J Clin Exp Dent. 2025;17(3):e324-8. Chronic Osteomyelitis of the Jaw.

Osteomyelitis

Journal section: Oral Medicine and Pathology doi:10.4317/jced.62596

Publication Types: Review https://doi.org/10.4317/jced.62596

Chronic Osteomyelitis of the Jaw. Osteomyelitis

Carmen López-Carriches 1, María Victoria Mateos-Moreno 1, Ricardo Taheri 2, Juan López-Quiles Martínez 3,
Cristina Madrigal-Martínez-Pereda 3

1
Associate Professor. Department of Dental Clinic Specialties. School of Dentistry. Universidad Complutense de Madrid. Spain
2
Doctor of Dental Surgery. DDS. Collaborator. School of Dentistry. Universidad Complutense de Madrid. Spain
3
Assistant Professor. Department of Dental Clinical Specialties. School of Dentistry. Universidad Complutense de Madrid, Spain

Correspondence:
Carmen López-Carriches
Facultad de Odontología
Universidad Complutense de Madrid
Avda Complutense s/n. López-Carriches C, Mateos-Moreno MV, Taheri R, López-Quiles Mar-
28040 Madrid tínez J, Madrigal-Martínez-Pereda C. Chronic Osteomyelitis of the Jaw.
[email protected] Osteomyelitis. J Clin Exp Dent. 2025;17(3):e324-8.

Article Number: 62596 http://www.medicinaoral.com/odo/indice.htm

© Medicina Oral S. L. C.I.F. B 96689336 - eISSN: 1989-5488
Received: 06/02/2025
eMail: [email protected]
Accepted: 17/02/2025
Indexed in:
Pubmed
Pubmed Central® (PMC)
Scopus
DOI® System

Abstract
Background: Chronic osteomyelitis of the jaw is an inflammatory reaction of bone tissue of infectious origin that
affects the medullary cavity. The main causes of osteomyelitis are odontogenic or traumatic.
Material and Methods: Bibliographic research, the following electronic databases have been searched: Pubmed
Medline and the Chochrane Library Plus.
Results: Clinical symptoms are pain, inflammation, suppuration, intraoral or extraoral drainage fistulas. Bone and
soft tissues that do not respond favorably to treatment, potentially can lead to bone sequestra.
Diagnosis should include a histopathological study throughout a proper biopsy. Identifying the responsible mi-
croorganisms is not easy, as the sample can be contaminated by nearby sites. However, a presumptive diagnosis can
be made through clinical and radiographic evaluation.
Treatment for osteomyelitis involves eliminating the source of infection and necrotic tissue, establishing drainage,
restoring blood supply, and controlling the infection with appropriate antimicrobial therapy.
Broad-spectrum antibiotics like penicillin or clindamycin are often prescribed initially, but the regimen may be
adjusted based on the microbiological findings.
Conclusions: Long-term antibiotic therapy is generally required, ranging from 4 to 6 weeks, depending on the se-
verity and chronicity of the infection.

Key words: Chronic Osteomyelitis, antibiotic, mandible, microbiology, surgery.

Introduction In this review, we will not discuss other forms of os-

Chronic osteomyelitis of the jaw is an inflammatory re- teomyelitis such as osteoradionecrosis, bisphosphona-
action of bone tissue of infectious origin that affects the te-related osteonecrosis, Garré’s osteomyelitis, or chro-
medullary cavity, Haversian systems, and the adjacent nic sclerosing osteomyelitis (1).
cortical bone.
This inflammatory reaction initially begins as an acute Epidemiology
infection. When it lasts more than four weeks, it is called The global availability of antibiotics, along with advan-
secondary chronic osteomyelitis. cements in dental and medical care, has reduced the in-

