CASE REPORTS

Osteomyelitis of the jaw

W. B. Donohue, d.d.s., m.sc, f.r.cd.[c] andL. M. Abelardo, d.m.d., Montreal

There has been a traditional reluc-tance in some circles to remove

teeth when an acute infection ispresent. Indeed, some modern text-books on surgery suggest thatteeth should not be removed in thepresence of an acute apical infec¬tion.1 There is a tendency to relyon antibiotic therapy as a means

of clearing up these foci of infec¬tion. Many authors have pointedout that while the removal of teethin these circumstances does carry a

certain degree of risk, the dangerof the infection spreading into thebone marrow is even greater if theteeth are not removed. One suchauthority categorically states "...we have never had osteomyelitisdevelop after extraction of an ab-scessed tooth . . ".2That the injudicious use of anti¬

biotics and unnecessary delay inremoving or adequately treating in¬fected teeth leads in some in¬stances to grave consequences is il¬lustrated by the following twocases.

Case 1In August 1965 a 45-year-old Ne¬gro woman presented with a swellingover the body of the mandible on

the left side. The diagnosis was celluli-tis and an acute periapical abscess.She was treated with tetracycline or¬

ally, 250 mg. every six hours; afterthree days this was changed to Pros-taphlin 500 mg. every six hours.Warm, moist packs were applied fora period of two weeks. Following thistreatment the swelling subsided. Ra¬diographs taken at this time showeda periapical radiolucency (Fig. 1),but the infected tooth was not re-

FIO. 1.Lateral oblique view of the man¬dible taken when the patient first pre¬sented herself for treatment because ofa cellulitis. The arrow indicates the initialarea of involvement which has been out¬lined for clarity.

moved.Three weeks later the patient re¬

turned to hospital with a recurrence

of the swelling. She was admittedand Prostaphlin therapy was rein-stituted along with hot compresses tothe side of the face. Urinalyses dis-closed no abnormality. Blood glucosewas 101 mg. per 100 ml. a.c. and161 mg. p.c.At the end of one week (six weeks

after the patient first presented withcellulitis) a consultation with an oralsurgeon was requested. The diagnosiswas now cellulitis and a localizedosteomyelitis, complicating an initialacute periapical abscess. The toothconcerned was removed, the swellingsubsided and the patient was dis¬charged. The radiographs taken atthis time showed an enlarged area ofbone destruction (Fig. 2).

Five weeks later, on September 30,when we first had the opportunity totreat the patient, she had recurrence

of the swelling over the left ramus ofthe mandible, trismus and a cuta¬neous fistula opposite the angle of thejaw. The diagnosis was diffuse sup¬purative osteomyelitis of the jaw. Cul-

FIG. 2.Lateral oblique view of the sameside six weeks after the first radiographwas taken. The outlined area shows theextent of radiolucency.

ture of the purulent exudate grewalpha hemolytic streptococci. The pa¬tient was admitted to hospital. Peni¬cillin was administered, the remainingteeth on the lower left side were re¬

moved and an intraoral sequestrec-tomy of the mandible was performed(Figs. 3 and 4).Tomographic roentgenograms of

the ramus of the mandible showedsequestrum formation along the pos¬terior border of the mandibular ramus

(Fig. 5). This was removed in a sec¬

ond procedure by an extraoral ap-

W. K. Donohue, d.d.s., m.sc, f.r.c.d.Tcl. Faculty of Dental Surgery. Divisionof Pathology, University of Montreal,Montreal, Quebec; and the Division ofOral Surgery, St. Mary's Hospital, Lake-shore General Hospital, Queen ElizabethHospital and Hopital Ste-Jeanne d'Arc.L. M. Abelardo, d.m.d., Faculty ofDental Surgery, Department of Preven¬tive Dentistry, University of Montrealand the Department of Dentistry, St.Justine Hospital, Montreal, Quebec.Reprint requests to: Dr. W. B. Donohue,Associate Professor, Division of Pathol¬ogy, Faculty of Dental Surgery, Univer¬sity of Montreal, P.O. Box 6128, Mont¬real 101, Quebec.

748 C.M.A. JOURNAL/OCTOBER 10, 1970/VOL. 103

FIGS. 3 and 4.The mandible after re¬moval of the remaining teeth on the af¬fected side. showing more clearly the ex¬tent of the bone destruction.

proach (Fig. 6). The wounds healedwithout complication. Her diabeteswas controlled with diet and insulin.The point of interest in this case is

that a period of six wreeks elapsedbetween the patient's initial complaintand the removal of the source of in¬fection (i.e. the tooth). During thegreater part of this time the patientwas kept on antibiotic therapy. Onecannot state that the removal of theinvolved tooth at the first visit wouldhave prevented the spread of the in¬fection. It is unlikely, however, thatshe could have had a worse result,and quite possibly the early removalof the tooth would have preventedthe spread of infection that occurred.No doubt the underlying diabeticcondition helped to prolong and in-tensify the course of the disease.

