Hyperbaric Oxygen Treatment of Mandibular Osteomyelitis: Report of Three Cases

Hyperbaric Oxygen Treatment of Mandibular Osteomyelitis: Report of Three Cases

H y p e r b a r ic o x y g e n tr e a tm e n t o f m a n d ib u la r o s te o m y e litis : re p o rt o f th r e e c a s e s Elgene G. Mainous, DDS, ...

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H y p e r b a r ic o x y g e n tr e a tm e n t o f m a n d ib u la r o s te o m y e litis : re p o rt o f th r e e c a s e s

Elgene G. Mainous, DDS, Long Beach, Calif P. J. Boyne, DMD, MS, San Antonio, Tex G. B. Hart, MD, Long Beach, Calif

H yperbaric oxygen was used in the treatm ent of intractable osteomyelitis of the mandible. Den­ tists are frequently called on to manage postoper­ ative bone infections. In spite of comprehensive a ntib io tic therapy, the occurrence of osteomye­ litis after tooth extraction is not infrequent. The dentist is then faced with management of an in­ tractable infection of the bone that seems to re­ sist all conventional therapy. Hyperbaric oxygena­ tion from the study reported here appears to of­ fe r a new type of treatm ent fo r these resistant cases of osteomyelitis.

The effect of hyperbaric therapy in improving healing is based on altered bone physiologic function 1-2 and its influence on the bacterial or­ ganisms involved .3-4 Distinct increase in arterial and venous oxygen pressure can be demonstrat­ ed during hyperbaric therapy. The direct effect o f the oxygen on cell mitosis and cell prolifera­ tion in areas o f tissue repair results in favorable changes in the healing environment.5-6 Hyperbaric oxygenation refers to the inhala­ tion of oxygen under conditions in which the pressure o f the surrounding breathing mixture is greater than atmospheric pressure. A t sea level, the atmosphere exerts a pressure of 14.7 pounds per square inch (psi). This is one atmo­ sphere absolute. (Pressure gauges are set to reach zero at normal atmospheric pressure; con­ sequently, a chamber pressurized to 14.7 psi can be said to be at a depth of 33 feet sea water or 2 atm absolute. A gauge pressure of 29.4 psi is 3 atm absolute, representing a depth o f 66 feet sea water.) Oxygen, although essential for life, also may be toxic under hyperbaric conditions greater than 3 atm absolute. The neurological effects of such toxic doses are convulsion and progres­ sive constriction of the peripheral vision. The 1426 ■JAD A, V ol. 87, December 1973

effects on respiratory tissue of oxygen toxicity are congestion, edema, and patchy collapse sep­ arated by areas of normal lung tissue. The established toxicity of hyperbaric oxy­ genation is well known, and a program o f hyper­ baric oxygen therapy with the use o f accept­ able ranges o f pressure has been undertaken during the past decade. The established ther­ apeutic use of hyperbaric oxygen at the present time is in the treatment o f carbon monoxide poi­ soning, clostridial gangrene, and decompression sickness .7'12 Hyperbaric oxygen therapy was instituted at the Long Beach Naval Hospital in oral and maxillofacial surgery three years ago. The treatment regimen was used in nonspecific osteom yelitis of the mandible 1315 and osteo­ radionecrosis of the mandible, and was used to promote osteogenesis in bone grafts to the mandible .16

T h e ra p y r e su lts Twenty-two cases o f osteomyelitis and 11 cases of osteoradionecrosis of the mandible have been treated with hyperbaric oxygen at Long Beach N aval Hospital during the past three years. Ex­ cellent results with objective and subjective healing of the diseased bone were noted in all patients who have completed therapy. Two pa­ tients with osteomyelitis and five patients with osteoradionecrosis who are presently under­ going therapy have improved status with resolv­ ing drainage and lessening of the pain.