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cidence of osteomyelitis. According to Koorbusch et al. are the virulence of the causative microorganisms, the
(2), it occurs more frequently in the jaw, with a wide age anatomical characteristics that allow the infection to
range and a higher incidence in men. Haeffs’ et al. 10- spread, and the immune response (1).
year study (3) found 62% of cases affected women, with The primary bacteria associated with this condition is
an average age of 53 years. Staphylococcus aureus. Although, it is not the only pa-
Sood’s et al. retrospective study (4) also found a higher thogen in jaw osteomyelitis, as the mouth harbors a wide
incidence in the lower jaw (55.55%) in comparison with microbiome associated with the teeth and supporting tis-
the maxilla. sues, which can act as pathogens. These include Strep-
Fenelon (1) found a slightly higher incidence in women tococcus, Bacteroides, and other opportunistic bacteria.
(53.7%) and an average age of 47.5 years. Impaired vascular perfusion is an important factor in the
onset and persistence of the condition. The vasculariza-
Etiopathogenesis tion of the jaw, in fact, makes it susceptible to osteom-
The main causes of osteomyelitis are odontogenic (den- yelitis (11).
tal infection) or traumatic (fracture). Patients with os- In Fenelon’s study (1), Streptococcus species were iso-
teomyelitis commonly have experienced a traumatic lated in 40.7% of the samples: S. constellatus, S. inter-
event such as a traumatic tooth extraction, a chronically medius, and S. anginosus, followed by S. mitis in 26.2%.
inflamed carious tooth, a periapical abscess, an infection Other isolated bacteria were Actinomyces (15.1%),
of adjacent soft tissues, or advanced chronic periodon- Staphylococcus epidermidis (7.5%), Fusobacterium
titis. (3.8%), Prevotella (3.8%), Veillonella (1.9%), Parvi-
Contaminated facial fractures, dental implants, wires, monas micra (1.9%), Eikenella corrodens (3.8%), Kleb-
microplates, or mini-screws can also trigger osteomyeli- siella oxytoca (1.9%), Campylobacter rectus (1.9%),
tis (2). Staphylococcus capitis (3.8%), Escherichia coli (1.9%),
In Fenelon’s retrospective study (1), 68% of patients had and Micrococcus luteus (1.9%).
a history of infection or dental treatment, and 16% had Haeffs et al. (3), found that Streptococcus was isola-
been placed dental implants. ted in 74% of the samples and Staphylococcus in 43%,
Implant-induced osteomyelitis has a very low incidence, showing antibiotic resistance.
estimated in some studies at only 0.02% (5). This cause
responds poorly to treatment and often requires additio- Clinical presentation
nal surgeries because the surface of implants promotes Chronic osteomyelitis clinical symptoms are pain, in-
bacterial adhesion (6). Cases of osteomyelitis associated flammation, suppuration, intraoral or extraoral drainage
with dental implants are increasingly being reported in fistulas. Bone and soft tissues that do not respond favo-
the literature (7). Immediately placed implants, history rably to treatment, potentially can lead to bone sequestra
of diabetes (8), or smoking women have been described (1).
as risk factors (9,10). In Koorbusch’s study (3), 74% of patients had inflam-
In many cases, the patient’s medical history may reveal mation, 71% had pain, 37% had a drainage fistula, and
a compromised resistance due to an altered immune only 3%-6% suffered pathological fractures, sequestra,
status. Some of these risk factors described are the pre- exposed bone, trismus, and fever occurred.
sence of neoplasia, tuberculosis, syphilis, malnutrition, The patient may also experience anesthesia or paresthe-
metabolic diseases, immunosuppression, advanced age, sia of the dental nerve (this is a late symptom of the di-
alcohol or tobacco abuse, etc. sease process) (3). Regional lymphadenopathy is usually
Many studies have found an increased relation to these present (1).
risk factors. Koorbusch (2) found that among patients
with osteomyelitis, 33.3% had cardiovascular disease, Diagnosis
13% were diabetic, 9.3% were immunocompromised, Diagnosis should include a histopathological study
7.4% had inflammatory rheumatic disease, and 5.6% throughout a proper biopsy. Identifying the responsible
were malnourished. Also, half were smokers, 20.4% microorganisms is not easy, as the sample can be conta-
consumed alcohol, and 7.4% were drug addicts. minated by nearby sites. Sometimes, no pathogens are
In Sood’s study (4), almost 78% of patients had an un- found in the microbiological culture, and only normal
derlying disease, and 48% used some substance. Moreo- microbiome from the mouth and throat are present (1).
ver, 74% of the diagnosed cases were related to a dental However, a presumptive diagnosis can be made through
risk factor. clinical and radiographic evaluation.
Haeffs (3) also found comorbidities in osteomyelitis pa- Traditionally, diagnosis by imaging has been performed
tients, particularly cardiovascular disease (52%), tobac- with a panoramic radiograph, but this method has is-
co addiction (45%), and psychiatric issues (45%). sues with superimpositions and does not show relevant
The most important factors in the disease’s progression changes in early stages (12). Therefore, more compre-

