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Odontogenic Infections of the Jaws and Associated Soft Tissues and Their Treatment with the Aid of Antibiotics
ODONTOGENIC INFECTIONS OF THE JAWS AND ASSOCIATED SOFT TISSUES AND THEIR TREATMENT WITH THE AID OF ANTIBIOTICS KURT
H. T:a:oMA, n.M.D. (>
THE sepsis of fractures compounded into the mouth, osteomyelitis, secondary neck infections and facial cellulitis are generally of odontogenic origin, caused by endemic bacteria derived from the oral cavity and the teeth. They frequently represent an extension from a latent dental focus that has become active or aggravated by trauma such as tooth extraction, or precipitated by lowered resistance caused by fatigue or a debilitating general disease. The advent of chemotherapy and especially the employment of antibiotics to prevent and combat infection has considerably altered the treatment of infections about the jaws. In some instances, these new agents are so effective that surgical interference is eliminated, while in others they make possible earlier surgical measures with greater safety to the patient and a more rapid convalescence. In most instances, however, the use of antibiotics combined with carefully planned and adequate surgery gives the best results. ANTIBIOTIC THERAPY
In considering therapeutic measures, the identification of the morbific organisms is as important as the finding of the immediate cause of the disease. A thorough bacteriologic study should be made in all cases because of the selective effect of the antibiotic drugs. If the infected tooth is still present, a culture may be made when it is extracted, although care must be taken to prevent contamination. When the patient has received penicillin previous to tooth extraction, clarase must be added to the culture media or there may be no growth. This, of course, would simply indicate that the organisms are penicillinsensitive. Both aerobic and anaerobic cultures are essential, and a smear should be examined for Vincent's organisms, because of the difficulty in growing the fusospirochetal organisms in vitro. The bacteria found most commonly in jaw and neck infections are the alpha and beta hemolytic streptococci, the nonhemolytic streptococcus and the Staphylococcus aureus and albus. Jaw infections are generally mixed infections with the following additional organisms: Bacillus coli, bacterioids, ramo8U8, perfringens, and other gramnegative bacilli and clostridia. Many of the latter are known to be (> Professor of Oral Surgery, Harvard University; Oral Surgeon and Chief of Dental Department, Massachusetts General Hospital, Boston.
1321
1322
KURT H. THOMA
penicillin-resistant, but are affected by streptomycin. Sensitivity tests should be used to determine the specific therapy. The importance of determining the exact bacteriologic factors is illustrated by two cases which are recorded briefly. CASE I.-J.B. (M.G.H. No. 551549), a 54 year old man, entered because of chronic osteomyelitis of the mandible of one year's duration. Two infected teeth had been extracted and penicillin treatment was used, but a draining sinus remained. The x-ray showed osteomyelitis which caused intermittent swelling and suppuration. Bacterial examination revealed a pure culture of Escherichia coli. The p&tient was treated with str.Jptomycin, 0.2 gm. every four hours and penicillin, 24,000 units every three hours. A saucerization and sequestrectomy of the involved section of the mandible was performed. This was followed by topical instillation of penicillin through a catheter to the bone cavity, and continuation of the intramuscular therapy. The wound was completely healed two and one-half weeks later.
Comment.-Because of the presence of penicillin-resistant organisms, previous treatment was unsuccessful until streptomycin was instituted. CASE 1I.-F.P. (M.G.H. No. 549851), a 42 year old man, presented an exten.sive swelling of the right side of the face which came on after the excision of an impacted third molar six months previously. He had been treated with poultices, penicillin and streptomycin, plus x-ray radiation. Multiple fistulas drained seropurulent discharge. Incision and drainage was performed on January 3. Anaerobic cultures yielded Clostridium sporogenes; the smear showed an abundance of spirochetes and fusiform. bacilli. There was no evidence of actinomycosis. The patient was given 48,000 units of penicillin every three hours, and streptomycin, 0.2 gm. every four hours, with slight improvement. Frequent irrigations of the fistula with an aqueous solution of chlorophyll was then instituted "on January 7 and continued until January 11, when the patient was discharged relieved. Three weeks later all fistulas had healed.