R eport of c a s e s Three representative cases of osteomyelitis from this series are presented. Treatment o f all cases consisted of evacuation of pus, the taking of rou­ tine cultures and sensitivity of the exudate, de­ bridement, sequestrectomy, antibiotic therapy, daily irrigation with 9-aminoacridine, and the hyperbaric oxygen. Vitamin E was given rou­ tinely to all patients in doses of 100 mg per day since it has been shown experimentally to re­

Fig 1 ■ C ase no. 1. Extraoral subm andibular sinus tracts. Fig 3 ■ C ase no. 1. Exposed m andibular sequestrum .

Fig 2 ■ C ase no. 1. Panoram ic radiograph of extensive m andibu­ lar osteomyelitis.

duce the possibility of oxygen toxicity. Prehyperbaric oxygen work-up for all patients consisted of a chest radiograph, electrocardio­ gram, complete blood count, sedimentation rate, platelet count, immunoelectrophoresis, and analyses for total lipids with fractions, serum glutamic oxaloacetic transaminase, serum glu­ tamic pyruvic transaminase, serum calcium, serum phosphorus, serum potassium, and se­ rum alkaline phosphatase. Eye refraction was tested before, during, and three months after hyperbaric therapy. ■ C ase no. 1: A 41-year-old white woman was referred to Long Beach Naval Hospital in Sep­ tember 1971 with a chief complaint of swelling and two draining fistulas of the submandibular area (Fig 1). A right mandibular molar had been removed in March 1971; afterward, the patient experienced a dry socket that her dentist treat­ ed by packing and curettage. Panoramic radiographic examination revealed extensive osteo­ myelitis of the right and left sides of the man­ dible (Fig 2). The operative procedure con­

sisted of incision and drainage along with the extraction of the remaining mandibular teeth on Sept 23. Hyperbaric oxygen therapy was started on Sept 21. After 30 hours of hyperbaric oxygen therapy at 2 atm, purulent exudate ceased and a 3-cm segment of the inferior mandible became exposed (Fig 3). On Feb 17, 1972, the exposed bone seques­ trum was removed from the right inferior bor­ der. A bed of healthy granulation tissue was found beneath the sequestrum (Fig 4). The patient received a total of 120 hours of hyperbaric oxygen therapy during a 60-day pe­ riod. Panoramic radiographs taken at 3, 6 , and 12 months after therapy (Fig 5) revealed osteo­ genesis of the lytic bone cavity in the left man­ dibular body and recontouring of the defect along the inferior border. Mainous— Boyne— Hart: H Y P E R B A R IC O XYGEN TR EA TM EN T ■1427

Fig 6 ■ C ase no. 2. Panoram ic radiograph of fracture and radiolucent area in left m andible.

Fig 5 ■ C ase no. 1. P anoram ic radiographs taken 3 (top), 6 (cen­ ter), and 12 m onths (bottom ) after hyperbaric oxygenation. Fig 7 ■ C ase no. 2. P anoram ic radiograph taken four m onths after hyperbaric oxygenation.

■ C ase no. 2 : A seven-year-old white boy suf­ fered trauma to his mandible July 24, 1971, when he was struck in the lower jaw with a golf club. A mandibular radiographic series was read as normal; a fracture of the mandible was not noticed. Thirty days after this trauma, an extra­ oral sinus tract developed over the left inferior border of the mandible. A physician treated the patient with antibiotics and when the drainage ceased, he surgically excised the sinus tract. Because of repeated drainage and the formation of a second sinus tract, the same procedure was repeated. On Sept 22, 1972, the patient was re­ ferred to an oral surgeon who took a panoramic radiograph. A diagnosis of fracture of the left side of the mandible was made. 1428 ■JAD A, Vol. 87, December 1973

The fracture line appeared to pass through the left permanent canine, and a radiolucent area was seen at the left inferior border of the man­ dible (Fig 6). Hyperbaric oxygen therapy was started on Sept 27, for 90 minutes a day at 2 atm absolute. On N ov 2, the sinus tract appeared to be heal­ ing, and there was no evidence of purulent exu­ date. The patient received a total of 50 hours of 100% hyperbaric oxygen at 2 atm absolute. A panoramic radiograph taken four months after the start of hyperbaric therapy revealed healing of the fracture site and osteogenesis in the radiolucent area of the left inferior border of the man­ dible (Fig 7).

