|Young Bui, D.D.S.
Osteomyelitis of the Jaws
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.
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
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.
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.
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 didnít want to perform the
surgery until the swelling had subsided. She was in so much pain
that she had the tooth extracted against the surgeonís 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.
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 ďAcute 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.Ē 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
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).
Reconstruction as necessary following resolution of the infection.
Hyperbaric oxygen therapy
Adapted from Osteomyelitis of the Jaws: A 50-year
Perspective, J. W. Hudson, D. D. S.
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