Osteomyelitis. Causes, symptoms, diagnosis and treatment of osteomyelitis.

Osteomyelitis of the jaw

In surgical dentistry, osteomyelitis of the jaw is considered a common disease. Osteomyelitis of the jaw (ICD 10 code M.86) - (osteomyelitis from the Greek osteon bone + myelos bone marrow) is a severe inflammation affecting soft tissue elements, bone tissue and periosteum. It is accompanied by necrotic damage (decomposition) of the bone, which subsequently leads to its deformation. The development of the pathological process is provoked by bacteriological microorganisms that penetrate the jaw bone together with infected blood or in response to post-traumatic damage - fractures and wounds.

Osteomyelitis of the jaw (ICD code M.86) is a serious pathogenic process that, without timely treatment, can lead to complications. The risk group consists of male patients under 40 years of age. The primary and main thing is to identify the symptoms of the disease, thanks to a clear differential diagnosis. Thus, dental surgeons from the West Dental family clinic network in Yanino-1 and Vsevolozhsk will help diagnose and treat the problem at a reasonable price.

The causes and symptoms of the disease, which specialist to contact and how to treat - we will consider below in the article.

Symptoms

The first symptom of a spinal infection is pain, but this symptom also occurs with other spinal diseases, and therefore a spinal infection develops almost unnoticeably and over a long period of time. In addition to back pain, there may be symptoms of general intoxication and inflammation of the body, such as fever, chills, sweating, weight loss, and increased pain at night. Spinal infection rarely involves nerve structures. However, the infection can move into the spinal canal and cause the development of an epidural abscess, which in turn can put pressure on the nerve elements. If it occurs in the cervical or thoracic spine, it can result in paraplegia or quadriplegia.

Causes

The main provocateur of the formation of osteomyelitis in the upper and lower jaw is considered to be pathogenic microflora - streptococci and anaerobes, present in the oral cavity of every person. They aggravate the infection, affecting the soft and hard components of the mouth. There are several ways to penetrate deeper into the pathological process:

1. Missed dental caries, which destroyed the enamel with dentin and penetrated into the pulp chamber.
2. Traumatization – crack, violation of the sealing material. The damage must be deep (fracture of the HF or LF) to provoke an infectious process (staphylococci).
3. Chronic infection occurs in other parts of the body. Pathological microorganisms can reach the jaw through the lymph nodes or blood vessels (ENT organs).

In most patients, osteomyelitis is located on the lower jaw, since the lower units are more likely to be affected by caries or trauma. Also, people with immunodeficiency and blood diseases are at risk, because they have difficulty healing wound surfaces and the immune function of the body is weakened.

Other factors:

• smoking;
• alcohol;
• Diabetes type I and II;
• eating disorders;
• syphilitic infection;
• radiation and chemotherapy.

If you miss and do not treat acute osteomyelitis in the upper or lower jaw, then the process becomes chronic, which is more difficult to treat and leads to many complications.

Risk factors

Bone tissue is generally resistant to infection. For osteomyelitis to occur, conditions must be present that increase the bones' vulnerability to infection.

Recent injuries or surgeries. In case of severe bone fractures or deep punctures, infection penetrates into the bone or nearby tissue. Surgical repositioning of bone fragments or endoprosthetic surgery may also inadvertently introduce infection into the bone.

Poor circulation. When blood vessels are damaged or the blood flow through them is disrupted, conditions arise for a deficiency of immune cells responsible for counteracting microbes and preventing the small number of microbes that accidentally enter the tissue from multiplying. What begins as a small cut can progress to a deep ulcer that can involve deeper tissue and even bone. Diseases that impair blood circulation include:

• Diabetes
• Peripheral artery disease often associated with smoking
• Sickle cell anemia

Medical catheters

A medical catheter connects the outside world with the internal organs. And although these catheters are necessary for some conditions, they can serve as conduits for infections into the body. Therefore, catheters increase the risk of infection, including osteomyelitis. Examples include:

• Catheters for dialysis
• Bladder catheters
• Intravenous catheters, which are necessary for long-term administration of medications (months or even years)

Intravenous drug administration

People who inject drugs are at greater risk of developing osteomyelitis because they typically use unsterile needles and do not clean the skin before injections.

