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Osteomyelitis of the Mandible and Maxilla
OSTEOMYELITIS OF THE MANDIBLE AND MAXILLA By THEODOR BLUM, D.D.S., M.D., New York City (Read before the American Society of Oral Surgeons and Exodontists, Cleveland, Ohio, September 6, 1923)
I
T may be well to recall that osteo called periostitis, of the bone proper myelitis of the mandible and maxilla osteitis, of the bone marrow osteomyelitis. may be hematogenous in origin or it It is impossible for one of these three may be caused by an infection originat structures to be involved without some ing from the teeth or their surrounding disturbance taking place in the other two. tissues. The hematogenous type may de The terms periostitis and osteomyelitis velop without any previous acute infec are the most common. While the acute tious disease or it may develop a few variety will in a few days become puru weeks after such an acute infection. As lent, the chronic variety, called perios the condition is rather rare, compara titis ossificans, is productive of new bone. tively speaking, it must suffice to state As osteomyelitis soon involves the peri that the cases run the same course and osteum and surrounding tissues as well, require similar treatment. Usually, how the term periosteo-osteomyelitis would ever, in the nonhematogenous variety, the be proper; however, it is not necessary. lesion is more extensive and consequently It has been previously mentioned that the sequestrum formation is larger. The caries is the most prevalent cause of hematogeous occurs most frequently in osteomyelitis. Statistics have shown that children. Of the acute infectious dis the frequency curve of the teeth involved eases that are occasionally followed by ascends from the central incisor to its osteomyelitis of the jaws, scarlet fever, apex when reaching the first molar and measles, chickenpox, influenza, typhoid then descends again to the third molar. fever and diphtheria must be mentioned. The mandible is more often involved Whether, in these cases, the previous in than the maxilla, the relation being 3 : 2 . fection alone is responsible for the osteo Although the oral surgeon seldom sees a myelitis or whether the general lowered case in the initial stage, it is known that resistance paves the way for the bone to it usually begins with a pericementitis; be attacked by the usual organisms found then the swelling appears and there is in this condition has not been decided. a rise in temperature, which at times is The majority of all cases of osteo very high and accompanied by chills. myelitis of the mandible and maxilla are The swelling is often noticed as an caused by an extension of the infection obliteration of the upper or lower fold of from a carious tooth, from a gangrenous the vestibule when appearing on the buc pulp of an apparently sound tooth, from cal or labial side. If pus develops on an alveolus after an extraction, or from the lingual side of the mandible, the a wound reaching the bone or periosteum, characteristic swelling of the submental as is most commonly seen in fractures region and immobility of the tongue are of the mandible. Naturally, those cases always present and the speech will be caused by caries are by far the most difficult. The lymph glands become in common. volved, enlarged and sensitive to palpa An inflammation of the periosteum is tion. In marked cases, a perilymphadJour. A .D . A., September, 1924
802
Blum— Osteomyelitis of the Mandible and Maxilla enitis develops, the submaxillary and submental glands being firmly adherent to the mandible. An infection of the mandibular incisors travels to the sub mental lymph glands, while infection of any of the other teeth affects the sub maxillary glands. Pus developing in the bone pierces the cortical plate, mak ing its way through the point of least resistance, as through the outer plate from the maxillary incisors or into the nose, through the palatal plate from the palatal roots of the maxillary teeth as well as those of the lateral incisors. The an trum becomes involved in those cases in which the proximity of the apex of the teeth invites such a course. On account of the anatomic relation of the first molar, an infection here is the most fre quent cause of this complication. Owing to the fact that the skin is nearer the mandible, and that pus, there fore, does not have to travel so far, and is also probably influenced by gravity, subcutaneous abscesses are mostly seen in the mandible. The anatomic relation of the upper fold of the vestibule readily explains this occurrence. Trismus will be found in osteomyelitis of the maxilla as well as the mandible, depending on how near the diseased area is to the muscles of mastication and on the extent of their involvement. While in minor cases the extraction of the responsible teeth may cause resolu tion of the whole process, the majority of cases will require surgical treatment. This consists chiefly of free drainage and watchful waiting. Wherever pus is found, a surgical incision is made; when ever bone is separating as a sequestrum, it is removed. Argyrol 25 per cent and iodoform gauze are preferred for dress ings. Although there is no objection to the removal of the responsible tooth, especially if it is a single rooted and loose; and while a patient may succumb to the disease, not on account of such an extraction, but in spite of it, I still prefer, in the majority of cases, to be satisfied
