Osteomyelitis can affect either of a patient's jaws, usually the lower one, and can take various forms:
Osteomyelitis complicating an infected tooth socket in an adult is more common in the mandible (5.8, 26.3). Suspect it if he has pain, swelling, tenderness, trismus, and fever after he has had an infected tooth removed (sometimes months before), or an alveolar abscess drained. If his osteomyelitis becomes chronic he may have sinuses over his lower face, or over the inferior border of his mandible (see Fig. 26-8). Often, he has trismus. His offending teeth are usually loose, and you may see pus discharging around them.
Osteomyelitis complicating an open fracture, (62.7, 69.7), especially a comminuted one of his lower jaw (unusual). A thorough wound toilet should prevent this, provided it is done reasonably early. The mandible has a good blood supply, so that even small pieces of bone may live, if they have some soft tissue connection.
Osteomyelitis in children, especially malnourished ones, may be the result of a subacute necrosis folowing septic thrombophlebitis. This is probably a manifestation of the same process that causes cancrum oris (26.6) and septic thrombophlebitis of the scalp (7.14). Osteomyelitis, particularly of the maxilla, can also be a complication of sickle-cell disease. A child's upper teeth become loose, a sequestrum forms, and pus discharges: (1) inside his mouth, (2) on the surface of his cheek close to his nose, or (3) at his zygomatic process.
OSTEOMYELITIS OF THE JAWS ACUTE OSTEOMYELITIS If a patient's osteomyelitis is due to an infected tooth, extract it, and see Section 26.3.
If it is due to an open fracture, it is probably subacute and can be satisfactorily treated by antibiotics. If infection persists, look for a sequestrum and if you find one, remove it.
If it is haematogenous (unusual, and more often in his lower jaw), drilling is not required, treat him with antibiotics. If infection persists, look for a sequestrum and remove it.
CHRONIC OSTEOMYELITIS X-RAYS. PA and oblique views may show a sequestrum (uncommon), or a patchy osteoporosis accompanied by new bone formation (dense thickened bone).
TREATMENT. Give him antibiotics (penicillin or chloramphenicol, 2.7) for up to 2 weeks. Improve his oral hygiene. Remove any loose teeth in the area.
If no sequestrum is present, extract his tooth or teeth.
If a sequestrum is present, remove it. There is no need to wait for an involucrum to form unless the sequestrum is very large. Involucra form poorly in the mandible, which, in this respect, is intermediate in its behaviour between a long bone and a flat one.
SEQUESTRECTOMY MAXILLA. As the dead bone separates, it loosens. Wait for the child's nutrition to improve. If the sequestrum is small and loose, remove it under sedation only. If it is larger, remove it under ketamine in toto or in pieces. If necessary, chip away a little living bone. Curette the residual defect. If the cavity bleeds, pack it for 5 minutes.
MANDIBLE. To avoid an unsightly scar, incise 1 cm below the inferior border of the ramus of his mandible. Cut through healthy skin and subcutaneous tissue near the sequestrum. Avoid, or clamp and tie, his facial artery and vein, as they cross the the ramus of his mandible 3 cm (in an adult) anterior to its angle. Chisel away the outer bone covering the sequestrum and curette the cavity. Close the wound loosely, leaving a corrugated drain through one end, or through a separate stab wound.
CAUTION ! Don't operate on a malnourished child until his general condition is acceptable.
DIFFICULTIES [s7]WITH OSTEOMYELITIS OF THE JAWS If a patient has has a HARD DISCOLOURED SWELLING of the soft tissues of his neck, suspect ACTINOMYCOSIS (rare), especially if it has multiple sinuses (uncommon in osteomyelitis), and persistently negative jaw X-rays rays. Look for ''sulphur granules' in the discharge from them. If the diagnosis is confirmed treat him with large does of penicillin (500 mg 4 times a day), or tetracycline over a period of at least 6 weeks.