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Osteitis of Mandible and Maxilla*
M in er— Osteitis o f M andible and M axilla
1703
OSTEITIS OF MANDIBLE AND MAXILLA* By LEROY M. S. MINER, M .D., D .M .D ., F.A.C.S., Boston, Massachusetts
N the ten-year period 1916-1925 inclusive, 176 cases o f osteitis o f mandible or m axilla were treated in the w ards o f the Massachusetts G eneral Hospital. T h e num ber treated in the outpatient departm ents was 101. Some o f the la tte r cases w ere received from the wards, being discharged to the out patient departm ent. O f the 176 cases, 100 were selected at random fo r study. Sixty o f these were in males and forty in females. T h e youngest patient was 16 months old, the oldest, 78 years. Eighteen pa tients were under 10 years; eleven from 10 to 2 0 ; nineteen from 20 to 30, and seventeen from 30 to 40. Sixtyfive per cent, therefore, occurred in patients under 40 years o f age, and 18 per cent were under 10. O f the re m aining patients, eleven were over 60 years. T h e parts affected w ere: entire m andible, 3 cases; right m andible, 4 5 ; le ft m andible, 3 1 ; entire m axilla, 2 ; right m axilla, 13; le f t m axilla, 5; both mandible and m axilla, 1 case; total, 100 cases. I t is interesting to note that 79 per cent o f the cases occurred in the mandible and 57 per cent were on the right side. O n ly one case involved both m andible and maxilla.
I
E T IO L O G Y
In a study o f the etiology o f these cases, seventy-three gave a positive *Read before the Section on M axillofacial Surgery and Surgical Prosthesis at the Seventh International Dental Congress, Philadelphia, Pa., Aug. 25, 1926.
history o f tooth disturbance as the start ing point o f trouble w ith the jaw . T oothache, follow ed by filling or ex traction, was the common history. In tw enty-one cases, a tooth previously broken off in extraction was thought by the patient to be the cause o f the trouble. Five cases gave a history o f a blow, o f w hich fo u r were from a fist, one from a kick from a horse. O ne case follow ed a fa ll fro m a horse, and one case fo l lowed a bullet wound. Seven cases, therefore, had traum a as an etiologic background. O f the rem aining tw enty cases, the history was either vague or uncertain, and therefore could be only recorded as undeterm ined. Follow ing is a resume o f etiologic factors: teeth, 73 cases; blows, 5 cases; fa ll, 1 case; bullet, 1 case; undeter m ined, 20 cases; total, 100 cases. These figures rather substantiate B lair and B row n’s statem ent that “ it is, a ll things considered, a safe clinical bet that pre vention o f decay and injury o f the teeth w ill prevent possibly quite a large per centage o f these bone infections.” Syphilis has often been regarded as as etiologic factor o f more or less im portance. F our cases in this group gave a positive W asserm ann reaction, two, a 4 + . T h irty cases were nega tive. In one o f these cases, in a 16 m onths old boy, in which syphilis was suspected, the reactions o f the father and the m other were also negative. In sixty-six cases, no W asserm ann test was made. A resume o f cases shows: posi
1704
T h e Journal o f the A m erican D ental Association
tive, fo u r; negative, th irty ; no test, sixty-six; total, 100. I n tw o o f the fo u r positive cases that came under my care, the tooth symptoms w ere first to develop and were prom i n e n t in the m ind o f the patient, but probably these were secondary to the syphilitic infection. H ow m any posi tive reactions m ight have been found in the group o f sixty-six in which no tests w ere made is, o f course, problematic. W h e n routine W asserm ann tests are made in unsuspected cases, less than three out o f 100 are found by a Boston clinician to be positive. D IA G N O S IS
I n my experience, osteitis o f the jaws has tw o distinct stages in a large per centage o f cases. T h e re is first the acute stage, the symptoms being char acteristic o f an acute inflam mation as sociated w ith an active infection. In this stage, an accurate diagnosis is fre quently impossible, fo r the symptoms are practically the same as in acute dentoalveolar abscess. Second, there is the chronic stage, which appears a fte r the acute symptoms have somewhat abated. T h e continuation o f all symptoms in a m ild form , including discharge o f pus, usually indicates the presence o f a true osteitis. I n the group o f cases studied, fortyone patients were adm itted to the hos pital in the acute stage; 59, in the chronic stage. In the forty-one acute cases, fourteen patients were later re adm itted fo r treatm ent o f the chronic condition. I t is entirely possible that a percentage o f these forty-one cases were not true osteitis, particularly seven cases in which local applications were sufficient fo r relief. T h e tem perature records show an average high recording in the acute
cases o f 101.5 degrees; w hile, in the chronic cases, the average is a fraction under 100 F. R O E N T G E N - R A Y D IA G N O S IS