803
with free drainage by an incision only, if pus is present. After the acute symp toms subside, the removal of such a tooth, possibly under conduction anesthesia, will not only allow the operator to chisel out roots or apices should the tooth frac ture, but will also permit him to curet if this is indicated. For infected soft tissues not communicating with the bone or the mouth, surgical solution of chlori nated soda (Dakin’s) or similar hypo chlorite solutions are indicated. For ir rigation of the bone itself, warm physi ologic solution of sodium chlorid or boric acid solution, in other words, a bland fluid, should be used and not a highly germicidal agent, since, in my experience employment of the latter has sometimes delayed the process of sequestration. Vaccines should be administered when ever indicated. As long as the belief is prevalent that lowered resistance has a good deal to do with the development and progress of the disease, it is extremely important to build up this resistance. A fluid diet is prescribed during the acute stages, con sisting mainly of fresh fruit juices, such as orange juice and lemonade, as well as milk and eggs in some form. Later on, fresh vegetables and cereals are added. In rare and selected minor cases, the responsible tooth may be saved by dental treatment and root amputation. Fistulous tracts, which are found in chronic cases, leading from the focus to the skin, give the sensation of a cord to the palpating finger. The fistulous opening itself may stop discharging and apparently heal entirely, only to open again with new pus formation. The contraction of this cord causes a char acteristic pulling in of the mouth of the fistula and the surrounding skin. The true nature of fistulae at the chin origi nating from mandibular incisors or cus pids has at times not been recognized and they have been treated as conditions arising from the skin, of benign or malig nant character. This is due to the fact
804
The Journal of the American Dental Association
that in most of the chin fistulae, the teeth that are responsible are not carious, but their pulps have lost their vitality through trauma. It is only by dental and roentgen-ray examination that the causative factor can be detected. In this connec tion, a few words may be said about howsuch an infection through the blood stream could possibly take place. Partsch relates that he has found organisms in these pulps that are never found in the blood. Furthermore, at no time were there ever serious general symptoms pres ent. He wonders whether organisms do not travel toward the pulp through some defect in the enamel. It seems that an infection through the gingival edge and pericementum is more plausible if the blood stream must be excluded. Osteomyelitis also develops as a com plication of severe stomatitis, mercurial stomatitis, noma and scurvy. Localized ulcerative stomatitis caused by a partly erupted tooth, generally a mandibular third molar (so-called in fected wisdom-tooth pocket) is quite im portant on account of the extension which may develop and affect the pericementum, the periosteum and even the bone proper, and the neighboring lymph glands. There is no limit regarding age, as third molars especially may erupt at any time. Pain is experienced along the bone in the region of the tooth and fetor ex ore and trismus are present. In advanced and serious cases, peritonsillar and pharyn geal abscesses complicate the case. The adjacent lymph nodes are always in volved and may become purulent so that an external incision is indicated. The organisms found are the spiro chete and the fusiform bacillus. I do not deem it advisable to cut the flap cover ing the erupted tooth during the acute stage, but to cleanse the pocket with 25 per cent argyrol on cotton swabs and insert a small strip of iodoform gauze to insure drainage. A hot mouth wash of physiologic solution of sodium chlorid should be used every hour. Fluid diet
and a purge are essential. If the tooth is decayed and beyond repair or without function, it should be extracted after the acute symptoms have subsided. If the antagonist biting on the flap is causing the injury, its removal must be con sidered. A complicating periostitis or osteomyelitis will be treated in the usual manner. In most cases of osteomyelitis, recovery ensues in due time, even though with the loss of a number of teeth and large por tions of bone. The most serious cases are those in which the bone and immediate surrounding tissues are hardly affected at all, and in some cases so slightly that a clinical examination does not dis close anything. Here the defensive powers of the body are utterly unable to cope with the infection, either on account of the virulence of the infection or be cause of lowered resistance, or both. The organisms and their poisons are carried