FIG. 5.Tomographic roentgenogram ofthe left mandibular ramus. The outlinedarea opposite the arrow indicates a se-questrum. The larger central area indi¬cates the extent of bone destruction.

FIG. 6.Tomographic roentgenogram ofthe left mandibular ramus following se-questrectomy.

Case 2A 50-year-old woman first com-

plained of a localized swelling of thejaw three years prior to her admis¬sion. She described it as a "gum boil"and stated that since it "burst" andcaused no pain she sought no treat¬ment.

In June 1963 the patient presentedto a hospital outpatient departmentcomplaining of pain in the jaw on theright side. She had an extraoral drain-ing fistula near the lower border ofthe mandible. Roentgenograms takenat this time (Figs. 7 and 8) showedconsiderable bone destruction involv¬ing the body of the mandible and theapices of the teeth. The diagnosis was

a chronic suppurative osteomyelitis ofthe jaw arising from a diffuse perio-dontitis.The patient was admitted to hos¬

pital and treated with crystallinepenicillin, 1,000,000 units every sixhours, for four days. Then a seques-trectomy was done via an extraoralapproach. However, no considerationwas given to removing the teeth caus¬

ing the osteomyelitis. Following se-

questrectomy, tetracycline, 250 mg.four times a day, was administeredfor three weeks. During the secondpostoperative week a purulent exu-

date started to drain from the incisionsites. Culture of the exudate pro¬duced a growth of alpha hemolyticstreptococcus and Aerobacter aero-

genes. The purulent discharge con¬

tinued in varying amount through¬out the month of July (Fig. 9). OnJuly 30 a consultation with the Divi¬sion of Oral Surgery was requestedand the patient was seen by us.

Within a few days the lower teethwere removed and an intraoral se-

questrectomy was done.One week after the removal of the

cause of the osteomyelitis (the teeth),drainage from the extraoral incisionsites ceased and the patient healed

FIG. 7.The extent of bone destructionalong the lower border of the mandibleis indicated by the black arrows. Theclear arrow indicates one of the infectedteeth with signs of an obvious periodon-titis at the apex and along the mesialsurface of the root.

FIG. 8.The areas of bone destructionarising from an extensive periodonititisare indicated by arrows. (Although theteeth were the obvious cause of the osteo¬myelitis, they were not removed prior toan extraoral sequestrectomy.)

without further complications.This case illustrates that seques¬

trectomy in osteomyelitis of the jaw isnot adequate treatment even whencombined with antibiotic therapy. Itis essential to remove the infectedteeth as a first step in treatment.

DiscussionWhile some authors advocate theremoval of teeth in the presence ofacute infection,2,8 several havecautioned against the removal ofa tooth with an acute alveolar ab¬scess.47 This difference of opinionin all probability stems from a lackof appreciation of the difference inpathogenesis of osteomyelitis whenseen in the long bones and in thejaw.

FIG. 9.Fistulas arising along the inci¬sion lines of extraoral sequestrectomy.(These fistulas occurred because the in¬fected teeth causing the disease werenot removed prior to sequestrectomy.)

C.M.A. JOURNAL/OCTOBER 10, 1970/VOL. 103 749

In the long bones, the most fre-quent causes of infection are septi-cemias in the younger age groups.8The next most common cause oc-curs as a complication of fracturesand is more common in adults. Incontrast, osteomyelitis of the jawsis rarely due to hematogenousspread.6 The great majority ofcases involving the jaws are due tocomplications of a primary dentalinfection; a lesser number arise asa complication of a fracture of thebone. In both cases the source ofthe infection is external.The causative organism in osteo-

myelitis of the limb bones is usuallya hemolytic staphylococcus, thestreptococci being somewhat lessfrequently responsible. In the jaws,however, because the infectionarises as a complication of dentalcaries, we are dealing with a mixedinfection where the hemolyticstreptococcus is frequently the pre-dominant organism.The evolution of the disease in

the two regions varies. In the longbones the infection arrives at themetaphysis via the blood streamif it is due to a hematogenous in-fection, and involves the diaphysislater; on occasion the infection isintroduced from the exterior as acomplication of trauma. In eithercircumstance the resultant osteo-myelitis develops in a bone with arelatively thick cortex.

