care of these medically complex patients, if taken, can prevent the additional suffering.
Dr. Sarla Menon, Associate Professor of Microbiology, Grant Medical College, Mumbai is acknowledged for species identification of the larvae.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]