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Osteomyelitis
Osteomyelitis

Osteomyelitis is a rare complication of tooth-related infections (incidence of 25 in 100,000).  In
most cases, it is the result of spread of infection from a
dento-alveolar (tooth) or periodontal
(
pyorrhoea / gum disease) abscess or from the para-nasal sinuses, by way of continuity
through
tissue spaces and planes.  It occasionally occurs as a complication of jaw fractures or
as a result of manipulations during surgical procedures.

Most patients are adult males with infection of the mandible (lower jaw).

Osteomyelitis of the maxilla (upper jaw) is a rare disease of neonates (newly born) or infants after either birth
injuries or uncontrolled middle ear infection.

It is classified as
acute or chronic osteomyelitis.


Acute Osteomyelitis

In the acute form (which rarely, may also be of hæmatogenous origin [i.e. seeded from the blood stream]), the
infection begins in the
medullary cavity (bone marrow) of the bone.  The resulting increase of intra-bony pressure
leads to a decreased blood supply (and hence diminution of white blood cells and other immune components) and
spread of the infection, by way of the
Haversian canals of the bone, to the cortical bone (definition) and
periosteum (below the periosteum, a thick fibrous two-layered membrane covering the surface of bones).  This
aggravates the
ischæmia (decreased blood supply), resulting in necrosis (the death of cells or tissues from severe
injury or disease, especially in a localised area of the body.  Causes of
necrosis include inadequate blood supply
[as in
infarcted tissue], bacterial infection, traumatic injury and hyperthermia) of the bone.



Acute Osteomyelitis of the Jaws — Potential Sources of Infection

  • Peri-apical infection
  • A periodontal pocket involved in a fracture
  • Acute gingivitis or pericoronitis (even more rarely)
  • Penetrating, contaminated injuries (open fractures or gunshot wounds)
The mandible (lower jaw), due to decreased vascularity (blood supply & flow), is involved 6 times more often than
the maxilla (upper jaw).

The
mandible has a relatively limited blood supply and dense bone with thick bony (cortical) plates.  Infection
causes acute inflammation in the
medullary (bone marrow) soft tissues and inflammatory exudate (a fluid with a
high content of protein and cellular debris which has escaped from blood vessels and has been deposited in tissues
or on tissue surfaces, usually as a result of inflammation. It may be septic or non-septic) spreads infection through
the marrow spaces.  It also compresses blood vessels confined in the rigid boundaries of the vascular canals.

Thrombosis (the formation or presence of a thrombus [a clot of coagulated blood attached at the site of its
formation] in a blood vessel) and obstruction then lead to further bone
necrosis.

Dead bone is recognisable microscopically by
lacunae (a cavity, space, or depression, especially in a bone,
containing cartilage or bone cells) empty of
osteocytes (a cell characteristic of mature bone tissue.  It is derived
from
osteoblasts and embedded in the calcified matrix of bone. Osteocytes are found in small, round cavities called
lacunae
and have thin, cytoplasmic branches) but filled with neutrophils (white blood cells) and colonies of bacteria
which proliferate in the dead tissue.

Pus, formed by liquefaction of necrotic soft tissue and inflammatory cells, is forced along the medulla and
eventually reaches the
sub-periosteal region by resorption (an organic process in which the substance of some
differentiated structure that has been produced by the body undergoes
lysis and assimilation) of bone.  Distension
of the
periosteum by pus stimulates sub-periosteal bone formation but perforation of the periosteum by pus and
formation of
sinuses on the skin or oral mucosa are rarely seen now.

At the boundaries between infected and healthy tissue,
osteoclasts (a specialised bone cell that absorbs bone)
resorb the periphery of the dead bone, which eventually becomes separated as a sequestrum (a fragment of dead
bone separated from healthy bone as a result of injury or disease).  Once infection starts to localise, new bone
forms around it, particularly
sub-periosteally.

Where bone has died and been removed, healing is by granulation with formation of coarse fibrous bone in the
proliferating connective tissue.  After resolution, fibrous bone is gradually replaced by compact bone and
remodelled to restore normal bone tissue and structure (and function).


Piercing, deep and constant pain predominates in the clinical presentation in adults, while low or moderate fever,
cellulitis, lymphadenitis, or even trismus may also be noted.

