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.
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
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
Bacterial sampling and culture
Vigorous (empirical) antibiotic treatment
Give specific antibiotics based on culture and sensitivities
Remove source of infection, if possible
Decortication if necessary
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 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.