Common causes of osteomyelitis.

The following groups of people are most susceptible to developing osteomyelitis:

• Elderly patients
• Intravenous drug addicts
• Patients with a weakened immune system

The immune system may be weakened as a result of the following conditions:

• Long-term use of corticosteroids to treat systemic diseases such as rheumatoid arthritis.
• Insulin-dependent diabetes mellitus
• Patients with transplanted organs
• Acquired immunodeficiency syndrome (AIDS)
• Malnutrition
• Cancer

Intravenous drug use is causing an increase in the number of patients with spinal infections. As a rule, the microorganism most often affecting the spine is Staphylococcus aureus, and among drug addicts who use intravenous drugs, Pseudomonas aeruginosa is often the causative agent of a spinal infection. Treatment of these two pathogens requires different antibiotic treatments.

In the recent past, Mycobacterium tuberculosis has been a common cause of spinal infections. At present, spinal tuberculosis practically does not occur in developed countries and is common only in poor, backward countries with a low standard of living. But drug addicts may have a tuberculous infection.

Most vertebral body infections occur in the lumbar spine due to the nature of the venous blood flow. With tuberculous lesions of the vertebrae, the cervical and thoracic spine are most often affected.

Classification

According to the method of penetration of osteomyelitis infection on both jaws, a classification has been compiled:

1. Hematogenous - pathogenic microorganisms move through the blood from other foci of infection. This feature is characteristic of secondary pathology of the upper oral part, which develops against the background of another disease (scarlet fever, diseases of the ENT organs). The bone elements of the oral apparatus are primarily affected, followed by the gingival tissue.
2. Odontogenic – infection comes from a tooth, damaged pulp or root (pulpitis, periodontitis, cyst, alveolitis).
3. Traumatic – advanced fractures and injuries of the maxillofacial area.

According to the symptoms, the process happens:

• spicy;
• subacute;
• chronic.

By distribution:

• local (with clear boundaries);
• vague (diffuse).

Spinal osteomyelitis

Paths of penetration of the pathogen of the infectious process

Very often, pathogenic microorganisms are carried into the spinal canal through the bloodstream from other foci of infection in the human body. In addition, an infection of the pelvic organs can spread to the vertebrae, since blood from there enters the veins of the lower parts of the spine. If an infection enters the spinal canal using one of the above methods, so-called hematogenous osteomyelitis develops. Also, the pathogen can penetrate the bone tissue of the spine during injury or injury to the latter. In this case, the development of non-hematogenous osteomyelitis is spoken of.

Risk group

Individuals who have:

1. History of open vertebral fractures and surgical interventions on the spine (including previous spinal punctures). With open bone fractures, the infectious agent can penetrate the bone tissue directly through the fracture site. During surgery involving bone tissue, the pathogen can enter it through the surgical field.
2. Diseases of the vascular or circulatory system, accompanied by phenomena of chronic stagnation and disruption of blood flow through the vessels, as well as a decrease in the number of cells - phagocytes, which protect the human body at the tissue level, capturing and absorbing pathogenic microorganisms and dead cells. This group of diseases includes diabetes mellitus and sickle cell anemia, as well as peripheral vascular diseases (in particular, obliterating atherosclerosis). The fact is that in clogged areas of blood vessels a favorable environment is created for the proliferation of pathogenic microorganisms, which subsequently, when the obstacle to blood flow is removed, spread throughout the human body, affecting, among other things, bone tissue. And in the presence of cellular (in particular, phagocytic) deficiency, nothing can prevent bacteria.
3. History of bladder catheterization or intravenous (particularly subclavian) catheter placement. Despite the fact that modern hospitals use only disposable catheters, they still remain the gateway for the penetration of an infectious agent from the external environment into the body.
4. Dependence on the use of drugs administered intravenously. As you know, very often unsterile needles are used to administer drugs, and the area of ​​skin at the injection site is not treated with an antiseptic solution. As a result, microorganisms such as Staphylococcus aureus and Pseudomonas aeruginosa enter the spinal canal through the bloodstream and provoke the development of spinal osteomyelitis. In addition, drug addicts quite often suffer from infectious diseases transmitted transmissibly (i.e., through the blood) such as viral hepatitis C and B, which significantly weaken the body’s immune system.
5. Weakened immune system. The body's defenses can be weakened by diseases such as rheumatoid arthritis, diabetes, cancer and AIDS. In addition, the immunity of people who have received donor organs is deliberately suppressed with special drugs. Also, a weakened immune system causes chronic malnutrition and exhaustion of the body. With severe immunodeficiency, the development of spinal osteomyelitis can be provoked even by the so-called conditionally pathogenic microflora, i.e. those microorganisms that are usually present in the body of every person, but under certain conditions cause the development of inflammation.
6. Pulmonary tuberculosis. Mycobacterium tuberculosis quite often causes inflammation of bone tissue, and in the spine, as a rule, it affects the vertebrae of the cervical and thoracic regions.
7. Elderly age.

