Osteomyelitis of the Jaws

Young Bui, D.D.S.
Osteomyelitis of the Jaws

Young Bui

34-YEAR-OLD African-American female presented to our office on a Sunday morning with severe tooth pain that had been keeping her up all night. She had no significant illness. However, she was allergic to penicillin, aspirin, and codeine. She had undergone root-canal treatment before with no adverse reaction.

Dental History

She had gone to see a general dentist regarding pain in response to heat and cold on tooth #19, which had an existing composite restoration. The composite was removed and the tooth was temporized to see whether the symptom would subside. She came back with acute pain on #19 and her dentist initiated root-canal treatment. She had one or two days of comfort after the RCT and then pain began again. Her dentist re-instrumented the canals, but the pain began to return a day or so later. She said that her dentist had gone in and instrumented the canals again on four or five other occasions, but the pain had never gone away. The pain was sharp and severe at times with no alleviation from painkillers. Her dentist decided to refer her to me for evaluation and treatment of this tooth.

Oral Examination

The tooth was very tender to percussion and finger pressure. The buccal gingival was very tender from #18 to #21, with most tenderness at the base of #19. It felt as though an abscess was ready to break through the cortical plate.

Radiograph

The X-ray showed no periapical radiolucency (PAR) or thickened PDL. Number 18 had had RCT done with no PAR. The jawbone had normal trabeculation with no significant pathology.

Treatment

I gave two carpules of 2 percent lidocaine with 1:100K epi as an inferior alveolar block. I isolated #19 under a rubber dam and gained access. The canals had already been instrumented to at least a .04 taper. I completed RCT in a single visit using the EZ-Fill® SafeSider® technique. There was no drainage through the tooth. I temporized the access with cotton and zinc phosphate cement and gave the patient Bextra 10 mg as an anti-inflammatory and Clindamycin 150 mg as an antibiotic.
She came back the next day with severe pain and swelling. I made an incision to relieve some pressure and prescribed Demerol 50 mg for pain. She continued to have pain for the next couple of days, with painkillers giving only a couple of hours of relief. She came back four days later, and I made another incision, which drained out at least 20 cc of purulent exudate. I referred her to an oral surgeon for apical surgery. The surgeon didn’t want to perform the surgery until the swelling had subsided. She was in so much pain that she had the tooth extracted against the surgeon’s advice. After the extraction, she felt better for about a week, but then the same severe pain started up again. She was admitted to the hospital by the same oral surgeon for examination. A CAT scan, MRI, and blood work revealed the patient to have osteomyelitis of the jaw. Surgery was done to remove the entire buccal plate of necrotic bone tissue, which had spread from #18 to #22. She was managed post-operatively with IV antibiotic consisting of Clindamycin 600 mg and Levofloxacin 500 mg. The pain has since subsided, and she is feeling a lot better.

Osteomyelitis

The cause of osteomyelitis is associated with Staphylococcus aureus, a skin surface bacterium. The organism is iatrogenically introduced into the deeper tissue planes by surgery or trauma, resulting in an infectious process that is either localized or hematogenously metastatic or both. However, the idea of S aureus as the primary pathogen of tooth-bearing bone does not hold true. Acute osteomyelitis of the jaw is usually a polymicrobial disease, with streptococci, Bacteroides, peptostreptococci, and other organisms involved.
Hudson (1993) wrote that “Acute osteomyelitis of the jaws may manifest itself with fever, malaise, facial cellulitis, trismus, and significant leukocytosis. Osteomyelitis of the jaws of a chronic nature has findings consistent with swelling, pain, purulence, intraoral or extraoral draining fistulae, and nonhealing bony and overlying soft tissue wounds.” Computerized tomography gives a more definitive picture of the calcified tissue involvement, especially with regard to disruption of the cortical plates. Diagnosis is based on the presence of painful sequestra and suppurative areas of tooth-bearing jaw bone unresponsive to debridement and conservative therapy.
The goal of definitive therapy is to attenuate and eradicate the proliferating pathogenic microorganisms and to support healing. Pathogenic supportive debris should be removed and vascular permeability to the infected area must be reestablished. This will aid the host immune response in coming into contact with the offending organisms. A typical treatment regimen for osteomyelitis of the jaws is presented in the table below.

Treatment Guideline for Acute or Chronic Osteomyelitis

Disrupt the infectious foci.
Debride any foreign bodies necrotic tissue, or sequestra.
Culture and identify specific pathogens for eventual definitive antibiotic treatment.
Drain and irrigate the region.
Begin empiric antibiotics based on Gram stain.
Stabilize calcified tissue regionally.
Consider adjunctive treatments to enhance microvascular reperfusion (usually reserved for refractory forms only).

Trephination
Decortication
Vascular flaps
Hyperbaric oxygen therapy

Reconstruction as necessary following resolution of the infection.

Adapted from Osteomyelitis of the Jaws: A 50-year Perspective, J. W. Hudson, D. D. S.

May-June 2003

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