away by the blood and lymph stream, and their presence gives rise to complications which, in my experience, have always re sulted in the death of the patient. Lud wig’s angina, a very rare condition, is a severe cellulitis of the tissues of the floor of the mouth. In spite of extensive free drainage, medication, etc., the pa tient will succumb in a few days. Those cases that show a fair amount of pus on incision are erroneously termed Lud wig’s angina. They are, as a rule, ab scesses developing either subperiosteally or after the breaking down of a lymph gland. It is characteristic of the cases of angina that, on incision, a very small quantity of pus, if any, is found; gener ally, a turbid serous fluid of extremely bad odor is noticed, and at times the gas bacillus is present. Another com plication is thrombosis of the cavern ous sinus, which, in all the five cases under my observation, originated from a focus in the mandible, four after ex tractions and one after pulp capping of a first molar. Edema of the eyelids and orbit, with a protrusion of the eyeball
Blum— Osteomyelitis of the Mandible and Maxilla and other eye symptoms, and the mark edly low general condition of the pa tient are the outstanding symptoms. As a rule, the differential diagnosis in osteomyelitis is simple. A few years ago, a central sarcoma of the mandible came under my observation. On account of looseness of the teeth, marked intraoral and extraoral swelling and softness of the tissues, which was mistaken for fluctua tion, the dentist in charge made the diag nosis of chronic osteomyelitis and insti tuted treatment accordingly. Such inter ference with malignant neoplasm hastens its extension and deprives the patient of the possibility of recovery. Even repeated palpation of a cancerous growth has been shown to cause.metastasis (Bloodgood). Of the specific inflammations of the jaws, tuberculosis and syphilis are the most important. In certain parts of the United States, actinomycosis occurs. It must suffice to say that it is caused by the ray fungus, which is easily detected by microscopic examination. Tubercu losis of the jaw may extend to the bone through a lesion of the mucosa or enter through the pulp of a carious tooth, causing osteomyelitis of tuberculous na ture; while, on the other hand, an ordi nary osteomyelitis may become tubercu lous through a secondary infection. Of course, tuberculosis may develop in the jaw bone as in any other bone of the body, the point of predilection being the infraorbital border of the maxilla. Ex tremely chronic and mild infection, as well as a simultaneous presence of dacty litis, is characteristic. Only tertiary syphilis of the jaw bones is found, and then most commonly in the maxilla. Gumma of the hard palate extends either downward or in the opposite direction, into the nose. It must be remembered that in about IS per cent of tertiary bone lesions, the Wasserman examination is negative. The examination of the spinal fluid and a provocative Wasserman test are indi cated, and specific treatment should be 140 West Fifty-Seventh Street
80S
instituted. Syphilitic hyperostosis may be the cause of trigeminal neuralgia. During the last winter, two cases of phosphorus necrosis came under my ob servation. In this connection, mention must be made that it is the white and yellow phosphorus that are responsible and not the red. According to authori ties on this subject, phosphorus osteo myelitis, or, as it is called, phosphorus necrosis of the jaws, is phosphorus poisoning plus infection.1 This resume of the subject was written mainly to emphasize one point, namely, where the responsibility lies in the majority of these cases of osteomyelitis: whether it is lack of knowledge or neg lect on the part of the general medical or dental practitioner or of the specialist. Can the profession be satisfied with the usual explanation of lowered resistance of the patient? It is true that thousands of injections are given properly and im properly, thousands of teeth are extracted with sterile and unsterile instruments, with or without the necessary knowledge of the operation and after-treatment; still, only rarely, comparatively speaking, does an infection of the bone develop. However, I have seen a number of cases in which neglect on the part of the oper ator was at least suspected, or lack of knowledge was quite apparent What remedy can be offered? The schools must pay more attention to the teaching of minor oral surgery, which should in clude considerable practical experience. The recent graduate should be compelled by law to practice at least one year under supervision, and no one should be per mitted to practice any surgical specialty of dentistry without having been pre pared in some way for such work and without giving some account of his or her ability to the authorities. 1. During the Fall of 1923, there came under my observation a case of osteomyelitis of the mandible and maxilla, somewhat similar to phosphorus necrosis; which, however, was caused by some radioactive substance used in the manufacture of luminous dials for watches. The condition has been termed “radium jaw.”