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hensive methods such as computed tomography (CT), should be noted that patients with chronic head and neck
cone-beam computed tomography (CBCT), single-pho- inflammation, even in the presence of pain and a fistula,
ton emission computed tomography (SPECT), positron may have malignant neoplasms, especially when antibio-
emission tomography (PET), magnetic resonance ima- tic therapy based provide a limited or no improvement.
ging (MRI), and radionuclide bone scans are advised to According to Hudson et al. (11), chronic osteomyelitis
be used (13). can transform to squamous cell carcinoma in 1,5-2% of
CBCT findings in osteomyelitis cases typically show a the cases. Differential diagnosis should be made with
sclerotic ring with a loss of bone trabeculation and re- sarcoma (22) and osteoblastoma (23).
duction of the alveolar cortical bone, with occasional
bone sequestra (14). The local extent of the disease Treatment
and its relationship with underlying structures are well Treatment for osteomyelitis involves eliminating the
appreciated with CBCT, and the diagnosis is even more source of infection and necrotic tissue, establishing dra-
accurate if combined with scintigraphy (15). inage, restoring blood supply, and controlling the infec-
SPECT and PET use radiopharmaceuticals that act at tion with appropriate antimicrobial therapy (11).
the molecular level, providing the exact location of the The approach includes conservative and surgical me-
lesion at an early stage and allowing the treatment res- thods. Conservative treatment is advised in early stages,
ponse to be evaluated later. Their main drawback is the while surgical treatment is often necessary in advanced
cost (16,17). or chronic cases, especially when bone sequestra is pre-
MRI allows for soft tissue evaluation without radiation sent (1,2,24).
and is a widely available technique (13,17). Conservative treatment includes the use of antibiotics and
In Fenelon’s retrospective study (1), one or more ima- anti-inflammatory medications. Antibiotic therapy should
ging diagnostic methods were used: CT was the main be used for the specific microorganisms isolated from cul-
one (87% of cases), followed by MRI (61%), panora- ture and sensitivity tests. Broad-spectrum antibiotics like
mic radiographs (38.9%), CBCT (11.1%), scintigraphy penicillin or clindamycin are often prescribed initially, but
(7.4%), and PET-CT (7.4%). the regimen may be adjusted based on the microbiological
Lesions are mainly localized in the molar region and findings. Long-term antibiotic therapy is generally requi-
the angle of the jaw. The radiographic appearance of red, ranging from 4 to 6 weeks, depending on the severity
the bone structure varies between patients, although it is and chronicity of the infection (1,22).
usually a poorly defined area of lower bone density with Hyperbaric oxygen therapy (HBOT) is another conser-
irregular trabecular patterns, in many cases, periosteal vative treatment option, especially in cases of osteom-
reactions can be observed (18). yelitis refractory to standard antibiotic therapy. HBOT
However, in some patients, the clinical presentation is enhances oxygen supply to the affected tissues, promo-
nonspecific, and radiographic signs are vague, making ting healing by increasing the oxygen concentration in
early diagnosis difficult. Early treatment is crucial for the bone and stimulating osteoclast activity to help re-
prognosis, depending on early diagnosis. In this regard, move necrotic bone. Its role is well established in chro-
bone scintigraphy can be useful, as it is highly sensiti- nic refractory osteomyelitis and osteoradionecrosis (23).
ve for identifying local bone disease. The detection rate According to a review by Lacey et al. (24), HBOT is
of bone infection ranges from 89% to 100% in studies often used as an adjunct therapy and can improve outco-
(11,17). Scintigraphy allows for the detection of osteom- mes when combined with surgery and antibiotic therapy.
yelitis three days after symptom onset. This method also Surgical intervention is indicated when there is necro-
allows to visualize the extent of the lesion, is useful for tic bone, fistulas, bone sequestra, or when conservative
planning surgical intervention, and helps in obtaining treatment fails. The surgical approach may include se-
representative biopsy tissues by identifying the region questrectomy (removal of dead bone), debridement (re-
of interest. It also helps to evaluate treatment success, moval of infected and necrotic tissue), or bone resection
as conventional radiographs continue to show an area of (in more severe cases). The goal is to remove all infected
altered bone tissue. With this technique, therapeutic suc- tissue and establish a clean area for healing. Bone graf-
cess is associated with a reduction in 99Tc throughout ting or reconstruction may be required after extensive
the lesion (18). resection to restore bone continuity and function (25).
Differential diagnosis should be made with several fi- In cases of chronic osteomyelitis, resective surgery com-
bro-osseous lesions, such as fibrous dysplasia, which is bined with local antimicrobial agents, such as antibio-
painless and more frequent in the maxilla (19), or Paget’s tic-impregnated beads or sponges, can help control the
disease or osteitis deformans (20). More importantly, it infection locally and minimize the need for prolonged
should be distinguished from invasive squamous cell car- systemic antibiotic therapy (26). In some cases, a micro-
cinoma of the jaw. Vezcau et al. (21) presented a case in vascular free tissue transplant is needed to reconstruct
which this tumor appeared as chronic osteomyelitis. It large defects (27).

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Fenelon’s study (1) found that 87% of patients requi- Institutional Review Board Statement
red surgery, with 50% needing one or more surgeries. Declared none.
The most common procedures were debridement and Data Availability Statement
sequestrectomy. In some cases, advanced reconstructive The datasets used and/or analyzed during the current study are availa-
surgeries were necessary. ble from the corresponding author.

Author Contributions
Postoperative care and follow-up C.L-C performed the study design, conceptualization, bibliographic
Postoperative care includes long-term antibiotics, regu- search, writing original draft, supervision. MV,M-M performed the
lar imaging to monitor the healing process, and manage- study design and supervised the paper. R.T. bibliographic search and
ment of any potential complications. Proper oral hygie- prepared the paper; J.L-Q-M and C.M-M-P, contributed to interpreta-
tion of the data and to the study design and supervision. All authors
ne and elimination of the primary infection source are have read and agreed to the published version of the manuscript.
crucial to prevent recurrence.
In cases involving dental implants, the implants are often Funding
removed, especially if they are the cause of infection or if This work has not received any funding.
the surrounding bone is affected. If the patient desires to Conflict of interest
replace the removed implants, they can be considered after There is no conflict of interest.
a complete healing and the resolution of the infection.
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