In the jaws the conditions aredifferent. As already mentioned,the infection is most often intro-duced from the exterior, usuallyowing to dental caries but occa-sionally through a fracture site.The maxilla is composed almostentirely of spongy bone with a verythin cortex. Any infectious processof this bone can either remain loca-lized or spread into the soft tissuesand result in a cellulitis, fistula orsinusitis. Because of its structureosteomyelitis of the maxilla is rare.

In the mandible, the commonersite of osteomyelitis of the jaws,any area of infection is surroundedby a plate of compact bone whichvaries considerably in thicknessfrom region to region. In most in-stances the alveolar process whichcontains the teeth is covered bya rather thin external layer of com-pact bone (Fig. 10).Whether the disease involves the

upper or lower jaw, the bone isseparated from the mouth by the

relatively thin oral mucosa. It isunderstandable why an infectiveprocess arising from a tooth mayeasily erode the thin alveolar corti-cal bone and secondarily involvethe soft tissues.

If, however, as occasionallyhappens in the mandible, the rootsof the tooth are midway betweenthe lateral and medial corticalplates and if the roots are suffi-ciently long, or if the verticalheight of the body or alveolar pro-cess of the mandible is short, thenthe apex of the tooth will be in thecentral region of the mandibularbone marrow, surrounded by a rel-atively thick layer of cortical bone(Fig. 11). Infections arising fromsuch teeth might develop as osteo-myelitis.

That this is fairly infrequent isevidenced by the few cases of os-teomyelitis of the jaws seen inclinical practice, even in the pre-antibiotic era. The incidence ofosteomyelitis arising from dentalalveolar abscesses has been quotedasDepending on the clinical course

of the disease, the surgical treat-ment of osteomyelitis of the longbones consists of antibiotic therapy,early drainage and later sequestrec-tomy and saucerization. Thesetechniques alone, however, are notadequate in treating this disease in

FIG. 10-cuts made through the mandi-ble. Notice the thinness of the corticalbone opposite the roots of the teeth.

Q

I

FIG. 11-cross-sections of the humanmandible. In these specimens the apicesof the teeth are more centrally placedin the marrow of the mandible.

the jaws, as illustrated by the twocases presented here. In the man-dible and maxilla there is the add-ed factor of the presence of teeth.It is essential that the teeth in-volved in the infection be treatedat the outset of the disease so asnot to prolong the condition unnec-essarily and mutilate the patient.

Other points in treatment de-serve emphasis. Firstly, the reasonfor removing infected teeth in thecase of an acute dental alveolarabscess is to eliminate the cause ofthe disease and establish drainage.Frequently these objectives can beattained by antibiotic therapy, en-dodontia and apical curettage,without removing the tooth.

Secondly, some authors have ad-vocated the use of hot, moist com-presses in the treatment of osteo-myelitis of the jaw.3' . Both of thecases reported above were so treat-ed at one time or another. Wecontend, however, that the use ofheat in bone infections serves tospread rather than contain the in-fection. Thoma and Goldman2mention that in their opinion theuse of heat is a common cause ofosteomyelitis of the jaws, and thisview is endorsed by others.4

Thirdly, in cases of osteomyelitisof the jaws, decortication, seques-trectomy and saucerization canfrequently be carried out by anintraoral approach, thus avoidingdisfiguring scars. When indicated,immediate reconstruction, using afree bone graft to the mandible,can also he carried out by the oralroute.'0

References1. WATTMAN, W. AND ELLIS, F. H.,

editors: Lewis' practice of sur-gery, Harper & Row, Publishers. NewYork, 1969, V. 4, chap. 4. p. 20.

2. THOMA, K. H. and GOLDMAN, H. M.:Oral pathology, 5th ed., The C. V.Mosby Company, St. Louis, 1960, p.704.

3. KRUGER, G. 0., editor: Textbook oforal surgery, 2nd ed., The C. V. Mos-by Company. St. Louis, 1964, p. 237.

4. D.&vis, L.: Christopher's textbook ofsurgery, 7th ed., XV. B. SaundersCompany, Philadelphia, 1960, p. 281.

5. COLE, XV. H. et al.: Textbook of sur-gery, 7th ed., Appleton-Century-CrOftsInc.. New York, 1959, p. 721.

6. WARREN, R. et al.: Surgery, W. B.Saunders Company, Philadelphia,1963, p. 552.

7. BAILEY, H. and LOVE, R. J.: A shortpractice of surgery, 10th ed.. H. K.Lewis Co. Ltd.. London, 1956. p. 107.

8. TUREK. S. L.: Orthopaedics: princi-ples and their application, 2nd ed.,J. B. Lippincott Co., Philadelphia,1959, p. 90.

9. MOWLEM, R.: Proc. Roy. Soc. Med.,38: 452. 1945.

10. OBWEGE5ER, H. L.: Oral ,3urg., 21:693. 1966.

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