Periostitis of the jaw

The inflammatory process localized in the periosteum, or commonly known as gumboil, has the medical name periostitis of the jaw.

Depending on the severity of the disease, it is divided into the following forms:

• simple - inflammation is caused by a bruise/fracture of the jaw bones, occurs with pronounced swelling and hyperemia without detection of pathogenic microorganisms;
• ossifying - a chronic inflammation characterized by the proliferation of periosteal layers, often affecting the soft tissues of the oral cavity;
• fibrous - a characteristic thickening of the periosteum layers occurs with significant formation of fibrous tissue;
• purulent - due to infectious processes in the teeth, an abscess is formed, the disease proceeds in an acute form.

The disease is not independent and is a complication due to various dental problems. Clinical practice indicates frequent cases of upper jaw pathology, developing covertly, thus posing the maximum threat to the patient. Often the disease is accompanied by severe pain syndrome and fever, so you should not self-medicate, and if alarming symptoms appear, immediately seek medical help.

ICD-10 code

The International Classification of Diseases under the code K10 includes a section on dentistry “other diseases of the jaw”, in which periostitis of the jaw is classified as an inflammatory pathology with the index K10.22, and chronic periostitis of the jaw – K10.23.

Causes of periostitis of the jaw

The pathology develops due to various factors. Being the most common complication of caries, this disease is dangerous due to the vagueness of symptoms and latent course. The initial formation of pus is observed in the roots of the teeth, then the focus of the disease spreads to the pulp, the outer and inner layers of the bone. Soft tissues are easily involved in the process if suppuration occurs in the gum area.

The following causes of the disease are identified:

• Dental diseases are the main cause of infection;
• inflammation of teeth without proper and timely treatment;
• penetration of microorganisms from the bloodstream or lymphatic system due to infectious diseases (for example, tonsillitis, sore throat, etc.);
• spread of infection in the presence of purulent wounds in the facial area or jaw fractures.

Periodontitis can also be a source of inflammation, as well as complications resulting from tooth extraction, especially against the background of respiratory diseases or hypothermia. Allergic and rheumatic forms are diagnosed extremely rarely.

Stressful conditions, a sharp decline in immunity, and dental interventions during periods of acute infectious conditions increase the risk of developing the disease.

[ 1 ], [ 2 ]

Symptoms of periostitis of the jaw

The disease begins with swelling of the tissues surrounding the tooth, the swelling gradually increases, and significant pain syndrome is felt upon palpation. The appearance of febrile temperature is associated with the swelling reaching critical sizes. The entire jaw, temple area and eyes are often involved in the pathological focus.

The following symptoms of the disease are distinguished:

• swelling and redness of the gum area;
• the thermometer mark reaches 38º C;
• in the area of the tooth there is a dull, pulsating type of pain syndrome;
• the pain covers the jaw where the inflammation is located;
• the pain may be moderate, but the pain becomes unbearable with the slightest impact on the affected tooth;
• facial asymmetry is observed, caused by unilateral swelling;
• regional lymphadenitis.

The symptoms of the disease vary depending on the etiology, pathogenesis, location of the septic focus and duration of clinical factors. Sluggish development is most often caused by a decline in the body's defenses, as a result of which the immune system does not give a bright response.

Periostitis of the jaw in children

The child's body has a number of features, and the anatomy of the structure of the maxillofacial tissues is no exception. The immune system matures only by the age of seven, bone tissue has a good blood supply, soft tissues are characterized by a high degree of hydrophilicity (this property causes severe swelling), the barrier function of the lymphatic system is not fully formed. All of the above factors cause immediate spread of periosteum inflammation by hematogenous and lymphogenous routes, which entails serious complications and forms primary chronic lesions.

There are acute (serous and purulent forms) and chronic (simple and hyperplastic stages) odontogenic periostitis of the jaw in children. The acute course is an independent disease or develops against the background of pulpitis, suppuration of the cyst of the dental roots, periodontitis, osteomyelitis. Inflammation of the periosteum of an acute course, especially with suppuration, is subject to surgical intervention followed by conservative therapy. If necessary, affected baby and permanent teeth are removed. In especially severe cases, dentists recommend taking antibiotics. After surgery, children are prescribed a gentle diet, bed rest, plenty of fluids and rinsing the mouth with decoctions of chamomile, St. John's wort or sage. Physiotherapeutic procedures help to eliminate swelling, relieve inflammation, relieve pain and normalize tissue functions: UHF, microwave, a course of laser therapy, treatment with fluctuating current.

