review article

Treatment Modalities In Management Of Osteomyelitis

Of The Jaws – A Review
Vijay Ebenezer*, Balakrishnan&, Swarnapriya$

Abstract
Osteomyelitis of the jaws is still a fairly common disease in maxillofacial clinics and hospitals, despite the introduc-
tion of antibiotics and the improvement of dental and medical care. Mainly three different types of osteomyelitis are
distinguished: acute and secondary chronic osteomyelitis and primary chronic osteomyelitis. They usually represent a
true bacterial infection of the jawbone. Suppuration, fistula formation, and sequestration are characteristic features of
this disease entity. Various treatment modalities are available for the different types of osteomyelitis of the jaw. Surgi-
cal and nonsurgical approaches were used to treat the patients. Surgical treatments included superficial debridement,
curettage, and extensive surgery. Nonsurgical treatments used were antibiotics, topical agents (chlorhexidine, saline),
palliative treatments (local anesthetics, analgesics, and narcotics), and hyperbaric oxygen (HBO). This article gives you
an overview of various treatment modalities for osteomyelitis of the jaw described by various authors.

Key words: Osteomyelitis, bone, maxillofacial, bacteria, surgical, antibiotics

Introduction inflammatory condition of the bone, beginning

T
in the medullar cavity and havarsian systems
he word “osteomyelitis” originates from
and extending to involve the periosteum of the
the ancient Greek words osteon (bone)
affected area. The infection becomes established
and muelinos (marrow) and means
in calcified portion of the bone when pus and
infection of medullary portion of the bone. The
edema in the medullary cavity and beneath the
term ‘osteomyelitis’, which was introduced by
periosteum compromises or obstructs the local
Nelaton1 in 1844 implies, ‘an infection of the
blood supply. Following ischemia, the infected
bone and marrow’.
bone becomes necrotic and leads to sequestrum
Common medical literature extends the definition formation, which is considered a classical sign of
to an inflammation process of the entire bone osteomyelitis (Topazian 1994, 2002).2
including the cortex and the periosteum,
recognizing that the pathological process is Etiology
rarely confined to the endosteum. It usually Osteomyelitis has been known to appear
encompasses the cortical bone and periosteum secondary to a dental infection or secondary to
as well. It can therefore be considered as an a surgical procedure in a young healthy patient.
Other causes demonstrated are dento-alveolar
*
Professor and Head, infection, trauma, operative procedures, radiation,
&
Professor, neoplasia, systemic bisphosphonate use, genetic
$
Senior lecturer, conditions, tobacco, uncontrolled diabetes and
Department of Oral and Maxillofacial Surgery, chronic alcohol consumption. 3,4
Sree Balaji Dental College and Hospital.
Bharath University, Pallikaranai, Chennai.
Although other etiological factors, such as
Corresponding author:
Dr. Vijay Ebenezer
traumatic injuries, radiation, and certain chemical
E mail id : drvijayomfs@yahoo.com substances, among others, may also produce

622 Indian Journal of Multidisciplinary Dentistry, Vol. 3, Issue 1, November 2012-January 2013
 review article

inflammation of the medullar space, the term r Hematogenous osteomyelitis

“osteomyelitis” is mostly used in the medical r Osteomyelitis in a united fracture (fracture
literature to describe a true infection of the bone with union)
induced by pyogenic microorganisms (Marx
r Osteomyelitis in a non-union (fracture with
1994).5
non-union)
Acute and secondary chronic osteomyelitis of r Postoperative osteomyelitis without fracture
the jaws is caused mostly by a bacterial focus
Classification systems described in the literature
(odontogenic disease, pulpal and periodontal
for osteomyelitis of the jaws:
infection, extraction wounds, foreign bodies, and
infected fractures). Primary chronic osteomyelitis Discussion
of the jaw is a rare, non-suppurative, chronic
inflammation of an unknown cause. Based on
differencesin ageatpresentation, clinical appearance
and course, as well as radiology and histology, the
disease may be sub classified into early and adult-
onset primary chronic osteomyelitis.
The prevalence, clinical course, and management
of osteomyelitis of the jawbones have changed
profoundly over the past 50 years. This is due to
mainly one factor: the introduction of antibiotic
therapy, specifically penicillin. The integration of
antibiotics into the therapeutic armamentarium has
led to a complete renaissance in the treatment of
most infectious diseases, including osteomyelitis
(Hudson 1993).6 Further factors such as
sophistication in medical and dental science as
well as the widespread availability for adequate
treatment, have additionally led to improvement
in the management of this disease. Modern
diagnostic imaging allows much earlier treatment
of bone infections at a more localized stage.

