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Oral & Dental Health

Osteomyelitis of the Jaw

Inflammation and infection of the bone marrow of the jaw (mandible or maxilla), extending to involve the cortical bone and periosteum, potentially leading to bone necrosis (sequestrum formation).

Also known as: Jaw Bone Infection

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Referral and warning signs

When to refer

Refer ALL suspected cases of jaw osteomyelitis URGENTLY to Hospital (H/RR) with Oral & Maxillofacial Surgery / Dental Specialist capability for diagnosis, IV antibiotics, and potential surgical debridement.

Red flags

  • Numbness or tingling of lower lip/chin (inferior alveolar nerve involvement).
  • Pathological fracture.
  • Extraoral draining sinus.
  • Signs of sepsis.
  • Failure to respond to standard dental abscess treatment.

Signs and symptoms

  • Acute Stage:
  • - Deep, intense pain in the jaw.
  • - Fever, chills, malaise.
  • - Swelling over the affected jaw area.
  • - Tenderness on palpation.
  • - Loosening of teeth in the affected segment.
  • - Regional lymphadenopathy.
  • - Paraesthesia or anaesthesia of the lower lip/chin (if inferior alveolar nerve involved - mandibular osteomyelitis).
  • - Difficulty opening mouth (trismus).
  • Chronic Stage:
  • - May have less intense pain, or intermittent pain.
  • - Persistent swelling.
  • - Draining sinus tracts (intraoral or extraoral) discharging pus.
  • - Formation of sequestra (fragments of dead bone) which may spontaneously exfoliate or require surgical removal.
  • - Pathological fracture (rare).

Risk factors

  • Odontogenic infection (most common cause) - spread from untreated dental abscess, periodontitis, pericoronitis.
  • Jaw fracture (open fracture, infected fixation).
  • Jaw surgery.
  • Radiation therapy to head/neck (Osteoradionecrosis - ORN).
  • Bisphosphonate use (Medication-Related Osteonecrosis of the Jaw - MRONJ).
  • Systemic illness impairing immunity/vascularity (Diabetes, Immunosuppression, Paget's disease).
  • Hematogenous spread (rare).

Diagnosis

Clinical assessment

Based on clinical features (pain, swelling, loose teeth, paraesthesia, draining sinuses). History of preceding dental infection, trauma, or risk factors.

Differential diagnosis

  • Dental abscess / Cellulitis (usually resolves faster with treatment).
  • Malignant tumour of the jaw (primary or metastatic).
  • Benign jaw tumours or cysts.
  • Fibrous dysplasia.
  • Actinomycosis.
  • Specific infections (TB, Syphilis).

Investigations

  • Dental X-rays (OPG, Periapicals): Early changes may be subtle (widening PDL, altered trabeculation). Later stages show 'moth-eaten' radiolucencies, sequestra formation, involucrum (new bone formation).
  • CT Scan: Better defines bony destruction, sequestra, and extent of involvement.
  • MRI Scan: Good for assessing soft tissue involvement, marrow oedema (early changes).
  • Bone Scan (Radionuclide): Sensitive for early inflammation but non-specific.
  • Culture and Sensitivity: From pus discharge or bone biopsy/debridement.
  • Biopsy: If malignancy suspected or diagnosis uncertain.
  • FBC, ESR/CRP (inflammatory markers).

Diagnostic criteria

Clinical suspicion supported by radiographic evidence of bone destruction/sequestra +/- positive culture/histology.

Management

Non-pharmacological management

  • Hospital Admission often required, especially for acute phase or complications.
  • Surgical Debridement: Removal of necrotic bone (sequestra), drainage of pus collections. Essential for chronic osteomyelitis. (LOC: RR)
  • Removal of Odontogenic Source: Extraction of involved teeth.
  • Stabilization: If pathological fracture occurs.
  • Nutritional support.
  • Hyperbaric Oxygen Therapy (HBO): May be adjunct in refractory cases/ORN (Specialist).

Pharmacological treatment

  • Prolonged Antibiotic Therapy: Essential. Start IV initially, then switch to oral. Duration often 4-8 weeks or longer.
  • - Empirical (before culture results): Broad spectrum covering Staph, Strep, anaerobes. E.g., Cloxacillin 500mg IV Q6H OR Clindamycin IV/PO PLUS Metronidazole 500mg IV/PO Q8H. (LOC: H)
  • - OR Amoxicillin/Clavulanate IV/PO.
  • - Tailor antibiotics based on Culture & Sensitivity results.
  • Pain Relief: Analgesics (NSAIDs, Paracetamol, Opioids).

Monitoring

Monitor clinical response (pain, swelling, drainage, fever). Monitor inflammatory markers (CRP/ESR). Monitor radiographic healing (slow).

Complications

  • Chronic draining sinuses.
  • Pathological fracture.
  • Sequestrum formation.
  • Spread of infection (deep neck spaces, sepsis).
  • Nerve damage (persistent paraesthesia).
  • Jaw deformity / Malocclusion.
  • Trismus.

Prevention

  • Prompt treatment of dental infections (caries, abscesses, periodontitis).
  • Appropriate management of jaw fractures.
  • Good oral hygiene.
  • Pre-radiation dental clearance.
  • Careful consideration before dental extractions in patients on bisphosphonates.

Patient education

  • Explanation of bone infection.
  • Need for prolonged antibiotic therapy.
  • Potential need for surgery (debridement).
  • Importance of addressing the source (dental infection).
  • Oral hygiene instructions.
  • Importance of follow-up.

Uganda-specific notes

Often a consequence of untreated dental abscesses. Diagnosis relies heavily on clinical suspicion and basic X-rays (OPG if available). Management requires referral for potential surgery and prolonged antibiotics. Access to specialists and advanced imaging is limited.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 23, Section 23.2.12

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