,! I
Comment.-In spite of both penicillin and streptomycin treatment, a mixed anaerobic infection of the face did not respond until chlorophyll raised the local tissue resistance to infection. SURGICAL TREATMENT
Surgical procedures should be carefully planned. The right method must be applied at the right time. The Removal of the Cause.-In odontogenic infections, the removal of the causative tooth is of primary importance. In most instances the infection spreads through the pulp canal of a carious tooth or root. Periodontal infection and pericoronal infection of a partly erupted impacted tooth are also etiologic factors. If the cause is not removed, recovery is delayed and complications may set in, as illustrated in ~e following case. CASE I1I.-O.D. (M.G.H. No. 29558), a 31 year old woman, had been treated for a submental phlegmon by chemotherapy and incision and drainage. She rei
H
;,11
ODONTOGENIC INFECTIONS OF THE JAWS
1323
turned three weeks later with an acute swelling. X-ray examination showed a retained molar root with extensive osteomyelitis of the mandible. A draining fistula which had remained from the previous incision led to the affected bone. Following removal of the infected tooth and sequestrectomy, the patient made a rapid recovery.
Cellulitis and abscesses of the fascial spaces may be caused by both deciduous and permanent teeth. Submaxillary, submental, sublingual,
Fig. 408.
Fig. 409.
Fig. 408.-0steomyelitis of the mandible due to furunculosis. Fig. 409.-Mter saucerization and sequestrectomy, a rubber catheter is inserted to the bone and the incision closed by suture.
parapharyngeal and infratemporal abscesses may develop. In lOme cases satisfactory results may be obtained by conservative treatment in order to retain incisors and canines, but in many cases extraction is indicated as soon as possible to remove the cause, and in some cases to establish drainage. Even in acute suppurative cases there is no great danger of complications from this procedure with the prophylactic use of penicillin.
1324
KURT H. THOMA
Osteomyelitis of the jaw is generally of dental origin; hematogenous infection and infection from furunculosis is rare. The tooth causing the acute infection is usually sore, but in widespread extension many teeth may be secondarily involved. Adequate dental radiographs are essential. In most cases, extraction is indicated as soon as a good penicillin level has been obtained. A case in which the osteomyelitis was caused by furunculosis was seen recently. VASE IV.-J.H. (M.C.H. No. 565446), a 36 year old man, presented clinical and x-ray evidence of osteomyelitis. A furuncle had formed in the subauricular region six months ago and residual tenderness persisted. Pain and swelling of the jaw developed two weeks before admission, but his dentist could find no infection associated with the teeth. However, he finally extracted the first molar. The second molar later became painful and loose, and was extracted after penicillin therapy was started. The symptoms became worse, and a lateral jaw film showed extensive osteomyelitis (Fig. 408). A radical saucerization and sequestrectomy was performed and a rubber catheter inserted for local instillation of penicillin (Fig. 409). The culture at operation grew out Micrococcus catarrhalis and Staphylocot:cus albus. Recovery was uneventful.
Comment.-The instillation of penicillin via an inlying catheter assures concentration of the drug not possible by the intramuscular route. Septic fractures often are due to the involvement of a tooth. Infection may penetrate from the gingival margin along the fracture, causing an abscess of the adjacent fascial spaces, and result in osteomyelitis with extensive loss of bone. It is a good rule to extract teeth in the fracture line even though they may be valuable for intermaxillary fixation. Today there are several good methods available for the fixation of jaw segments which have been made edentulous by such extractions. The following case illustrates the formation of a submaxillary abscess from a fracture along a tooth. CASE V.-M.R. (M.C.H. No. 474164), a 23 year old woman, had contracted a fracture of the mandible which was reduced and immobilized by intermaxillary wire fixation. A submaxillary swelling developed with fever and leukocytosis. When the lip was retracted to remove the wiring, the abscess broke intraorally and a • large amount of frank pus discharged. The tooth in the fracture line was removed and the mandible again immobilized with intermaxillary wiring. The submaxillary abscess was evacuated and a rubber catheter inserted for the local instillation of penicillin. Sepsis ceased and bone repair followed uneventfully.