Classification of osteomyelitis
According to Shafer(1957),7 osteomyelitis of
thejaws can manifest itself as acute suppurative
osteomyelitis, chronic suppurative osteomyelitis,
chronic focal sclerosing osteomyelitis, chronic
diffuse sclerosing osteomyelitis and chronic
osteomyelitis with proliferative periostitis.
Kelly classification:
This classification system emphasizes the etiology
of the infection and its relationship to fracture
healing.
Surgical treatment as an adjunct to medical management
is usually necessary. Treatment of systemic conditions
and supportive therapy consisting of high protein,
high vitamin diet with adequate hydration should be
instituted simultaneously. Heidsieck et al. Utz et al,
Luhr & Ehmann et al, and Bell et al (1964) 9 suggested
a conservative management consisting of treatment
with antibiotics, corticosteroids in combination or

Indian Journal of Multidisciplinary Dentistry, Vol. 3, Issue 1, November 2012-January 2013 623
 review article
alone. Heidsiecket al 9 in addition recommends sub-
periosteal resection of the mandible if pain persists
even after conservative management.
Resistance to therapy as an infrequent but
important problem in osteomyelitis has been
reported by several authors. Management
strategies of chronic suppurative osteomyelitis
are centralized on timely and thorough surgical
debridement and culture-directed antibiotics
(Coviello and Stevens, 2007; Kim and Jang,
2001; van Merkesteynet al., 1997).10 A variety
of antibiotic regimens are recommended for
chronic jaw osteomyelitis, including amoxicillin,
co-amoxiclav, cephalexin, and metronidazole
(Mandracchiaet al., 2004; Gutierrez, 2005).11
Other options include Clindamycin due to its
excellent absorption and bioavailability in bone
infections (Scolozziet al., 2005).12
Hyperbaric oxygen therapy is generally
considered a useful adjunct in treatment of chronic
osteomyelitis, but so far its value has not been
conclusively demonstrated.13 Depenbusch et al.11
reported that all patients treated with hyperbaric
oxygen had failed to respond to what was
considered adequate surgical and pharmacological
treatment. However, no specifications were
given.14 Although hyperbaric oxygen treatment
is generally considered an adjunct to antibiotic
and surgical therapy, a simultaneous combination
of these three modalities is not often used in
treatment of chronic osteomyelitis of the jaws.
SIPPEL et al.15 reported that hyperbaric oxygen
was used after antibiotic therapy, while EVANS
et al.16 used simultaneous administration of
antibiotics and hyperbaric oxygen.
The optimal treatment for osteomyelitis is
unknown. In the comparative study done by few
authors17, surgical treatment failed more often than
nonsurgical treatment. Although this difference
was not statistically significant, this trend can be
seen in previous descriptive studies (Lugassyet
al., 200418; Marx et al., 200519; Miglioratiet al.,
2005)20. According to Marx et al. (2005)19, surgery
often resulted in further deterioration. Therefore,
624 Indian Journal of Multidisciplinary Dentistry, Vol. 3, Issue 1, November 2012-January 2013
systemic culture-based antibiotic treatment, and
basic oral care should serve as the first line of
treatment. Surgery may be indicated for more
extensive lesions. Although the literature on
treatment of chronic osteomyelitis of the jaws is
scarce, the results of HJ0RTING HANSENet al 21
and TILLMAN et al 22 indicate that a combined
antibiotic and surgical approach is effective in
chronic suppurative osteomyelitis, and therefore
this combination of treatments is recommended
in this type of osteomyelitis. Hyperbaric oxygen
treatment seems to be indicated only when this
regimen has failed.
Van Merkesteyn et al 23 (1997) has reported
treatment of chronic suppurative osteomyelitis
of the mandible that is often considered difficult
to treat and may lead to refractory osteomyelitis.
Sixteen patients with chronic suppurative
osteomyelitis of the mandible were treated
with a relatively simple protocol, consisting
of sequestrectomy or decortications and i.v.
antimicrobial therapy for one week, followed by
oral penicillin for three weeks. Only one case has
showed recurrence of symptoms which was treated
successfully in the second session. It is concluded
that combined surgical and antimicrobial therapy
should be sufficient to cure most cases of chronic
suppurative osteomyelitis of the mandible.
In the case of super imposed osteomyelitis HBO
therapy has been proved to be beneficial which is
administered as 100% oxygen at 2.5 atmospheric
pressure, for 120 min, 5 days a week.24 HBO
enhances oxygen-dependent leukocyte killing
through the production of hydrogen peroxide
and super-oxide by providing increased oxygen
tension in the hypoxic tissue. Secondly, optimal
tissue oxygen tension enhances osteogenesis
and neovascularisation to fill the dead space
with new bone and soft tissues.25 HBO has also
been shown to enhance osteoaclastic activity to
remove bony debris.25 Synergistic effects of HBO
on bone healing with bone morphogenic protein
were also demonstrated. Finally, HBO has also
been shown to potentiate the antimicrobial effects