In the acute stage, the roentgen ray is o f indifferent value except to indicate possible etiologic factors o f a dental or traum atic character. Changes in the cellular structure are not sufficiently m arked to show in roentgen-ray projec tion except in the very virulent cases. In the chronic Stage, the roentgen ray is, o f course, o f great service. In all but two o f the cases studied, the roentgen-ray diagnosis, w hen one was made, was confirmed later by the postoperative diagnosis. O ne case was diagnosed as probably m alignant, and in the second, a tentative diagnosis of Paget’s disease or o f actinomycoses was m ade. Both cases, microscopically, were chronic inflammation. TREATM ENT
T hom as Fillebrow n, professor o f oral surgery fo r m any years at H arvard, used to say th at the best treatm ent for osteitis was patience. T h is observation applies, o f course, to the chronic phase during sequestration. D u rin g the early part o f the acute state, cold or hot packs may be o f service to prevent tissue de struction and extension o f the disease. In seven cases already referred to, only local applications were used. These cases were discharged as relieved. I n cision and drainage was the procedure in the rem aining cases. Prom pt relief o f the acute symptoms follow s this treatm ent as a rule. T h e use o f a curet here usually indicates poor judgm ent. T h e im portant consideration in the treatm ent o f the chronic phase is the time to do sequestrectomy. Blair and Brown say “ it is difficult to set an exact
M in er— Osteitis o f M andible and M axilla time but in the ordinary straight fo r w ard acute osteomyelitis o f the jaw dead bone w ill have separated itself in ninety days.” In attem pting to get statistics regard ing sequestration, the unreliability o f the patients’ memory and the inaccuracy o f their statements make the figures o f doubtful value. In fifty-eight cases o f the series, sequestrectomy was per form ed. T h e longest duration o f the disease, as given by the patient, was forty years (a sequestrectomy was perform ed in this case), and the shortest time was three weeks. I have seen sequestration take place in seven days in the violent type. F rom six to twelve weeks was the aver age duration o f the series, w ith the peak tow ard the low rather than tow ard the high extreme. H O S P IT A L IZ A T IO N
In the acute phase, the average hos pital stay was nine and one h a lf days; in the chronic stage, fifteen days. C O M P L IC A T IO N S O F T R E A T M E N T
T h e physical condition o f the patient is sometimes an im portant consideration in the m atter o f treatm ent. In a recent case, the patient had a cardio-renal syn drome, and, w hile w aiting fo r opera tion, had a pulm onary throm bus, which nearly caused death. A t no time since has the .condition made it possible to care adequately fo r the jaw condition. Fractures, extension o f infection to m axillary and fro n tal sinuses and to tem poral bone, septicemia, cellulitis, acute cervical adenitis, tetany, tuber culosis and endocarditis were all seen in this series. T h ere .were three cases in which the temporal bone was invaded.
1705
R ESU LTS O F T R E A T M E N T
T h ere were three deaths in this series o f 100 cases. Osteomyelitis o f the jaw is not regarded as particularly serious, and yet the m ortality happened to be as high as it is in other conditions re garded as more im portant. I f treatm ent has been fundam entally sound there should be no deform tiy nor lim itation o f motion. Both o f these unfo rtu n ate sequelae are seen occasion ally, and serve to emphasize the need o f correct treatm ent. T h e onset, progress, course and treat m ent o f osteomyelitis o f the mandible is fairly w ell illustrated by the follow ing case. REPO R T O F CASE
A physician, aged 53, suffered fro m tooth ache in the lotver right jaw . Extraction was performed, with nerve block anesthesia. The jaw was stiff the follow ing day, w ith severe pain. Swelling was pronounced in thirty-six hours, with increasing pain and progressive trismus. In four days, there was marked swelling and the pain was unbearable. Ice packs gave no relief. H ot poultices were used on the sixth day. Incision and drainage was carried out at the hospital on the seventh day, and a large amount o f pus was evacu ated. A drop in temperature and recession of other symptoms followed. Some swelling and discharge of pus continued. A fter two weeks the swelling increased again. D rain age was insufficient. A t the fo u rth week, in consultation, I found extensive destruction of bone of both the horizontal and ascending ramus. Sequestrectomy was perform ed on the forty-second day. T hree large sequestra were easily removed. The involucrum was well organized. T he patient was in hospital fo r this operation eleven days, and was dis charged to a local hospital. F our weeks later (ten weeks from onset), another sequestrum exfoliated. At twelve weeks, the swelling was practically gone. M otion is still some what limited, but is im proving daily. There is no deformity. 363 M arlboro Street.