Comment.-The tooth in the line of fracture was the source of ~epsis and bony union was prevented while the tooth was retained. The Elimination of Pus and Necrotic Tissue.-In some cases the use of antibiotics may result in resolution without operative interference, particularly if such treatment is instituted before pus has formed and before bone necrosis has set in. F.ascial abscesses which previously had to be incised and drained, and cases of acute osteomyelitis which previously went on to sequestration may thus be cured without sur-
III
ODONTOGENIC INFECTIONS OF THE JAWS
1325
gery. Many patients do not present themselves for treatment early enough, however, and require elimination of accumulated pus arid excision of dead bone. In fascial abscesses the pus may be aspirated by means of a syringe, and the immediate injection of penicillin in dilution of 1000 units per
Fig. 410.
Fig. 411.
Fig. 410.-Compound, comminuted fracture of the mandible complicated by a cyst and submandibular cellulitis. X-ray taken after the tube was inserted into the cyst for local instillation of penicillin. Fig. 411.-Fracture reduced and immobilized by skeletal fixation with accessory wire suture. Note: The pins on the right do not extend into the cyst; the x-ray appearance is due to angulation when the exposure was made. X-ray was taken eight weeks after reduction showing healing of bone.
cubic centimeter may be beneficial. In most cases incision and evacuation of the pus, followed by instillation of penicillin through a tube inserted into the abscess cavity gives more satisfactory results (Fig. 414). The advantage of this method over the aspiration technic is that penicillin or streptomycin can be instilled every three or four
1326
KURT H. THOMA
hours to supplement the parenteral administration. Similar treatment may be used in acute infection of odontogenic cysts. CASE Vr.-T.M. (M.G.H. No. 559630), a 54 year old man, contracted a compound, comminuted fracture through a large cyst in the anterior part of the mandible. His face swelled and he suffered severe pain. Temperature was 103 0 F., and the white cell count 17,300. He received 48,000 units of penicillin every three hours and on the following day, under local anesthesia, an incision was made beneath the chin to evacuate the purulent contents of the cyst. A rubber catheter was inserted and sutured to the skin, and the wound closed (Fig. 410). Ute intramuscular injections of penicillin were continued and supplemented with local instillations. The culture revealed the presence of Staphylococcus albus. After the acute infection had subsided, the cyst was enucleated, the cavity filled with fibrin foam, closed by suture, and skeletal jaw fixation applied. Five days later the patient was discharged. After eight weeks the x-ray showed satisfactory bone healing (Fig. 411), so that the appliance could be removed. When tested, it was found that the jaw had healed satisfactorily and all signs of infection subsided.
In fractures complicated by osteomyelitis a sequestrectomy usually is necessary, and best accomplished from an extraoral approach. If the bone loss is not too great, union may be expected if the jaw is properly immobilized. I have had excellent results with skeletal fixation, using pins in the anterior fragment far away from the infection, and my peripheral bone clamp on the posterior fragment in the infected region. Since its use does not involve drilling into the bone, there is no danger of spreading the infection. CASE VII.-S.McK. (M.G.H. No. 533145), a 46 year old woman, had been struck on the jaw six weeks previously, and contracted a fracture. She had received medical care which included penicillin therapy for four days. She had a submaxillary swelling and multiple draining fistulas (Fig. 412). X-ray examination revealed a fracture complicated by osteomyelitis. A molar extended into the fracture line (Fig. 413). The temperature was 99.4 0 F., and the white cell count 11,000. She received 32,000 units of penicillin every three hours and two days· later a sequestrectomy was performed, a rubber catheter inserted, and the fracture immobilized by means of skeletal fixation. Pins were used in the anterior fragment, and a peripheral bone clamp at the angle of the jaw (Fig. 414). Seven days later the catheter was removed and two days later the patient was discharged. The appliance was removed seven weeks after the operation when a satisfactory union had been obtained.
In osteomyelitis the removal of necrotic bone, when completel} sequestrated, may be a simple procedure, especially if an intraorai approach is possible. In other instances, the sequestrum may be encased or inaccessible, and an extra oral approach is preferable. The bone is decorticated to expose the infected channels so that all necrosis can be removed. Saucerization should be carried out to eliminate Fig. 414.-Mter sequestrectomy the fractures was immobilized by means of peripheral clamp at the angle of the jaw and two half pins inserted into the anterior fragment. A rubber catheter was inserted to the infected area for the instillation of penicillin.