of aminoglycosides, and possibly sulpha drugs
and vancomycin, in the killing of susceptible
bacteria.25
Osteomyelitis is a surgical disease, complete
surgical debridement and not a particular antibiotic
regimen is the most important factor for a successful
outcome. In these cases, data about previous use
of antimicrobial agents is very relevant, since
these drugs may affect the susceptibility of the
microorganisms associated to head and neck
infections, especially osteomyelitis, where the
treatment lasts for weeks ( Brook., 2008b26).
In the case presented by SC Yeoh et al, S
MacMahon et al, M Schifter et al(2005)27, the
patient was prescribed a four week course of oral
clindamycin, which, in combination with surgical
débridement was successful. Management of
symptomatic cases with drugs like clindamycin
have been effective for anaerobic infections
in bone, prior to which culture and antibiotic
sensitivity tests (both aerobic and anaerobic)
have to be done. Saucerization or partial surgical
removal of large masses has not been beneficial,
and reasonable efforts should be made to preserve
teeth because a protracted clinical course of
osteomyelitis and pain have followed elective
extractions.28 Reconstruction of the surgical
defect (vascularised grafts) has been reported to
have 95% success. Implant supported prosthesis
would improve the functional efficiency.29
Chronic osteomyelitis of maxilla and mandible
are associated to previous oral infections and
their microbiota consists primarily of oral
microorganisms, especially anaerobes, most of
them susceptible to blactams and clindamycin.
In addition, the surgical procedures also acquire
relevance in the treatment and failure to accomplish
them is a major cause of treatment failure.30 Several
studies reported that there was no association
between dose of oral BP or other risk factors
and inflammation of the jaw31 and risk factors
of oral bisphosphonate-induced osteomyelitis are
controversial. Further investigation is required to
Indian Journal of Multidisciplinary Dentistry, Vol. 3, Issue 1, November 2012-January 2013
review article
clarify other risk factors for oral bisphosphonate-
induced osteomyelitis.32
Conclusion
Osteomyelitis of the jaws is a serious complication
of untreated odontogenic infection. It is a
difficult disease to treat. Long term antimicrobial
therapy is usually sufficient for acute cases.
Proper surgical intervention combined with
long term antimicrobial therapy gives good
results in chronic osteomyelitis. Hyperbaric
oxygen therapy combined with antimicrobial
therapy and surgical intervention if required
provided complete cure in chronic and recurrent
osteomyelitis. However, regular clinical follow-
up and radiographic examinations in the affected
site is the most important part for the success of
the standard therapy.
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