I
T may be well to recall that osteo called periostitis, of the bone proper myelitis of the mandible and maxilla osteitis, of the bone marrow osteomyelitis. may be hematogenous in origin or it It is impossible for one of these three may be caused by an infection originat structures to be involved without some ing from the teeth or their surrounding disturbance taking place in the other two. tissues. The hematogenous type may de The terms periostitis and osteomyelitis velop without any previous acute infec are the most common. While the acute tious disease or it may develop a few variety will in a few days become puru weeks after such an acute infection. As lent, the chronic variety, called perios the condition is rather rare, compara titis ossificans, is productive of new bone. tively speaking, it must suffice to state As osteomyelitis soon involves the peri that the cases run the same course and osteum and surrounding tissues as well, require similar treatment. Usually, how the term periosteo-osteomyelitis would ever, in the nonhematogenous variety, the be proper; however, it is not necessary. lesion is more extensive and consequently It has been previously mentioned that the sequestrum formation is larger. The caries is the most prevalent cause of hematogeous occurs most frequently in osteomyelitis. Statistics have shown that children. Of the acute infectious dis the frequency curve of the teeth involved eases that are occasionally followed by ascends from the central incisor to its osteomyelitis of the jaws, scarlet fever, apex when reaching the first molar and measles, chickenpox, influenza, typhoid then descends again to the third molar. fever and diphtheria must be mentioned. The mandible is more often involved Whether, in these cases, the previous in than the maxilla, the relation being 3 : 2 . fection alone is responsible for the osteo Although the oral surgeon seldom sees a myelitis or whether the general lowered case in the initial stage, it is known that resistance paves the way for the bone to it usually begins with a pericementitis; be attacked by the usual organisms found then the swelling appears and there is in this condition has not been decided. a rise in temperature, which at times is The majority of all cases of osteo very high and accompanied by chills. myelitis of the mandible and maxilla are The swelling is often noticed as an caused by an extension of the infection obliteration of the upper or lower fold of from a carious tooth, from a gangrenous the vestibule when appearing on the buc pulp of an apparently sound tooth, from cal or labial side. If pus develops on an alveolus after an extraction, or from the lingual side of the mandible, the a wound reaching the bone or periosteum, characteristic swelling of the submental as is most commonly seen in fractures region and immobility of the tongue are of the mandible. Naturally, those cases always present and the speech will be caused by caries are by far the most difficult. The lymph glands become in common. volved, enlarged and sensitive to palpa An inflammation of the periosteum is tion. In marked cases, a perilymphadJour. A .D . A., September, 1924
802
Blum— Osteomyelitis of the Mandible and Maxilla enitis develops, the submaxillary and submental glands being firmly adherent to the mandible. An infection of the mandibular incisors travels to the sub mental lymph glands, while infection of any of the other teeth affects the sub maxillary glands. Pus developing in the bone pierces the cortical plate, mak ing its way through the point of least resistance, as through the outer plate from the maxillary incisors or into the nose, through the palatal plate from the palatal roots of the maxillary teeth as well as those of the lateral incisors. The an trum becomes involved in those cases in which the proximity of the apex of the teeth invites such a course. On account of the anatomic relation of the first molar, an infection here is the most fre quent cause of this complication. Owing to the fact that the skin is nearer the mandible, and that pus, there fore, does not have to travel so far, and is also probably influenced by gravity, subcutaneous abscesses are mostly seen in the mandible. The anatomic relation of the upper fold of the vestibule readily explains this occurrence. Trismus will be found in osteomyelitis of the maxilla as well as the mandible, depending on how near the diseased area is to the muscles of mastication and on the extent of their involvement. While in minor cases the extraction of the responsible teeth may cause resolu tion of the whole process, the majority of cases will require surgical treatment. This consists chiefly of free drainage and watchful waiting. Wherever pus is found, a surgical incision is made; when ever bone is separating as a sequestrum, it is removed. Argyrol 25 per cent and iodoform gauze are preferred for dress ings. Although there is no objection to the removal of the responsible tooth, especially if it is a single rooted and loose; and while a patient may succumb to the disease, not on account of such an extraction, but in spite of it, I still prefer, in the majority of cases, to be satisfied