Fig. 412.
Fig. 413.
Fig. 412.-Submaxillary abscess with multiple fistulas due to septic fracture. Fig. 413.-X-ray of patient shown in Figure 412 taken during operation with the intratracheal tube in place. It shows teeth involved in the fracture line with osteomyelitis and formation of sequestrum.
Fig. 414 (legend on opposite page).
1328
KURT H. THOMA
overhanging margins. The wound is then closed in layers either completely or around a rubber catheter inserted tCl the area for the instillation of local penicillin or streptomycin as already recommended. Case I and IV were treated in this manner.
Fig. 415.
Fig. 416.
Fig. 415.-X-ray showing osteomyelitis of the mandible with pathologic fracture. FIg. 416.-Segment of necrotic bo~e excised and a rubber catheter ins.erted for the local in&tillation of penicillin.
In chropic cases of osteomyelitis which have resisted treatment, a completely necrotic segment of the jaw ma~ have to be excised. The continuity, of the bone is restored later oy a bone graft. The following case serve's as an illustration. CASE VHI.-R.W. (M.e.H. No. 507899), a 46 year old man, had been treated for osteomyelitis of the mandible for two years. Several sequestrectomies had been performed Itnd an operation for sequestrectomy and saucerization was performed with penicillin therapy. In spite of this, the infectiOIi.· continued and ~finally a pathologic fracture resulted (Fig. 415). The patient suffered severe' pitin. A culture disclosed Bacillus coli and Staphylococcus albus; a smear showed Vincent's spirella and fusiform: bacilli. He was hospitalized again and given both penicillin and streptomycin. Mter two days the diseased segment of the mandible was completely ex-
ODONTOGENIC INFECTIONS OF THE JAWS
1329
cised (Fig. 416). He was given local therapy through a rubber catheter in addition to the intramuscular injections. The wound healed promptly, and ten days after the operation he was discharged completely relieved. He is to return after six months for a bone graft to restore the continuity of the jaw.
POSTOPERATIVE
TREATME~T
The after-care 'is important in all jaw infections. Treatment with the specific antibiotic should be continued until all signs of infection have subsided. In most oral cases, the patient receives a liquid diet high in prQtein, calories and vitamin content. Infection depletes the vitamin stores in the body, and patients with severe or prolonged dental infection become easily dehydrated because of the difficulty or discomfort in ingestion. Intravenous infusions should be administered freely to supply the necessary fluid and electrolyte requirements. Repeated blood transfusions greatly aid in improving the general condition of dental patients affiicted with chronic suppuration and help to overcome the infection. The oral hygiene, often neglected, is of prime importance to prevent secondary infection and to minimize .' sepsis. ,
SUMMARY
Odontogenic infections of the jaws and associated soft tissues are mixed bacterial invasions by both penicillin sensitive and resistant organisms. Antibiotic therapy is effective only when the etiologic organisms are carefully identified by both culture and smear. The local instillation of the antibiotic agent to the septic zone via an inlying catheter to augment intramuscular therapy has proved most effective in a large series of 'severe infections. The use of antibiotics should be combined with carefully planned and adequate surgery. Oral tissues have an extremely high resistance to infection, yet when invaded present serious problems with solemn complications. Careful preoperative planning and meticulous postoperative care are necessary to prevent poor cosmetic and functional end results. REFERENCES Hoffman, W. S.: Penicillin: Its Use and Possible Abuse. J. Am. Dent. A., 84:89, 1947. Smith-Petersen, M. N., Larson, C. B. and Cochran, N.: Local Chemotherapy with Primary Closure of Septic Wounds by Means of Drainage and Jrrigation Cannulae. ]. Bone & Joint Surg., 27:562, 1945. Thoma, K. H.: Acute Osteomyelitis of the Mandible Following Submental Phlegmon. Am. J. Orthodontics & Oral Surg. (Oral Surg. Sect.), 29:544, 1943. Idem: Septic Compound Mandibular Fracture Complicated with Submaxillary and Pterygoid Abscess Treated with Penicillin. Am. ]. Orthodontics & Oral Surg. (Ora) Surg. Sect.), 80: 158, 1944.