In the
mandible, changes in sensation affecting the lower lip (paræsthesia or dysæsthesia of the lower lip) may
accompany the disease.  When the disease spreads to the
peri-osteum (definition) and the surrounding soft
tissues, a firm painful
œdema (definition) of the region is observed, while the tooth becomes loose and there is
discharge of
pus from the periodontium.  Radiographic examination reveals osteolytic (definition) or radiolucent
(definition) regions


Therapy entails combined surgical (incision, drainage, extraction of the tooth and removal of
sequestrum) and
chemo-therapeutic
treatment (with antibiotics).


Summary of Treatment of Osteomyelitis

Essential Measures

  • Bacterial sampling and culture
  • Vigorous (empirical) antibiotic treatment
  • Drainage
  • Give specific antibiotics based on culture and sensitivities
  • Give analgesics
  • Debridement
  • Remove source of infection, if possible

Adjunctive Treatment

  • Sequestrectomy
  • Decortication if necessary
  • Hyperbaric oxygen*
  • Resection and reconstruction for extensive bone destruction

*Mainly of value for
osteo-radionecrosis and possibly, anærobic infections.

Anæsthesia of the lower lip usually recovers with elimination of the infection.  Rare complications include
pathological fracture caused by extensive bone destruction, chronic
osteomyelitis after inadequate treatment,
cellulitis due to spread of exceptionally virulent bacteria or septicæmia in an immuno-deficient patient.


Chronic Osteomyelitis

Chronic osteomyelitis is characterised by a clinical course lasting over a month.  It may occur after the acute phase
or it may be a complication of tooth-related infection without a preceding acute phase.  The clinical presentation is
milder, with painful exacerbations and discharge of pus or sinus tracts.


Websites:

Patient UK

Canadian Dental Association

BMJ Case Reports

Radiopaedia


Useful Articles:

Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology & Endodontology 2005. Diagnosis and Classification
of Mandibular Osteomyelitis

Gülhane Týp Dergisi 2007.  Mandibular osteomyelitis developing due to a failed root canal treatment in a patient
with multiple myeloma

Journal of Dental Research, Dental Clinics, Dental Prospects 2009.  Localized Osteomyelitis of the Mandible
Secondary to Dental Treatment - Report of a Case

Dental Update 2010.  Osteomyelitis of the Mandible Secondary to Pericoronitis of an Impacted Third Molar.

British Dental Journal 2010.  Osteomyelitis presenting in two patients - a challenging disease to manage.

Case Reports Dent 2013.  Rapidly Progressing Osteomyelitis of the Mandible

J Adv Clin Res Insights 2016.  Chronic Suppurative Osteomyelitis - A Case Report

J Dent Oral Disorders 2017.  Diagnosis & Treatment of Osteomyelitis of the Jaw - A Systematic Review (2002 -
2015) of the Literature

Acta Sci Microbiol 2018.  The Contagious Orifice - Maxilla & Mandible

Clin Case Rep 2018.  Treatment of Diffuse Sclerosing Osteomyelitis of the Jaw with Denosumab shows
Remarkable Results—A Report of Two Cases

Ann Maxillofac Surg 2019.  Chronic Diffuse Sclerosing Osteomyelitis of the Mandible

Dental Update 2019.  Diagnosis and Management of Chronic Osteomyelitis and Cemento-Osseous Dysplasia of
the Mandible

Local Damage to / Disease of the Jaws
  • Fractures, including gunshot wounds
  • Radiation damage
  • Paget's disease
  • Osteopetrosis

Impaired Immune Defences

  • Acute leukaemia
  • Poorly-controlled diabetes mellitus
  • Sickle cell anaemia
  • Chronic alcoholism or malnutrition
  • AIDS

  • Infection from micro-organisms with great virulence.  In such cases, even a peri-apical abscess may be
    implicated in osteomyelitis.

Acute Osteomyelitis of the Jaws — Key Features

  • Mandible mainly affected, usually in adult males
  • Infection of dental origin - anærobes are important
  • Pain and swelling of jaw
  • Teeth in the area are tender; gingivæ (gums) are red and swollen
  • Sometimes paræsthesia of the lip
  • Minimal systemic upset
  • After about 10 days, X-rays show 'moth-eaten' pattern of bone destruction
  • Good response to prompt antibiotic treatment and debridement
Last Updated 26th December 2019