Symptoms

1. Constant aching pain in the back, aggravated by movement, which does not go away with rest. In addition, pain may intensify at night and, as a rule, is not relieved by taking analgesics and using dry heat.
2. Signs of general intoxication of the body: - slight increase in body temperature; - chills; - sweating; - loss of body weight.
3. If the infectious process spreads into the spinal canal, a local abscess may develop, which will lead to compression and inflammation of the nerve roots. As a result, the function of innervated organs will be disrupted; in the most severe cases, paralysis and paresis may develop.

Diagnostics

In the early stages, diagnosing spinal osteomyelitis is difficult. The assumption of the presence of this pathology is made on the basis of the patient’s complaints, taking into account his belonging to any of the risk groups. Detection of this disease is possible only after a complete instrumental and laboratory examination of the patient. Full diagnostics include:

1. X-ray examination of the spine. However, it should be borne in mind that the X-ray picture may remain normal during the first month after the onset of the disease; As a rule, changes in X-ray images appear after the destruction of half or more of the cells of the bone tissue of the spine. If intervertebral discs are involved in the pathological process, the radiologist may note a decrease in the distance between the vertebral bodies and signs of destruction of the end plates.
2. Magnetic resonance imaging (MRI) of the spine. To detect osteomyelitis, an MRI is performed - an examination of the spine with the introduction of a contrast agent, which accumulates in large quantities in the vertebrae affected by the infection, since the inflammatory reaction present in them is accompanied by an increase and subsequent slowdown of local blood flow and swelling.
3. Scintigraphy is a method in which radioactive isotopes are introduced into the patient’s body, and with the help of gamma rays emitted by them, an image of the area under study is obtained on a special screen. This method helps to detect the presence of changes in the spinal column, but with its help it is impossible to specify what pathology occurs in this case: a tumor, hernia or osteomyelitis.
4. Bacteriological blood culture (for sterility). In 50 percent of cases, this analysis allows us to identify the causative agent of the disease and determine which group of antibacterial drugs it is most sensitive to.
5. General blood analysis. As a rule, this analysis reveals the presence of an inflammatory reaction in the patient’s body, as evidenced by an increase in the number of leukocytes and erythrocyte sedimentation rate (ESR). The last indicator for spinal osteomyelitis will be changed in more than 80 percent of cases. In addition, this analysis is one of the main indicators of the effectiveness of the treatment: if the drugs are selected correctly, the leukocyte formula quickly returns to normal. However, it must be taken into account that an indicator such as ESR responds to a decrease in the inflammatory process quite slowly, and often remains elevated after the patient has been cured.
6. Tissue biopsy. It is carried out percutaneously during spinal puncture using a needle method (with mandatory preliminary computed tomography or fluorography to accurately determine the location of the altered tissue) or open method (if the source of infection is difficult to access, or there is damage to the nervous tissue). Allows you to accurately identify the causative agent of infection.