H. T:a:oMA, n.M.D. (>
THE sepsis of fractures compounded into the mouth, osteomyelitis, secondary neck infections and facial cellulitis are generally of odontogenic origin, caused by endemic bacteria derived from the oral cavity and the teeth. They frequently represent an extension from a latent dental focus that has become active or aggravated by trauma such as tooth extraction, or precipitated by lowered resistance caused by fatigue or a debilitating general disease. The advent of chemotherapy and especially the employment of antibiotics to prevent and combat infection has considerably altered the treatment of infections about the jaws. In some instances, these new agents are so effective that surgical interference is eliminated, while in others they make possible earlier surgical measures with greater safety to the patient and a more rapid convalescence. In most instances, however, the use of antibiotics combined with carefully planned and adequate surgery gives the best results. ANTIBIOTIC THERAPY
In considering therapeutic measures, the identification of the morbific organisms is as important as the finding of the immediate cause of the disease. A thorough bacteriologic study should be made in all cases because of the selective effect of the antibiotic drugs. If the infected tooth is still present, a culture may be made when it is extracted, although care must be taken to prevent contamination. When the patient has received penicillin previous to tooth extraction, clarase must be added to the culture media or there may be no growth. This, of course, would simply indicate that the organisms are penicillinsensitive. Both aerobic and anaerobic cultures are essential, and a smear should be examined for Vincent's organisms, because of the difficulty in growing the fusospirochetal organisms in vitro. The bacteria found most commonly in jaw and neck infections are the alpha and beta hemolytic streptococci, the nonhemolytic streptococcus and the Staphylococcus aureus and albus. Jaw infections are generally mixed infections with the following additional organisms: Bacillus coli, bacterioids, ramo8U8, perfringens, and other gramnegative bacilli and clostridia. Many of the latter are known to be (> Professor of Oral Surgery, Harvard University; Oral Surgeon and Chief of Dental Department, Massachusetts General Hospital, Boston.
1321
1322
KURT H. THOMA
penicillin-resistant, but are affected by streptomycin. Sensitivity tests should be used to determine the specific therapy. The importance of determining the exact bacteriologic factors is illustrated by two cases which are recorded briefly. CASE I.-J.B. (M.G.H. No. 551549), a 54 year old man, entered because of chronic osteomyelitis of the mandible of one year's duration. Two infected teeth had been extracted and penicillin treatment was used, but a draining sinus remained. The x-ray showed osteomyelitis which caused intermittent swelling and suppuration. Bacterial examination revealed a pure culture of Escherichia coli. The p&tient was treated with str.Jptomycin, 0.2 gm. every four hours and penicillin, 24,000 units every three hours. A saucerization and sequestrectomy of the involved section of the mandible was performed. This was followed by topical instillation of penicillin through a catheter to the bone cavity, and continuation of the intramuscular therapy. The wound was completely healed two and one-half weeks later.
Comment.-Because of the presence of penicillin-resistant organisms, previous treatment was unsuccessful until streptomycin was instituted. CASE 1I.-F.P. (M.G.H. No. 549851), a 42 year old man, presented an exten.sive swelling of the right side of the face which came on after the excision of an impacted third molar six months previously. He had been treated with poultices, penicillin and streptomycin, plus x-ray radiation. Multiple fistulas drained seropurulent discharge. Incision and drainage was performed on January 3. Anaerobic cultures yielded Clostridium sporogenes; the smear showed an abundance of spirochetes and fusiform. bacilli. There was no evidence of actinomycosis. The patient was given 48,000 units of penicillin every three hours, and streptomycin, 0.2 gm. every four hours, with slight improvement. Frequent irrigations of the fistula with an aqueous solution of chlorophyll was then instituted "on January 7 and continued until January 11, when the patient was discharged relieved. Three weeks later all fistulas had healed.
