Osteomyelitis of the temporomandibular joint

introduction

Osteomyelitis is an inflammation of the bone marrow caused by an infection.
This inflammation can be either acute or chronic. Not infrequently, such an infection affects the jawbone.
The lower jaw is affected up to six times more often than the upper jaw, mainly because the vascular supply in this bone is worse.

causes

Causes of osteomyelitis in this location may include:

  • dental disease
    and
  • dental infections
  • dead teeth
  • Tooth removal (tooth extractions)
  • abscesses
    or
  • Cysts in the mouth
  • open jaw fractures / jaw fracture
  • purulent sinusitis
    or
  • by irradiation

damage incurred in this area.
The pathogens that may be responsible for such an inflammation include:

  • Staphylococcus aureus
  • Prevotella melaninogenica
  • enterococci
  • Pseudomonas
    and
  • Klebsiella

symptoms

The symptoms of jaw osteomyelitis vary depending on whether it is acute or chronic osteomyelitis.
Fortunately, acute osteomyelitis is relatively rare nowadays, as it is a serious disease.
Patients suffer from a greatly reduced general condition (severe disease state):

  • the body temperature is increased
  • strong pain
  • Swelling (thick cheek)
    and
  • the flow of pus

are typical.
Partly it comes to loosening and the failure of individual teeth and spontaneous fractures of the jawbone, as bone tissue is destroyed (these areas are called bone necrosis, dead bone areas are also called sequester).
The local symptoms of chronic osteomyelitis are similar, but not so sudden, and generally less pronounced.
Systemic symptoms such as fever are usually absent.
In addition, this disease can also cause:

  • halitosis
  • dysfunction
    and
  • Lymph node swelling (eg on the lower jaw)

come. Sometimes it also happens that the teeth do not fit together so well (occlusion disorders).
In severe cases, this chronic form may persist for months or even years.

Pain

Not all patients have pain in osteomyelitis.

An inflammation of the bone marrow in the jaw (osteomyelitis) can have various symptoms.

Often, osteomyelitis develops as a result of an abscess, for example after removal of the wisdom teeth. It is characteristic that after the opening of the abscess, the pain first disappears, but then come again.

Osteomyelitis in the jaw is usually associated with pain. However, this pain does not have to be present continuously, more often it is even that the patient has an infection which is associated with pain, then follows a painless period in which the infection spreads slowly and then it comes to osteomyelitis in the jaw, which then again associated with greater pain. However, it is important to know that pain in osteomyelitis can occur in the jaw, but they do not give a clear indication and do not necessarily exist.

Many patients have little pain in spite of progressive osteomyelitis in the jaw, so it is important to pay attention to other symptoms such as swelling or displacement of the jaw. Equally important, however, is not to ignore the pain and wait until it disappears as pain-free periods are not atypical despite progressive osteomyelitis in the jaw.

diagnostics

First, a medical history (anamnesis) and an examination of the affected area by a doctor (preferably an ENT doctor or a dentist) are necessary.

In the diagnosis of osteomyelitis play in the acute stage, an increased blood cell lowering rate (BSG) and a large number of white blood cells in the blood picture (leukocytosis) a major role.
For both forms of osteomyelitis applies that they can be detected in the X-ray, but in some cases quite late.
Better are usually computed tomography (CT), magnetic resonance imaging (MRI) or even bone scintigraphy.
However, all these methods are also more expensive and expensive, which is why they are only used if the suspicion could not be confirmed previously. You can save the diagnosis only with a tissue sampling (biopsy) of the affected region.

An important differential diagnosis for osteomyelitis in the jawbone is a bone tumor.

therapy

The therapy depends on the severity of the disease. Sometimes, in early stages, conservative treatment with a corresponding antibiotic is sufficient, usually for about three weeks.
A drug option is also the bisphosphonates, which help to prevent the degradation of bone substance.

If the conservative treatment should not promise any improvement or has already been tried unsuccessfully, surgery can also be performed. This will remove the sequestrum and dead pieces of bone. Sometimes some teeth have to be removed. In addition, the outermost bone layer can be removed (decortication) to ensure better blood flow to the bone. Here, too, a consistent continuation of antibiotic therapy is extremely important.

The last option is always the (partial) resection of jawbone, which can be replaced with plates or transplants.

surgery

An osteomyelitis in the jaw should always be treated conservatively, as far as the disease state still allows. Since it is an inflammation, an antibiotic should first be administered so that it stops the inflammation and thus prevents the progression of osteomyelitis.
In addition, a hyperbaric oxygen therapy can be carried out to kill bacteria that survive only under conditions without oxygen ( anaerobes ).

Often, osteomyelitis in the jaw has progressed so far that only surgery can help. In this operation, the jawbone that has died of advanced osteomyelitis must be removed, as well as the outermost bone layer, so that the remaining intact jawbone receives improved blood flow ( vascularization ).
In particularly bad cases, however, it may be that a complete part of the jaw must be removed because the bone area is already dead. This is called jaw resection. Although this represents a drastic procedure, this is still possible because the inflammation can continue to progress and can attack not only the jawbone but also other bones of the skull. This is absolutely to be avoided. In order for the jaw to be "refilled" with bone, either bone grafts or plates must be used to stabilize the jaw.

course

Usually, osteomyelitis in the jaw goes well, as good treatment options are available.
The most serious complication of acute osteomyelitis is the chronification of this condition. In some, osteomyelitis results in tooth loss, impaired chewing function, or even spread of the infection to other parts of the body.

prophylaxis

In order to prevent osteomyelitis of the jaw, adequate hygiene of the oral cavity and teeth is the most important measure (this also includes regular check-ups at the dentist!).
In addition, one should try not to be too generous with the use of antibiotics, as it will eventually have bacteria easier to try infection and are already resistant to the corresponding antibiotics.
In case of unclear pain and swelling in the jaw area, a doctor should be consulted immediately.


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