Fig 8 ■ Case no. 3. Panoramic radiograph taken 11 days after tooth extraction.

Fig 10 ■ Case no. 3. Panoramic radiographs taken three (top) and six months (bottom) after hyperbaric oxygenation. Fig 9 ■ Case no. 3. Panoramic radiograph taken one month after tooth extraction shows subcondylar involvement.

■ C ase no. 3: A 21-year-old white man had the m andibular left first prem olar rem oved on July 13, 1972. T he procedure was described by the dentist as being a simple tooth extraction with­ out undue traum a. H e was referred to Long Beach N aval H ospital on July 24, with a chief com plaint of pain, swelling, and trism us of the left side of the mandible. Panoram ic radiographs revealed osteom yelitis of the left side of the mandible. Clinically, the left mandibular second prem olar and third molar were mobile and ex­ truded from their sockets, and these teeth were extracted with the patient under local anes­ thesia (Fig 8). H yperbaric oxygen therapy was started on July 27. A fter ten tw o-hour treatm ents at 2 atm absolute, the facial swelling and trism us had re­

solved, and the patient was free of pain. On August 14, the patient com plained of recurrence of pain in the left m andibular condyle region. The panoram ic radiograph revealed a radiolucent area of the left subcondylar area and a pathological fracture at the left parasym physis (Fig 9), The patient received a total of 120 hours of hyperbaric oxygen therapy at 2 atm absolute. Panoram ic radiographs at three and six months after the start of hyperbaric therapy revealed osteogenesis of the radiolucent areas of the m an­ dible (Fig 10). N o mobility could be dem onstrated at the pathological fracture site on the left side of the mandible at the conclusion o f the treatm ent. N o sinus tract developed; the patient was free of pain through the course of disease and was able to function in his job in a norm al manner. Mainous—Boyne—Hart: HYPERBARIC OXYGEN TREATMENT ■ 1429

D is c u s s io n A cute osteom yelitis of the m andible m ost fre­ quently results from odontogenic infection or a postextraction com plication that m ay follow a single simple tooth extraction. D uring the acute phase, th e osteom yelitis m ay involve the cor­ tical bone or the bone m arrow , rem aining largely localized. T he process m ay, how ever, extend throughout the entire m andible, spreading rapid­ ly throughout the m arrow spaces and m ay even extend through the m andibular canal to involve the condyle. In the m andible, the acute infec­ tion tends to cause com pression and throm bo­ sis of the m andibular neurovascular bundle, and th e subperiosteal swelling m ay strip the perios­ teum from th e bone; this renders the affected area alm ost avascular. This process results in infected cavities within the m arrow spaces and bone sequestration. T he com pression of the m andibular nerve tends to cause anesthesia of th e affected side or sides. Sinuses form in the soft tissue overlying the affected bone and m ay open and close periodical­ ly depending on the acuteness of the inflamma­ tion. Clinical findings of all of the patients treat­ ed by us in this study w ere severe pain, mobil­ ity o f teeth in the adjacent areas, swelling o f the soft tissue overlying the affected bone, and sinus form ation in the soft tissue with lym phadenopathy and severe m andibular trism us. Elevated w hite blood cell count and sedim entation rate w ere alw ays present. T he degree o f elevated tem perature depended on the acuteness of the disease.

S u m m a ry A cu te osteom yelitis of the m andible is one of the m ajor challenges to the dental profession. T he disease often fails to respond to antibiotic therapy, surgical incisions and drainage, and sequestrectom y. H yperbaric oxygen used as a m odality in the treatm ent o f intractable osteom yelitis produced a favorable response by shortening healing time in term s o f closure of draining fistulas, rapid osteogenesis o f large lytic areas, elim ination of sequestrum s with the form ation of beds of healthy granulated tissue over the viable bone, and reduction in the destruction of hard and soft tissue. A dditionally, it was noted that once treat­ 1430 «JADA, Vol. 87, December 1973

m ent was instituted, the patients w ere alm ost free of pain, and nonnarcotic analgesics w ere able to control the m inor discom fort th at the pa­ tient occasionally experienced. T he use o f hyperbaric oxygen therapy appears to have a definite place in the future m anage­ m ent o f patients with osteom yelitis o f the m an­ dible.