,! I
Comment.-In spite of both penicillin and streptomycin treatment, a mixed anaerobic infection of the face did not respond until chlorophyll raised the local tissue resistance to infection. SURGICAL TREATMENT
Surgical procedures should be carefully planned. The right method must be applied at the right time. The Removal of the Cause.-In odontogenic infections, the removal of the causative tooth is of primary importance. In most instances the infection spreads through the pulp canal of a carious tooth or root. Periodontal infection and pericoronal infection of a partly erupted impacted tooth are also etiologic factors. If the cause is not removed, recovery is delayed and complications may set in, as illustrated in ~e following case. CASE I1I.-O.D. (M.G.H. No. 29558), a 31 year old woman, had been treated for a submental phlegmon by chemotherapy and incision and drainage. She rei
H
;,11
ODONTOGENIC INFECTIONS OF THE JAWS
1323
turned three weeks later with an acute swelling. X-ray examination showed a retained molar root with extensive osteomyelitis of the mandible. A draining fistula which had remained from the previous incision led to the affected bone. Following removal of the infected tooth and sequestrectomy, the patient made a rapid recovery.
Cellulitis and abscesses of the fascial spaces may be caused by both deciduous and permanent teeth. Submaxillary, submental, sublingual,
Fig. 408.
Fig. 409.
Fig. 408.-0steomyelitis of the mandible due to furunculosis. Fig. 409.-Mter saucerization and sequestrectomy, a rubber catheter is inserted to the bone and the incision closed by suture.
parapharyngeal and infratemporal abscesses may develop. In lOme cases satisfactory results may be obtained by conservative treatment in order to retain incisors and canines, but in many cases extraction is indicated as soon as possible to remove the cause, and in some cases to establish drainage. Even in acute suppurative cases there is no great danger of complications from this procedure with the prophylactic use of penicillin.
1324
KURT H. THOMA
Osteomyelitis of the jaw is generally of dental origin; hematogenous infection and infection from furunculosis is rare. The tooth causing the acute infection is usually sore, but in widespread extension many teeth may be secondarily involved. Adequate dental radiographs are essential. In most cases, extraction is indicated as soon as a good penicillin level has been obtained. A case in which the osteomyelitis was caused by furunculosis was seen recently. VASE IV.-J.H. (M.C.H. No. 565446), a 36 year old man, presented clinical and x-ray evidence of osteomyelitis. A furuncle had formed in the subauricular region six months ago and residual tenderness persisted. Pain and swelling of the jaw developed two weeks before admission, but his dentist could find no infection associated with the teeth. However, he finally extracted the first molar. The second molar later became painful and loose, and was extracted after penicillin therapy was started. The symptoms became worse, and a lateral jaw film showed extensive osteomyelitis (Fig. 408). A radical saucerization and sequestrectomy was performed and a rubber catheter inserted for local instillation of penicillin (Fig. 409). The culture at operation grew out Micrococcus catarrhalis and Staphylocot:cus albus. Recovery was uneventful.
Comment.-The instillation of penicillin via an inlying catheter assures concentration of the drug not possible by the intramuscular route. Septic fractures often are due to the involvement of a tooth. Infection may penetrate from the gingival margin along the fracture, causing an abscess of the adjacent fascial spaces, and result in osteomyelitis with extensive loss of bone. It is a good rule to extract teeth in the fracture line even though they may be valuable for intermaxillary fixation. Today there are several good methods available for the fixation of jaw segments which have been made edentulous by such extractions. The following case illustrates the formation of a submaxillary abscess from a fracture along a tooth. CASE V.-M.R. (M.C.H. No. 474164), a 23 year old woman, had contracted a fracture of the mandible which was reduced and immobilized by intermaxillary wire fixation. A submaxillary swelling developed with fever and leukocytosis. When the lip was retracted to remove the wiring, the abscess broke intraorally and a • large amount of frank pus discharged. The tooth in the fracture line was removed and the mandible again immobilized with intermaxillary wiring. The submaxillary abscess was evacuated and a rubber catheter inserted for the local instillation of penicillin. Sepsis ceased and bone repair followed uneventfully.
