Treatment of acute and subacute localized osteomyelitis with chemotherapy

TREATMEMT QF ACUTE AND SUBACUTE L~CA~IZB~ ~~T~~~~~L~T~~ WITH CHEMOTHERAPY

XTXL the recent ad\,ent oi’ ehemot,herapy,

acute

usteoniyelitis

of

the

niax-

illa or mandible was we of the most dreaded an:1 severe diseases occurring G3sa postoperative eorl~piicatiou linowrl to oral surgery. Karelp was it possible .to keep the infect,ion localized arid confined to its original area of involvement. The resultant destruction of bone was extensiv?. The period of treatment was ‘protracted, ranging from many months to several years. Extensive and frequent surgical intervention was almost invariably required to establish and maintain drainage, and to eliminate sequestra. Pery often this sorgical intervention included disfiguring extraoral incisions. The over-all effects on the patient were both disheartening and debilitating. In the two cases I:eportcd in this paper, the success in maintaining localization, speed of recovery, minimum of surgical intervention required, absence of debilitating effects: and the rapidity of bone regeneration following treatment with chemotherapy present an encouraging contrast to t’he former COLIW! 01 this disease. case Reports Case L-L. I?;., a 4!I-year-old white man. P~EZinLi11QI~yOcrsc Hz’sfory.-The patier:t had his upper right cuspid arid first, molar extracted on Aug. 7, 1947. Both had been abutment teeth, with polcl crowns carrying the pontics. ii moderate degree of periodontoclasia was noted a~-ound both teeth. The preoperative roentpenogram sent with the patient shows a thickening of the periodontal membrane, a moderate amount of alveolar resorption around! the cuspid, and somewhat less resorption around the molar tooth (Fig. 1). The teeth had been extracted under infiltration anesthesia. The dentist reported that they had been simple extractions, with no undue trauma. On postoperatire examinat,ion two days later, healing apl3earrti t0 he On Bug. 19, 1947! the patient retnrned tb the dentist progressing satisfactorily. complaining of fever and malaise, alid for three days he had a consta.nt tasTe of pus in his mouth, and there was a bulging mass extruding from the site of the molar socket. Radiopral)hic examination disclosed an irregular area of marked alveolar radiolucence extendin, o- from the cuspid to the molar socket. The dentist irrigated the area, and implanted penicillin cones into the sockets (Fig. 2). The patient’s condition continued to deteriorate; however. and ON Sept. 6, 1947, he was referred to me for diagnosis and treatment.

TREATJIEST

OF ACUTE

ASD

SUBACUTE:

LOCALIZED

OSTEOMYELITIS

843

Clinical Ezn&aatim---A proliferative mass of hypertrophic tissue extruded from the molar socket. About 1 cm. distal to this an oval area of ulceration approximately 4 by 6 mm. in dim.ension was visible. The surface of the cuspid socket appeared red and ulcerated (Fig. 3). On slight pressure, an exudate of pus was expressed from these areas. No marked pain, but some tenderness was noted. His temperature was 100.6” F. The patierlt complained of general weakness, loss of appetite, and a slight nausea. Roentgeqtograpl& Exalnai?zation.-There was marked radiolucence in the affected area, with considera.ble evidence of destruction of the alveolar bone between the two sockets. A few spurs of bone projected into the radiolucent area from the underlying bone. This underlying bone was irregular in outline and density, and presented a somewhat moth-eaten appearance, especially in the projecting spurs ,(Fig. 4). A full-skull plate taken posteroanteriorly showed no evidence of extension of .the destructive process beyond the area described. Diagnosis.-osteolnyelitis

of the maxilla,

localized,

subacute.