803
with free drainage by an incision only, if pus is present. After the acute symp toms subside, the removal of such a tooth, possibly under conduction anesthesia, will not only allow the operator to chisel out roots or apices should the tooth frac ture, but will also permit him to curet if this is indicated. For infected soft tissues not communicating with the bone or the mouth, surgical solution of chlori nated soda (Dakin’s) or similar hypo chlorite solutions are indicated. For ir rigation of the bone itself, warm physi ologic solution of sodium chlorid or boric acid solution, in other words, a bland fluid, should be used and not a highly germicidal agent, since, in my experience employment of the latter has sometimes delayed the process of sequestration. Vaccines should be administered when ever indicated. As long as the belief is prevalent that lowered resistance has a good deal to do with the development and progress of the disease, it is extremely important to build up this resistance. A fluid diet is prescribed during the acute stages, con sisting mainly of fresh fruit juices, such as orange juice and lemonade, as well as milk and eggs in some form. Later on, fresh vegetables and cereals are added. In rare and selected minor cases, the responsible tooth may be saved by dental treatment and root amputation. Fistulous tracts, which are found in chronic cases, leading from the focus to the skin, give the sensation of a cord to the palpating finger. The fistulous opening itself may stop discharging and apparently heal entirely, only to open again with new pus formation. The contraction of this cord causes a char acteristic pulling in of the mouth of the fistula and the surrounding skin. The true nature of fistulae at the chin origi nating from mandibular incisors or cus pids has at times not been recognized and they have been treated as conditions arising from the skin, of benign or malig nant character. This is due to the fact
804
The Journal of the American Dental Association
that in most of the chin fistulae, the teeth that are responsible are not carious, but their pulps have lost their vitality through trauma. It is only by dental and roentgen-ray examination that the causative factor can be detected. In this connec tion, a few words may be said about howsuch an infection through the blood stream could possibly take place. Partsch relates that he has found organisms in these pulps that are never found in the blood. Furthermore, at no time were there ever serious general symptoms pres ent. He wonders whether organisms do not travel toward the pulp through some defect in the enamel. It seems that an infection through the gingival edge and pericementum is more plausible if the blood stream must be excluded. Osteomyelitis also develops as a com plication of severe stomatitis, mercurial stomatitis, noma and scurvy. Localized ulcerative stomatitis caused by a partly erupted tooth, generally a mandibular third molar (so-called in fected wisdom-tooth pocket) is quite im portant on account of the extension which may develop and affect the pericementum, the periosteum and even the bone proper, and the neighboring lymph glands. There is no limit regarding age, as third molars especially may erupt at any time. Pain is experienced along the bone in the region of the tooth and fetor ex ore and trismus are present. In advanced and serious cases, peritonsillar and pharyn geal abscesses complicate the case. The adjacent lymph nodes are always in volved and may become purulent so that an external incision is indicated. The organisms found are the spiro chete and the fusiform bacillus. I do not deem it advisable to cut the flap cover ing the erupted tooth during the acute stage, but to cleanse the pocket with 25 per cent argyrol on cotton swabs and insert a small strip of iodoform gauze to insure drainage. A hot mouth wash of physiologic solution of sodium chlorid should be used every hour. Fluid diet
and a purge are essential. If the tooth is decayed and beyond repair or without function, it should be extracted after the acute symptoms have subsided. If the antagonist biting on the flap is causing the injury, its removal must be con sidered. A complicating periostitis or osteomyelitis will be treated in the usual manner. In most cases of osteomyelitis, recovery ensues in due time, even though with the loss of a number of teeth and large por tions of bone. The most serious cases are those in which the bone and immediate surrounding tissues are hardly affected at all, and in some cases so slightly that a clinical examination does not dis close anything. Here the defensive powers of the body are utterly unable to cope with the infection, either on account of the virulence of the infection or be cause of lowered resistance, or both. The organisms and their poisons are carried away by the blood and lymph stream, and their presence gives rise to complications which, in