Comment.-The tooth in the line of fracture was the source of ~epsis and bony union was prevented while the tooth was retained. The Elimination of Pus and Necrotic Tissue.-In some cases the use of antibiotics may result in resolution without operative interference, particularly if such treatment is instituted before pus has formed and before bone necrosis has set in. F.ascial abscesses which previously had to be incised and drained, and cases of acute osteomyelitis which previously went on to sequestration may thus be cured without sur-
III
ODONTOGENIC INFECTIONS OF THE JAWS
1325
gery. Many patients do not present themselves for treatment early enough, however, and require elimination of accumulated pus arid excision of dead bone. In fascial abscesses the pus may be aspirated by means of a syringe, and the immediate injection of penicillin in dilution of 1000 units per
Fig. 410.
Fig. 411.
Fig. 410.-Compound, comminuted fracture of the mandible complicated by a cyst and submandibular cellulitis. X-ray taken after the tube was inserted into the cyst for local instillation of penicillin. Fig. 411.-Fracture reduced and immobilized by skeletal fixation with accessory wire suture. Note: The pins on the right do not extend into the cyst; the x-ray appearance is due to angulation when the exposure was made. X-ray was taken eight weeks after reduction showing healing of bone.
cubic centimeter may be beneficial. In most cases incision and evacuation of the pus, followed by instillation of penicillin through a tube inserted into the abscess cavity gives more satisfactory results (Fig. 414). The advantage of this method over the aspiration technic is that penicillin or streptomycin can be instilled every three or four
1326
KURT H. THOMA
hours to supplement the parenteral administration. Similar treatment may be used in acute infection of odontogenic cysts. CASE Vr.-T.M. (M.G.H. No. 559630), a 54 year old man, contracted a compound, comminuted fracture through a large cyst in the anterior part of the mandible. His face swelled and he suffered severe pain. Temperature was 103 0 F., and the white cell count 17,300. He received 48,000 units of penicillin every three hours and on the following day, under local anesthesia, an incision was made beneath the chin to evacuate the purulent contents of the cyst. A rubber catheter was inserted and sutured to the skin, and the wound closed (Fig. 410). Ute intramuscular injections of penicillin were continued and supplemented with local instillations. The culture revealed the presence of Staphylococcus albus. After the acute infection had subsided, the cyst was enucleated, the cavity filled with fibrin foam, closed by suture, and skeletal jaw fixation applied. Five days later the patient was discharged. After eight weeks the x-ray showed satisfactory bone healing (Fig. 411), so that the appliance could be removed. When tested, it was found that the jaw had healed satisfactorily and all signs of infection subsided.
In fractures complicated by osteomyelitis a sequestrectomy usually is necessary, and best accomplished from an extraoral approach. If the bone loss is not too great, union may be expected if the jaw is properly immobilized. I have had excellent results with skeletal fixation, using pins in the anterior fragment far away from the infection, and my peripheral bone clamp on the posterior fragment in the infected region. Since its use does not involve drilling into the bone, there is no danger of spreading the infection. CASE VII.-S.McK. (M.G.H. No. 533145), a 46 year old woman, had been struck on the jaw six weeks previously, and contracted a fracture. She had received medical care which included penicillin therapy for four days. She had a submaxillary swelling and multiple draining fistulas (Fig. 412). X-ray examination revealed a fracture complicated by osteomyelitis. A molar extended into the fracture line (Fig. 413). The temperature was 99.4 0 F., and the white cell count 11,000. She received 32,000 units of penicillin every three hours and two days· later a sequestrectomy was performed, a rubber catheter inserted, and the fracture immobilized by means of skeletal fixation. Pins were used in the anterior fragment, and a peripheral bone clamp at the angle of the jaw (Fig. 414). Seven days later the catheter was removed and two days later the patient was discharged. The appliance was removed seven weeks after the operation when a satisfactory union had been obtained.
In osteomyelitis the removal of necrotic bone, when completel} sequestrated, may be a simple procedure, especially if an intraorai approach is possible. In other instances, the sequestrum may be encased or inaccessible, and an extra oral approach is preferable. The bone is decorticated to expose the infected channels so that all necrosis can be removed. Saucerization should be carried out to eliminate Fig. 414.-Mter sequestrectomy the fractures was immobilized by means of peripheral clamp at the angle of the jaw and two half pins inserted into the anterior fragment. A rubber catheter was inserted to the infected area for the instillation of penicillin.