Trentlment.-The extrud.ing hypertrophic tissue was removed with electrocautery. On exploration, it was found that the ulcerated area as well as the tooth sockets connected with a large underlying cavity in the alveolar bone. The remnants of the penicillin cones were removed. The cavity was first irrigated with normal saline solution at body temperature, followed by irriga.tion with tyrothricin, 2.5 per cent solution, and then a wet dressing of tyrothricin was introduced into the cavity for ten minutes. A gauze dressing prepared with B. I. P. paste (bismuth subnitrate, iodoform, and petrolatum) was then packed into the cavity and permitted to remain until the following day. This latter dressing being radiopaque, gave an accurate roentgenographic picture of the extent of bone destruction (Fig. 5). It also helped to keep debris out of the involved area, and, being a physiologic irritant, could do no harm to the unde?lying bone structure. Penicillin, Romansky formula, 300,000 units, was then This same treatment was, repeated on four sucadministered intramuscularly. cessive days, until a total of 1,200,OOO units of penicillin had been administered.. On the third day of t,reatment, Sept. 8, 1947, the B. I. P. dressing had been forced ont of the cavity, and t,wo small bone sequestra were noted near Following the surfa,ce. These were removed without need for anesthesia. these four daily treatments, the patient was seen on alternate days, the saline and tyrothricin irrigations and the B. I. P. dressings being continued until Sept.. 18, 1947. After the removal of the sequestra, it was noted that the dressings mere being expelled from the cavity within a few hours, despite the fact that progressively smaller. dressings were being inserted. The suppuration had decreased notably on the second day of treatment, and foilowing the removal of the sequestra, no further suppuration was noted. After Sept. 18, 1947, the patient was seen semiweekly for two weeks, then once a week for two weeks, for irrigation with tyrothricin and periodic roentgenographic examination (Figs. 6 and 7). These gave evidence that the cavity had begun to fill in, and on the external surface of the gingival mucosa, 0111~ two small orifices about 2 to 3 111111. in dep./& still persisted at the sites of the tooth sockets. These orifices

11. ,J. URINGER

TREATillENT

OF ACUTE

AND

SUBACUTE

LOCALIZED

845

OSTEOIVIYELXTIS

were scarified on two successive days (Fig. 8), and the patient was disc:haIrged from further active treatme:nt. On Jan. 17, 1948, the patient r~eturned. (Xnitally, there m‘as normal healthy mucosa, completely healed, with no evid en’ce of loss ()f anato mica1 contour (Fig. 9). Roentgenographic exam ination shlowed almosit complc:te bone regeneration in the area (Fig. 10).

Fig.

8.

Fig.

9.

Fig.

10.

846

1:.

i. OKISWK

CUSC:History.-The patient had the lower four anterlor ta&r (two central incisors and two lateral incisors) extracted on Sov. 12, 1947. The dentist had noted no pathology other than a moderately marked periodontoclasia, and the, extractions had been simple. Postope;*atiue examination on the following day showed apparently normal healing. On the sevent,h day fol.!owing the extractions, the patient returned, -vvit,h considerable edema. in .the p”r”lent exudate discharging from the area. area, intraorally, and a constaut On the ninth day, a large sequestrum of bone measuring 2 by 1 cm. worked itself free and, protruding from the surface, was removed. Despite this and On Nov. regular irrigation of the area, the suppuration continued unabated. 26, 1947, the paCent was referred to me for diagnosis and tre:atrnent. ~‘rehninary

Cll:~~ical Exnnbin'utio~i,.--So evidence of extraoral swelling was present. Some tenderness was noted in the sublingual region on palpation. Intraorally, edema, redness, and loss of tissue tone TTere noted in the affected area. The labial and lingual aspects of the gingival mucosa were separated at the crest of the ridge, as t,hough they had been c,nt. Considerable purulent exudate was expressed at the slightest pressure (Fig. 11). His temperature was 99.4” F. The patient complained of loss of appetite, and despite the fact that he was constantly sucking and spitting out the pus, he said that he felt sick to his stomaeh. Roentgenogcaphic EzanGnation.-The lower cuspids were in position. There was marked radiolucence of the alveolar bone lying between these teeth. This radiolucence extended downward about 1.5 cm. The alveclar bone at the base of the area was sonlewhat irregular in outline, and had a typical worm-eaten appearance (Figs. 12 and 13).