Treatment

1. Conservative . Includes a set of activities such as:

A) Antibacterial therapy:

• intravenous administration of broad-spectrum antibiotics or antibiotics to which the highest sensitivity of the pathogen was revealed during bacterial blood culture and compilation of an antibiogram. A combination of several antibiotics is often used, enhancing the effect of each other. Antibacterial agents are administered intravenously, usually within a month.
• oral antibiotics for the next two weeks
• for tuberculous etiology of spinal osteomyelitis, treatment is carried out with specific drugs that most effectively affect mycobacteria, and continues for a year.

B) Taking immunostimulating and restorative drugs, as well as detoxification therapy (removing toxins from the patient’s body that are formed during the life and death of the infectious agent).

B) Peace. Physical activity is limited; for two to three months, wearing a special corset is recommended to fix the spine. The corset is removed after positive changes appear on X-ray photographs.

2. Surgical . Indicated if:

A) there is compression of the nerve fibers by the abscess, which is removed during surgery.

B) the ongoing antibacterial treatment does not give a positive result; foci of infection in this case are sanitized through surgery.

C) there is a large number of bone destruction and severe deformation of the vertebrae. Bone elements are surgically restored and the spine is stabilized, which reduces the risk of further destruction.

Complications

1. Necrosis (death) of bone tissue due to the presence of an inflammatory process and impaired blood circulation at the site of inflammation. Small areas of necrosis (so-called sequestra) are removed surgically; the remaining tissue is restored. If a large area of ​​necrosis is removed, the prognosis is less favorable.
2. Arthritis of nearby joints (septic arthritis) - occurs due to the spread of infection beyond the spinal column.
3. The transition of the disease to a sluggish chronic form, the formation of fistulous openings connecting the source of infection with the external environment.
4. Skin cancer can develop as a result of the formation of osteomyelitis fistulas and subsequent degeneration of the skin around the fistula openings.
5. Sepsis is the entry into the blood and subsequent spread of pathogenic microorganisms and their toxins beyond the source of inflammation.
6. Spinal disorders.
7. Damage to nearby organs (bronchi, pleura, aorta).

Author: K.M.N., Academician of the Russian Academy of Medical Sciences M.A. Bobyr

Osteomyelitis of the upper and lower jaw: symptoms

The course of the disease process is slow, and the first sign is pain in the area of ​​the affected unit.

Then joins:

• spread of pain to nearby segments;
• swelling and redness of the gum tissue;
• periodontal damage, which causes mobility of units;
• pain in the temporal region;
• numbness of the chin;
• difficulty eating;
• speech defects;
• unpleasant odor from the mouth;
• increase in l/u;
• swelling in the problem area.

Acute osteomyelitis on the lower jaw (ICD M.86) develops very rapidly in conjunction with an increase in temperature and chills. In the absence of outflow of pus, abscesses and phlegmons form, which requires immediate surgery. This pathology in a child may be confused with mumps (mumps).

With osteomyelitis on the lower jaw (ICD-10 code M.86), in addition to damage to the alveolar part and body, the inflammatory process can spread to its branch and processes. One important feature is complications from the soft tissue elements around the NP - many muscles and tissue spaces.

After the acute period (1-2 weeks), the subacute period begins, after the formation of a fistula for the discharge of pus. The condition improves, pain decreases, and the mobility of units increases—gastrointestinal diseases develop. The subacute form becomes chronic, which lasts several months. As a result, in adults the clinical history ends with the removal of necrotic tissue, with a favorable outcome.

2. Osteomyelitis in children and adults

Osteomyelitis in children

, as a rule, occurs in an acute form.
Acute osteomyelitis
develops quickly and is easier to treat. Overall it is better than chronic osteomyelitis. Osteomyelitis in children usually occurs in the area of ​​the bones of the arms and legs.

In adults, osteomyelitis can be acute or chronic

. People with diabetes, HIV, or peripheral vascular disease are more likely to develop chronic osteomyelitis that persists or recurs even despite treatment. Chronic or acute osteomyelitis in adults often affects the pelvis or vertebrae. And in patients with diabetes, the bones of the legs often suffer.