my experience, have always re sulted in the death of the patient. Lud wig’s angina, a very rare condition, is a severe cellulitis of the tissues of the floor of the mouth. In spite of extensive free drainage, medication, etc., the pa tient will succumb in a few days. Those cases that show a fair amount of pus on incision are erroneously termed Lud wig’s angina. They are, as a rule, ab scesses developing either subperiosteally or after the breaking down of a lymph gland. It is characteristic of the cases of angina that, on incision, a very small quantity of pus, if any, is found; gener ally, a turbid serous fluid of extremely bad odor is noticed, and at times the gas bacillus is present. Another com plication is thrombosis of the cavern ous sinus, which, in all the five cases under my observation, originated from a focus in the mandible, four after ex tractions and one after pulp capping of a first molar. Edema of the eyelids and orbit, with a protrusion of the eyeball
Blum— Osteomyelitis of the Mandible and Maxilla and other eye symptoms, and the mark edly low general condition of the pa tient are the outstanding symptoms. As a rule, the differential diagnosis in osteomyelitis is simple. A few years ago, a central sarcoma of the mandible came under my observation. On account of looseness of the teeth, marked intraoral and extraoral swelling and softness of the tissues, which was mistaken for fluctua tion, the dentist in charge made the diag nosis of chronic osteomyelitis and insti tuted treatment accordingly. Such inter ference with malignant neoplasm hastens its extension and deprives the patient of the possibility of recovery. Even repeated palpation of a cancerous growth has been shown to cause.metastasis (Bloodgood). Of the specific inflammations of the jaws, tuberculosis and syphilis are the most important. In certain parts of the United States, actinomycosis occurs. It must suffice to say that it is caused by the ray fungus, which is easily detected by microscopic examination. Tubercu losis of the jaw may extend to the bone through a lesion of the mucosa or enter through the pulp of a carious tooth, causing osteomyelitis of tuberculous na ture; while, on the other hand, an ordi nary osteomyelitis may become tubercu lous through a secondary infection. Of course, tuberculosis may develop in the jaw bone as in any other bone of the body, the point of predilection being the infraorbital border of the maxilla. Ex tremely chronic and mild infection, as well as a simultaneous presence of dacty litis, is characteristic. Only tertiary syphilis of the jaw bones is found, and then most commonly in the maxilla. Gumma of the hard palate extends either downward or in the opposite direction, into the nose. It must be remembered that in about IS per cent of tertiary bone lesions, the Wasserman examination is negative. The examination of the spinal fluid and a provocative Wasserman test are indi cated, and specific treatment should be 140 West Fifty-Seventh Street
80S
instituted. Syphilitic hyperostosis may be the cause of trigeminal neuralgia. During the last winter, two cases of phosphorus necrosis came under my ob servation. In this connection, mention must be made that it is the white and yellow phosphorus that are responsible and not the red. According to authori ties on this subject, phosphorus osteo myelitis, or, as it is called, phosphorus necrosis of the jaws, is phosphorus poisoning plus infection.1 This resume of the subject was written mainly to emphasize one point, namely, where the responsibility lies in the majority of these cases of osteomyelitis: whether it is lack of knowledge or neg lect on the part of the general medical or dental practitioner or of the specialist. Can the profession be satisfied with the usual explanation of lowered resistance of the patient? It is true that thousands of injections are given properly and im properly, thousands of teeth are extracted with sterile and unsterile instruments, with or without the necessary knowledge of the operation and after-treatment; still, only rarely, comparatively speaking, does an infection of the bone develop. However, I have seen a number of cases in which neglect on the part of the oper ator was at least suspected, or lack of knowledge was quite apparent What remedy can be offered? The schools must pay more attention to the teaching of minor oral surgery, which should in clude considerable practical experience. The recent graduate should be compelled by law to practice at least one year under supervision, and no one should be per mitted to practice any surgical specialty of dentistry without having been pre pared in some way for such work and without giving some account of his or her ability to the authorities. 1. During the Fall of 1923, there came under my observation a case of osteomyelitis of the mandible and maxilla, somewhat similar to phosphorus necrosis; which, however, was caused by some radioactive substance used in the manufacture of luminous dials for watches. The condition has been termed “radium jaw.”