Fig. 412.
Fig. 413.
Fig. 412.-Submaxillary abscess with multiple fistulas due to septic fracture. Fig. 413.-X-ray of patient shown in Figure 412 taken during operation with the intratracheal tube in place. It shows teeth involved in the fracture line with osteomyelitis and formation of sequestrum.
Fig. 414 (legend on opposite page).
1328
KURT H. THOMA
overhanging margins. The wound is then closed in layers either completely or around a rubber catheter inserted tCl the area for the instillation of local penicillin or streptomycin as already recommended. Case I and IV were treated in this manner.
Fig. 415.
Fig. 416.
Fig. 415.-X-ray showing osteomyelitis of the mandible with pathologic fracture. FIg. 416.-Segment of necrotic bo~e excised and a rubber catheter ins.erted for the local in&tillation of penicillin.
In chropic cases of osteomyelitis which have resisted treatment, a completely necrotic segment of the jaw ma~ have to be excised. The continuity, of the bone is restored later oy a bone graft. The following case serve's as an illustration. CASE VHI.-R.W. (M.e.H. No. 507899), a 46 year old man, had been treated for osteomyelitis of the mandible for two years. Several sequestrectomies had been performed Itnd an operation for sequestrectomy and saucerization was performed with penicillin therapy. In spite of this, the infectiOIi.· continued and ~finally a pathologic fracture resulted (Fig. 415). The patient suffered severe' pitin. A culture disclosed Bacillus coli and Staphylococcus albus; a smear showed Vincent's spirella and fusiform: bacilli. He was hospitalized again and given both penicillin and streptomycin. Mter two days the diseased segment of the mandible was completely ex-
ODONTOGENIC INFECTIONS OF THE JAWS
1329
cised (Fig. 416). He was given local therapy through a rubber catheter in addition to the intramuscular injections. The wound healed promptly, and ten days after the operation he was discharged completely relieved. He is to return after six months for a bone graft to restore the continuity of the jaw.
POSTOPERATIVE
TREATME~T
The after-care 'is important in all jaw infections. Treatment with the specific antibiotic should be continued until all signs of infection have subsided. In most oral cases, the patient receives a liquid diet high in prQtein, calories and vitamin content. Infection depletes the vitamin stores in the body, and patients with severe or prolonged dental infection become easily dehydrated because of the difficulty or discomfort in ingestion. Intravenous infusions should be administered freely to supply the necessary fluid and electrolyte requirements. Repeated blood transfusions greatly aid in improving the general condition of dental patients affiicted with chronic suppuration and help to overcome the infection. The oral hygiene, often neglected, is of prime importance to prevent secondary infection and to minimize .' sepsis. ,
SUMMARY
Odontogenic infections of the jaws and associated soft tissues are mixed bacterial invasions by both penicillin sensitive and resistant organisms. Antibiotic therapy is effective only when the etiologic organisms are carefully identified by both culture and smear. The local instillation of the antibiotic agent to the septic zone via an inlying catheter to augment intramuscular therapy has proved most effective in a large series of 'severe infections. The use of antibiotics should be combined with carefully planned and adequate surgery. Oral tissues have an extremely high resistance to infection, yet when invaded present serious problems with solemn complications. Careful preoperative planning and meticulous postoperative care are necessary to prevent poor cosmetic and functional end results. REFERENCES Hoffman, W. S.: Penicillin: Its Use and Possible Abuse. J. Am. Dent. A., 84:89, 1947. Smith-Petersen, M. N., Larson, C. B. and Cochran, N.: Local Chemotherapy with Primary Closure of Septic Wounds by Means of Drainage and Jrrigation Cannulae. ]. Bone & Joint Surg., 27:562, 1945. Thoma, K. H.: Acute Osteomyelitis of the Mandible Following Submental Phlegmon. Am. J. Orthodontics & Oral Surg. (Oral Surg. Sect.), 29:544, 1943. Idem: Septic Compound Mandibular Fracture Complicated with Submaxillary and Pterygoid Abscess Treated with Penicillin. Am. ]. Orthodontics & Oral Surg. (Ora) Surg. Sect.), 80: 158, 1944.