Osteomyelitis of the jaw is a purulent, infectious and inflammatory process that engulfs all structural components of the jaw bone and leads to osteonecrosis. Osteomyelitis of the jaw is accompanied by general symptoms (weakness, fever, chills) and local signs (pain, restriction of mouth opening, tooth mobility, inflammatory infiltration of soft tissues of the face, formation of fistulas, sequestration, abscess, etc.). Osteomyelitis of the jaw is diagnosed on the basis of clinical and radiological signs, hemogram studies. Treatment of osteomyelitis of the jaw includes antimicrobial and detoxification therapy, removal of an infected tooth, drainage of a subcostal abscess, sequestrectomy.
Osteomyelitis of the jaw is a purulent-inflammatory disease of the maxillofacial region, characterized by infection and destructive changes in the bone tissue of the jaws. Osteomyelitis of the jaws occupies one of the leading places in the structure of surgical dentistry among odontogenic inflammatory lesions, along with acute and chronic periodontitis, periostitis of the jaw. Among osteomyelitis of various localization, osteomyelitis of the jaws accounts for about 30% of cases. Odontogenic osteomyelitis of the jaw is more often diagnosed at the age of 20-40 years, mainly in men. Osteomyelitis of the lower jaw develops 2 times more often than the upper one.
Taking into account the source and mechanism of infection, osteomyelitis of the jaws is divided into odontogenic (associated with dental pathology), hematogenic (associated with infection from distant foci with blood flow) and traumatic (associated with direct damage to the jaws).
By the nature of the clinical course, jaw inflammation can be acute, subacute or chronic. In accordance with the predominance of the processes of building or death of bone matter, 3 clinical and radiological forms of chronic odontogenic osteomyelitis of the jaws are distinguished: productive (without sequestration), destructive (with sequestration) and destructive-productive.
Depending on the prevalence of the purulent-necrotic process, osteomyelitis of the jaw can be limited (localized within the alveolar process or the body of the jaw in the area of 2-4 teeth) and diffuse (diffuse lesion of a significant part or the entire jaw).
Odontogenic (stomatogenic) osteomyelitis is the most common type of pathology, occurring in 75-80% of cases. As a rule, the development of odontogenic osteomyelitis of the jaw is etiologically associated with advanced caries, pulpitis, periodontitis, pericoronitis, alveolitis, dental granuloma or tooth cyst. In this case, the penetration of infection into the jaw bone occurs through the infected pulp and the root of the tooth.
The primary source of infection in hematogenous osteomyelitis of the jaw can be boils and carbuncles of the maxillofacial region, purulent otitis, tonsillitis, omphalitis and umbilical sepsis of newborns, infectious foci in diphtheria, scarlet fever, etc. With the hematogenic spread of infection, the jaw bone is first affected, and the tissues of the teeth are involved in the purulent-inflammatory process a second time.
Traumatic osteomyelitis can be a consequence of a jaw fracture, a gunshot wound, damage to the mucous membrane of the nasal cavity. In these cases, the infection enters the bone tissue from the external environment. Traumatic osteomyelitis of the jaw accounts for 11% of cases, hematogenic – 9%.
The pathogenic microflora that causes osteomyelitis of the jaws can be detected in the form of monocultures or microbial associations and is mainly represented by Staphylococcus aureus, group B streptococcus, E. coli, Klebsiella, proteus, Fusobacteria, Pseudomonas aeruginosa and other pathogens.
The state of general and local immunity has a certain significance for the development of osteomyelitis of the jaw. Osteomyelitis of the jaw is often accompanied by blood diseases, diabetes mellitus, polyarthritis, rheumatism, liver and kidney diseases.
Acute osteomyelitis of the jaw bone manifests suddenly, with common symptoms. There is a sharp rise in body temperature to febrile values, chills, general weakness, weakness, lack of appetite, sleep disorder.
With odontogenic osteomyelitis of the jaw, the patient is concerned about pain in the area of the causal tooth, which is the source of infection. The pain from the local soon becomes diffuse, radiating into the ear, eye socket, temple. The infected tooth, as well as the intact teeth adjacent to it, become mobile; the mucous membrane of the gum becomes edematous. Purulent contents are often separated from the gingival pockets; a fetid putrid smell emanates from the patient’s mouth. When infiltration spreads to soft tissues, there is a restriction of mouth opening, pain when swallowing, difficulty breathing. Osteomyelitis of the lower jaw occurs with a violation of the sensitivity of the lower lip (numbness, tingling, crawling goosebumps), the mucous membrane of the vestibule of the mouth and the skin of the chin.