1703
OSTEITIS OF MANDIBLE AND MAXILLA* By LEROY M. S. MINER, M .D., D .M .D ., F.A.C.S., Boston, Massachusetts
N the ten-year period 1916-1925 inclusive, 176 cases o f osteitis o f mandible or m axilla were treated in the w ards o f the Massachusetts G eneral Hospital. T h e num ber treated in the outpatient departm ents was 101. Some o f the la tte r cases w ere received from the wards, being discharged to the out patient departm ent. O f the 176 cases, 100 were selected at random fo r study. Sixty o f these were in males and forty in females. T h e youngest patient was 16 months old, the oldest, 78 years. Eighteen pa tients were under 10 years; eleven from 10 to 2 0 ; nineteen from 20 to 30, and seventeen from 30 to 40. Sixtyfive per cent, therefore, occurred in patients under 40 years o f age, and 18 per cent were under 10. O f the re m aining patients, eleven were over 60 years. T h e parts affected w ere: entire m andible, 3 cases; right m andible, 4 5 ; le ft m andible, 3 1 ; entire m axilla, 2 ; right m axilla, 13; le f t m axilla, 5; both mandible and m axilla, 1 case; total, 100 cases. I t is interesting to note that 79 per cent o f the cases occurred in the mandible and 57 per cent were on the right side. O n ly one case involved both m andible and maxilla.
I
E T IO L O G Y
In a study o f the etiology o f these cases, seventy-three gave a positive *Read before the Section on M axillofacial Surgery and Surgical Prosthesis at the Seventh International Dental Congress, Philadelphia, Pa., Aug. 25, 1926.
history o f tooth disturbance as the start ing point o f trouble w ith the jaw . T oothache, follow ed by filling or ex traction, was the common history. In tw enty-one cases, a tooth previously broken off in extraction was thought by the patient to be the cause o f the trouble. Five cases gave a history o f a blow, o f w hich fo u r were from a fist, one from a kick from a horse. O ne case follow ed a fa ll fro m a horse, and one case fo l lowed a bullet wound. Seven cases, therefore, had traum a as an etiologic background. O f the rem aining tw enty cases, the history was either vague or uncertain, and therefore could be only recorded as undeterm ined. Follow ing is a resume o f etiologic factors: teeth, 73 cases; blows, 5 cases; fa ll, 1 case; bullet, 1 case; undeter m ined, 20 cases; total, 100 cases. These figures rather substantiate B lair and B row n’s statem ent that “ it is, a ll things considered, a safe clinical bet that pre vention o f decay and injury o f the teeth w ill prevent possibly quite a large per centage o f these bone infections.” Syphilis has often been regarded as as etiologic factor o f more or less im portance. F our cases in this group gave a positive W asserm ann reaction, two, a 4 + . T h irty cases were nega tive. In one o f these cases, in a 16 m onths old boy, in which syphilis was suspected, the reactions o f the father and the m other were also negative. In sixty-six cases, no W asserm ann test was made. A resume o f cases shows: posi
1704
T h e Journal o f the A m erican D ental Association
tive, fo u r; negative, th irty ; no test, sixty-six; total, 100. I n tw o o f the fo u r positive cases that came under my care, the tooth symptoms w ere first to develop and were prom i n e n t in the m ind o f the patient, but probably these were secondary to the syphilitic infection. H ow m any posi tive reactions m ight have been found in the group o f sixty-six in which no tests w ere made is, o f course, problematic. W h e n routine W asserm ann tests are made in unsuspected cases, less than three out o f 100 are found by a Boston clinician to be positive. D IA G N O S IS
I n my experience, osteitis o f the jaws has tw o distinct stages in a large per centage o f cases. T h e re is first the acute stage, the symptoms being char acteristic o f an acute inflam mation as sociated w ith an active infection. In this stage, an accurate diagnosis is fre quently impossible, fo r the symptoms are practically the same as in acute dentoalveolar abscess. Second, there is the chronic stage, which appears a fte r the acute symptoms have somewhat abated. T h e continuation o f all symptoms in a m ild form , including discharge o f pus, usually indicates the presence o f a true osteitis. I n the group o f cases studied, fortyone patients were adm itted to the hos pital in the acute stage; 59, in the chronic stage. In the forty-one acute cases, fourteen patients were later re adm itted fo r treatm ent o f the chronic condition. I t is entirely possible that a percentage o f these forty-one cases were not true osteitis, particularly seven cases in which local applications were sufficient fo r relief. T h e tem perature records show an average high recording in the acute
cases o f 101.5 degrees; w hile, in the chronic cases, the average is a fraction under 100 F. R O E N T G E N - R A Y D IA G N O S IS