Dinglzosis.--Osteom!~elitis

of the mandib!e, localized, acute.

l’reat,n&ezt.-Due to the separation between the labial and linguai aspects of the gingival mucosa, no incision was needed. The area was irrigated with normal saline solution at body temperature, followed by irrigation and wet dressings of tyrothricin inserted into the cavity for ten mitmtes. A B. I. P. dressing was then inserted into the cavity overnight (Fig. 1-r). The same treat. merit was repeated on the following day, and a diminution in tile amonnt of suppuration was noted. The patient then went on a four-day business trip, during which time treat,ment was discontinued. IIe returned for treatment on Dec. 3, 1947; at which time some improvement was noted, although an exudate of pus could still be expressed upon pressure. Treatment was resumed, with the addition of intramuscular administration of 300,000 units of penicillin, Romansky formula. This treatment, was repeated on the following da!;. On the third day, a large sequestrum! in&din g a port,ioii of labial cortical bone, was noted at IAe surface of the area and removed (Fig. 15). The same treatment was again repeated, and then a B. 1. P. dressing inserted and a roentgenogram taken (Fig. 16) to determine the extent of the eavit,y. The treatment was continued on the fourth da>-> until a total of 3,200YOO0units of penicillin had been ad-

TREATMEiYT

OF ACUTE

.YND

SUBACUTE

LOCALIZED

OSTEOMYELITIS

84-i

ministered. After the sequestrum had been remored, it was noted that the B. I. P. dressings, although progressively reduced in size, were being expressed from the cavity within a few boars after insertion. Three days after the final chemotherapeutic treatment, the color and tissue tone of the gingival mucosa appeared comparatively normal, with no edema present. Even upon exerting

Figs.

11-13.

considerable pressure, pus could no longer be expressed from the area. Roentgenographically, the worm-Eaten appearance of the underlying bone previously noted was no longer in evidence, and the area of radiolucence appeared to be reduced in size and intensity (Fig. 17). The margins of the separated mucosa were then freshened and scarified, and on Dec. 11; 1947, the patient was discharged from further active treatment, with instructions to return for periodic roentgenographic examination.

848

31. J . ORISUEK

On Jan. 27, 1948, roentgenographic examination showed evidence of marked bone regeneration (Figs. 18 and 19). Clinically, the gingival mucosa appeared normal. There had been a loss of approximately 2 mm. of vertical dimension at the crest of the ridge (Fig. 20). The patient had had four anterior teeth added to his lingual bar denture, and he was wearing them in comfort. Fig.

Fig.

16.

IQg.

Ii.

Fig.

18.

1

ummary

or @O 101

measures were iinarailing to hait II both these cases, routine postoperative Tn Case 1, therapy attempted by inserting penieilbn cure the infection. The proKS locally into the affected area proved completely ineffective, ged presence of these cones aud the progressive deterioration after their

TREATXENT

OF ACUTE

A1ND

SUBACUTE

LOCALIZED

OSTEOMYELITIS

$49

insertion would indicate that they may have aggravated the condition by acting as foreign boldies in the area. In Case 2, the local use of tyrothricin, without accompanying systemic therapy, produced improvement, but .failed to effect a complete cure. In both cases, combined local and systemic chemotherapy was highly effective. Although the amount of surgical intervention required in bo,th cases was minimal, it was essential. Despite the fact that suppuration was notably diminished shortly after treatment was instituted, it was not until the sequestra were removed that suppuration ceased entirely and a cure was ,effe&ed. In both cases, the infections were successfully confined to the limits of the original areas of involvement, the fever and malaise were rapidly overcome, and very shortly after the active infection was checked, evidence of rapid bone regeneration was noted.

Conclusions Chemotherapy with the antibiotics appears to be highly effectiT-e in the treatment of acute and subacute osteomyelitis of the maxilla and mandible. Adequate dosage must be used and maintained in the blood level for a sufficient period of time to achieve complete bacteriostasis. Combined systemic and local therapy most readily achieves this. Chemotherapy alone, however, cannot effect a cure. To effect a cure, the principles df sterilization, evacuation, and obliteration must still be observed. Chemotherapy provides the sterilization of thse infection. Evacuation of the contents of the diseased area, both PUS and seqaestra, by means of surgery, must then be performed before obliteration of the resultant cavity by bone and tissue regeneration can take place. 57 WEST

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