The opinions or assertions contained herein are the private ones of the authors and are not to be construed as official or reflecting the views of the Navy Department of the Naval service at large. Illustrations were taken by HM2 James Spencer, USN, medical photographer, Naval Hospital, Long Beach, Calif. Dr. Mainous, a captain in the US Navy Dental Corps, is chief of dental service and head of oral surgery, Naval Hospital, 7500 E Carson St, Long Beach, Calif 90801. Dr. Boyne was formerly assistant dean, University of California at Los Angeles School of Dentistry, and now is dean, University of Texas Dental School at San Antonio. Dr. Hart, a captain in the US Navy Medical Corps, is chief of surgery at the Naval Hospital, Long Beach, and is as­ sistant clinical professor of surgery, University of California at Irvine. 1. Goldhaber, P. The effect of hyperoxia on bone resorption in tissue culture. Arch Pathol 66:635 Nov 1958. 2. Shaw, J.L., and Bassett, C.A. The effects of varying oxygen concentrations on osteogenesis and embryonic cartilage in vitro. J Bone Joint Surg [Am ] 49:73 Jan 1967. 3. Hamblen, D.L. Hyperbaric oxygenation. Its effect on experi­ mental staphylococcal osteomyelitis in rats. J Bone Joint Surg [Am ] 50:1129 Sept 1968. 4. McAllister, T.A., and others. Inhibitory effects of hyperbaric oxygen on bacteria and fungi. Lancet 2:1040 Nov 16, 1963. 5. Persson, B.M. Growth in length of bones in change of oxy­ gen and carbon dioxide tensions. Acta Orthop Scand 117:29 Suppl 1968. 6. Meijne, N.G. Hyperbaric oxygen and its clinical value: with special emphasis on biochemical and cardiovascular aspects. Springfield, III, Charles C Thomas, 1970, p 185. 7. Slack, W.K. Hyperbaric oxygen. Int Anesthesiol Clin 5:212 Spring 1967. 8. Smith, G., and others. Treatment of coal-gas poisoning with oxygen at 2 atmospheres pressure. Lancet 1:816 April 21, 1962. 9. Walder, D.N. Some problems of working in an hyperbaric environment. “ Prae monitus prae munitus.” Ann R Coll Surg Engl 38:288 May 1966. 10. Pascale, L.R., and Wallyn, R.J. Surgical applications of the hyperbaric chamber. Surg Clin North Am 48:63 Feb 1968. 11. Johnson, J.T., and others. Hyperbaric oxygen therapy for gas gangrene in war wounds. Am J Surg 118:839 Dec 1969. 12. Trippel, O.H., and others. Surgical uses of the hyperbaric oxygen chamber. Surg Clin North Am 46:209 Feb 1966. 13. Depenbusch, F.L.; Thompson, R.E.; and Hart, G.B. Use of hyperbaric oxygen in the treatment of refractory osteomyelitis: a preliminary report. J Trauma 12:807 Sept 1972. 14. Sippel, H.W.; Nyberg, C.D.; and Alvis, H.J. Hyperbaric oxy­ gen as an adjunct to the treatment of chronic osteomyelitis of the mandible: report of case. J Oral Surg 27:739 Sept 1969. 15. Slack, W.K.; Thomas, D.A.; and Perrins, D. Hyperbaric oxy­ genation in chronic osteomyelitis. Lancet 1:1093 May 22, 1965. 16. Mainous, E.G., and others. Restoration of resected man­ dible by grafting with combination of mandible homograft and autogenous iliac marrow, and postoperative treatment with hyper­ baric oxygenation. Oral Surg 35:13 Jan 1973.