In the acute stage, the roentgen ray is o f indifferent value except to indicate possible etiologic factors o f a dental or traum atic character. Changes in the cellular structure are not sufficiently m arked to show in roentgen-ray projec tion except in the very virulent cases. In the chronic Stage, the roentgen ray is, o f course, o f great service. In all but two o f the cases studied, the roentgen-ray diagnosis, w hen one was made, was confirmed later by the postoperative diagnosis. O ne case was diagnosed as probably m alignant, and in the second, a tentative diagnosis of Paget’s disease or o f actinomycoses was m ade. Both cases, microscopically, were chronic inflammation. TREATM ENT
T hom as Fillebrow n, professor o f oral surgery fo r m any years at H arvard, used to say th at the best treatm ent for osteitis was patience. T h is observation applies, o f course, to the chronic phase during sequestration. D u rin g the early part o f the acute state, cold or hot packs may be o f service to prevent tissue de struction and extension o f the disease. In seven cases already referred to, only local applications were used. These cases were discharged as relieved. I n cision and drainage was the procedure in the rem aining cases. Prom pt relief o f the acute symptoms follow s this treatm ent as a rule. T h e use o f a curet here usually indicates poor judgm ent. T h e im portant consideration in the treatm ent o f the chronic phase is the time to do sequestrectomy. Blair and Brown say “ it is difficult to set an exact
M in er— Osteitis o f M andible and M axilla time but in the ordinary straight fo r w ard acute osteomyelitis o f the jaw dead bone w ill have separated itself in ninety days.” In attem pting to get statistics regard ing sequestration, the unreliability o f the patients’ memory and the inaccuracy o f their statements make the figures o f doubtful value. In fifty-eight cases o f the series, sequestrectomy was per form ed. T h e longest duration o f the disease, as given by the patient, was forty years (a sequestrectomy was perform ed in this case), and the shortest time was three weeks. I have seen sequestration take place in seven days in the violent type. F rom six to twelve weeks was the aver age duration o f the series, w ith the peak tow ard the low rather than tow ard the high extreme. H O S P IT A L IZ A T IO N
In the acute phase, the average hos pital stay was nine and one h a lf days; in the chronic stage, fifteen days. C O M P L IC A T IO N S O F T R E A T M E N T
T h e physical condition o f the patient is sometimes an im portant consideration in the m atter o f treatm ent. In a recent case, the patient had a cardio-renal syn drome, and, w hile w aiting fo r opera tion, had a pulm onary throm bus, which nearly caused death. A t no time since has the .condition made it possible to care adequately fo r the jaw condition. Fractures, extension o f infection to m axillary and fro n tal sinuses and to tem poral bone, septicemia, cellulitis, acute cervical adenitis, tetany, tuber culosis and endocarditis were all seen in this series. T h ere .were three cases in which the temporal bone was invaded.
1705
R ESU LTS O F T R E A T M E N T
T h ere were three deaths in this series o f 100 cases. Osteomyelitis o f the jaw is not regarded as particularly serious, and yet the m ortality happened to be as high as it is in other conditions re garded as more im portant. I f treatm ent has been fundam entally sound there should be no deform tiy nor lim itation o f motion. Both o f these unfo rtu n ate sequelae are seen occasion ally, and serve to emphasize the need o f correct treatm ent. T h e onset, progress, course and treat m ent o f osteomyelitis o f the mandible is fairly w ell illustrated by the follow ing case. REPO R T O F CASE
A physician, aged 53, suffered fro m tooth ache in the lotver right jaw . Extraction was performed, with nerve block anesthesia. The jaw was stiff the follow ing day, w ith severe pain. Swelling was pronounced in thirty-six hours, with increasing pain and progressive trismus. In four days, there was marked swelling and the pain was unbearable. Ice packs gave no relief. H ot poultices were used on the sixth day. Incision and drainage was carried out at the hospital on the seventh day, and a large amount o f pus was evacu ated. A drop in temperature and recession of other symptoms followed. Some swelling and discharge of pus continued. A fter two weeks the swelling increased again. D rain age was insufficient. A t the fo u rth week, in consultation, I found extensive destruction of bone of both the horizontal and ascending ramus. Sequestrectomy was perform ed on the forty-second day. T hree large sequestra were easily removed. The involucrum was well organized. T he patient was in hospital fo r this operation eleven days, and was dis charged to a local hospital. F our weeks later (ten weeks from onset), another sequestrum exfoliated. At twelve weeks, the swelling was practically gone. M otion is still some what limited, but is im proving daily. There is no deformity. 363 M arlboro Street.