In acute osteomyelitis of the jaw, there is pronounced inflammatory infiltration, swelling and hyperemia of soft tissues, regional lymphadenitis, due to which the contour of the face becomes asymmetric. For acute osteomyelitis of the jaws, the formation of subperiosteal abscesses, parotid phlegmon, adenophlegmon is typical. Diffuse osteomyelitis of the upper jaw can be complicated by odontogenic sinusitis, phlegmon of the eye socket, thrombophlebitis of the branches of the facial vein.
In the subacute course of osteomyelitis of the jaw, the general condition improves, inflammatory infiltration and suppuration decreases, but the pathological mobility of the teeth persists and even increases. Chronic osteomyelitis of the jaw is characterized by a prolonged course and can develop as an outcome of acute osteomyelitis or as a primary chronic process.
The destructive form proceeds with symptoms of intoxication and lymphadenitis, against which fistulas with purulent exudate and bulging granulations form, as well as large sequesters. Chronic destructive osteomyelitis often leads to a pathological fracture of the jaw. In the destructive and productive form of chronic osteomyelitis, multiple small sequesters are formed. In the productive form, due to the predominance of the processes of active construction of bone matter in the periosteum, there are no fistulas and sequesters; there is a deformation of the jaw, ankylosis of the TMJ, trism, infiltrates of soft tissues.
In the acute phase, due to the absence or non-expression of radiological signs of osteomyelitis of the jaws, the disease is diagnosed by a dental surgeon or traumatologist on the basis of clinical and laboratory data. Deviations of the hemogram in osteomyelitis of the jaw are represented by neutrophilic leukocytosis, lympho- and eosinopenia, an increase in ESR. In the biochemical analysis of blood, C-reactive protein is detected in large quantities, hyperglobulinemia and hypoalbuminemia are noted; in the general analysis of urine, erythrocytes, cylinders, traces of protein are detected. To identify the pathogen, bacteriological seeding of the separated from the focus of inflammation is shown.
In the subacute and chronic phases, the dynamics of bone changes increases, revealed during radiography or tomography of the jaws: areas of osteoporosis and osteosclerosis, coarse-fibrous bone pattern, foci of sequestration are detected. When probing fistulas, uneven contours of bone sequesters are detected. Acute osteomyelitis of the jaw requires differential diagnosis with purulent periostitis, acute periodontitis, suppurated jaw cysts, specific lesions of the jaws (tuberculosis, actinomycosis, syphilis), tumors of the jaws.
The approach to the treatment of osteomyelitis consists of a complex of local and general measures. The primary task in osteomyelitis of the jaw is the elimination of the primary purulent focus: in the odontogenic form, tooth extraction, in the hematogenic form, rehabilitation of infection, in the traumatic form, PST of infected and PST of gunshot wounds. Periostotomy, evacuation of pus, washing of the bone cavity with antiseptic solutions, drainage with a rubber graduate is carried out. Movable intact teeth are subject to medical splinting.
General measures include detoxification, symptomatic, immunomodulatory, desensitizing therapy. Massive antibacterial therapy with cephalosporins, semi-synthetic penicillins, macrolides is prescribed. Hyperbaric oxygenation, plasmapheresis, hemosorption, lymphosorption, autohemotherapy, blood UFOs, local physiotherapy procedures (UHF therapy, ultrasound therapy, magnetotherapy) are actively used.
In case of chronic osteomyelitis of the jaw, sequestrectomy can be performed on the basis of an X-ray picture – removal of sequestered bone sections. After removal of sequesters and granulations, the bone cavity is washed and filled with directed osteoplastic materials with antibiotics. At the threat of pathological fractures, splinting of the jaws is carried out.
Prognosis and prevention
Timely diagnosis and proper management of acute osteomyelitis of the jaw in most cases ensures recovery. With an unfavorable course of osteomyelitis of the jaw, the upward spread of the purulent process can lead to the development of meningitis, meningoencephalitis, brain abscess; descending infection leads to lung abscess, mediastinitis and sepsis. Such complications often lead to death.
The outcomes of chronic osteomyelitis are often pathological fractures, ankylosis of the TMJ, false joints, scar contractures of the masticatory muscles. Productive forms of chronic osteomyelitis of the jaws can be complicated by amyloidosis of the kidneys and heart.
Prevention of osteomyelitis of the jaw involves timely therapeutic treatment of caries, pulpitis, periodontitis; sanitation of purulent foci in the body, strengthening immunity, prevention of injuries of the maxillofacial region.