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Diagnostics

If you experience pain in the tooth area of ​​unknown etiology, or changes in the gums, contact your dentist (he has a Leica M320 operating microscope in his arsenal), who will then refer you to a surgeon or orthopedist as necessary. At the initial stage of pathology, the doctor chooses to collect complaints and study them, visual and instrumental examination. The degree of mobility of the units and their pain, the state of the oral mucosa is determined.

It is important to distinguish the acute period of the disease from periostitis, cysts and periodontitis, so the experience of a specialist is very important.

This is a purulent infectious process, which means that general blood and urine tests will be of research significance. To type the pathogen, a tank is performed. sowing of pus.

In the chronic stage, bone changes are already noticeable, so X-rays (CT) are necessary, for which West Dental has a panoramic CBCT Pax-i3D. The image shows sequestration and the depth of the process.

Treatment of osteomyelitis

Treatment of this disease requires mandatory hospitalization of the patient in the traumatology or surgical department of the hospital. Conservative treatment options include antibiotic therapy, detoxification, immunotherapy, probiotics, and local wound treatment.

Surgical methods include sanitation of a purulent focus, removal of non-viable bone tissue, and performing restorative operations (bone filling, osteosynthesis with an Ilizarov apparatus).

Timely consultation with a doctor is the key to successful treatment of the disease and prevention of serious complications to which it can lead.

Complications

If you see a doctor in time, make a diagnosis and choose the right treatment, the prognosis will be favorable.

If you ignore all the conditions, complications will arise:

1. Meningitis
2. Abscess of the brain and lung.
3. Orbital phlegmon.
4. Sinusitis.
5. Vein thrombophlebitis.
6. Sepsis.
7. Mediastinitis.

Pathological data require immediate assistance to prevent death.

The chronic process, with its long course, affects the soft tissue and bone areas of the maxillofacial area, and is accompanied by:

• traumatization;
• changes in the TMJ;
• the formation of adhesions in the joints and scars on the masticatory muscles;

Such disorders limit chewing movements or lead to immobility.

Treatment

The effectiveness of therapy depends on the initial causes of the formation of the inflammatory process. Therefore, in osteomyelitis of the jaw, comprehensive treatment is important, not only by a dentist, but it is recommended to go for a consultation with doctors of medical specialties.

1. Sanitation of the oral cavity with antiseptic solutions. Further spread of infection to surrounding structures is prevented. Also, necrotic soft tissue formations are eliminated.
2. Anti-inflammatory drugs. Minimize intoxication of the body.
3. Immobilize the fracture, and if there is a tooth in it, then remove it.
4. Taking antibiotics, regardless of provoking factors.
5. Intraosseous lavage may be necessary and will provide positive results. Minimizes the occurrence of complications and quickly prevents the growth of a harmful process.
6. In case of a fistula, sequestrectomy is performed - necrotic areas of bone tissue are eliminated under anesthesia, taking into account the extent of the damage.
7. If the teeth are mobile, they are splinted.
8. After eliminating symptoms and carrying out all interventions, physical therapy, vitamins and immunomodulators are recommended.

Prevention of such pathology consists only of timely and regular visits to the dentist’s office and treatment of pathological processes in the oral cavity. Do not treat yourself at home, so as not to make it worse. Also, it is necessary to strengthen the body’s immune system, avoid injuries and not let the pathological process become chronic.

Types of osteomyelitis

• Acute hematogenous osteomyelitis. The cause of development can be diseases such as: sore throat (acute tonsillitis), ear inflammation, tooth suppuration, measles, scarlet fever, pneumonia, boil, panaritium.
• Post-traumatic osteomyelitis. The cause may be: contaminated soft tissue injuries, surgical treatment of closed fractures, gunshot wounds, surgical interventions, open fractures.
• Contact osteomyelitis. Causes: transfer of infection from surrounding soft tissues to the bone.
• Pediatric osteomyelitis. Infants are more susceptible to this disease than adults. A previous staphylococcal or streptococcal infection can cause a child to develop osteomyelitis.
• Chronic osteomyelitis. Reasons: frequent infections (three to four times a year), weakness of the immune system, the presence of other diseases, such as cancer.