Chronic periostitis of the jaw in children is diagnosed at an older age. Clinically, the disease manifests itself as a characteristic, painless thickening of the jaw. In this case, the fate of the infected tooth is determined with the obligatory intake of antibiotics. Electrophoresis (potassium iodide, lidase), ultrasound and laser therapy are often prescribed. Children with a chronic form of pathology are under dispensary observation until the normalization of clinical and radiological indicators.

Acute periostitis of the jaw

In most cases, acute periostitis is diagnosed on the lower jaw. Acute periostitis of the jaw is called an odontogenic process limited to the periodontium and caused by the penetration of pathogenic microorganisms into the gum tissue. Acute course is caused by:

• caries without proper and timely therapy - the disease begins latently with a slow accumulation of pus in the root area. Development into the active stage occurs due to any minor irritation of the tooth, which is characterized by inflammation of the jaw bones. From the closed space, pus, tearing tissue, spreads along the periosteum;
• advanced periodontitis serves as a trigger for the development of the acute form of the disease;
• This form of the disease is caused by non-pathogenic staphylococcus present in the oral cavity, which differentiates itself from a previous viral disease, a significant decrease in immunity, etc.

The acute process is divided into: serous, purulent limited and purulent diffuse. The serous form during the period of origin (first-second day of inflammation) is characterized by moderate pain and pronounced swelling of the soft tissues of the jaw area.

[ 3 ], [ 4 ], [ 5 ]

Acute odontogenic periostitis of the jaws

Purulent infection of the body of the jaw or the periosteum of the alveolar process with the localization of the primary inflammation in the periodontal tissues. This phenomenon often occurs on the jaw from below and is called acute odontogenic periostitis of the jaws. The cause of the pathology is complications of dental problems (difficulty in eruption, injuries during removal, etc.) and mixed flora - streptococci, staphylococci, gram-positive and gram-negative organisms, putrefactive bacteria.

A zone of edema is formed in the periosteum, and tissue structures are separated from the bone. Areas of leukocyte infiltration with vascular changes are revealed under a microscope. This form of the disease is characterized by a severe clinical course: pulsating pain syndrome, temperature up to 38º C, leukocytosis and regional lymphadenitis. Diagnosis of the acute stage of the pathology is complicated by the fact that X-rays do not detect changes in bone tissue.

With timely referral to a specialist, correct differentiation of pathology and proper treatment, rapid recovery occurs. In case of disease progression, abscess, acute osteomyelitis of the jaw, phlegmon of soft tissues are not excluded.

[ 6 ], [ 7 ]

Chronic periostitis of the jaw

Patients with periosteal pathology most often consult a specialist at the stage of disease development, since this form of the disease is characterized by a pronounced, difficult to bear pain syndrome. In turn, this fact reduces the risk of relapses and minimizes cases of chronic course.

Chronic periostitis of the jaw is common in immunodeficiency of the first/second stage. The chronic form of the pathology is often diagnosed in children and adolescents. Incomplete or spontaneous emptying of purulent discharge in the acute stage leads to a ridge-like compaction on the gum, where purulent exudate constantly accumulates. Moreover, the appearance of the chronic form of the disease is possible in the absence of an acute phase.

Chronic disease lasts from a couple of months to several years with regular alternations of remission and deterioration of the condition. The clinical picture is characterized by:

• inflammation of the submandibular lymph nodes and absence of pain upon palpation;
• the oval of the face is characterized by minor changes;
• there is a painless lump in the jawbone area;
• swelling and hyperemia of the skin in the affected area.

X-rays and a thorough collection of anamnesis help diagnose the pathology.

[ 8 ], [ 9 ]

Purulent periostitis of the jaw

The accumulation of pus in the periosteum occurs as a result of previous infectious diseases. In clinical practice, emptying of purulent contents through the dental canal is often observed if it is empty, through a gum pocket or fistula. If there is no outlet for pus, the infection from the periodontium moves to the periosteum. Purulent exudate can spread to several adjacent teeth.

There are limited and diffuse purulent periostitis of the jaw. The limited form is characterized by inflammation of the alveolar plate, in the case of a diffuse course, the pathological focus spreads to the entire body of the jaw, including the base.

Limited periostitis is characterized by a strong pain syndrome, covering the entire jaw with irradiation to the ears, eyes and temporal region. For this reason, patients complain of a broken, weak state with constant insomnia, terrible headaches and loss of appetite. Pus can spontaneously flow into the oral cavity, which will bring long-awaited relief.

The inflammatory process often involves the tongue, submandibular area, cheek, upper palate and tonsils. Such spread of purulent exudate complicates speech and chewing functions. The pain is characterized as intense, pulsating, reaching its peak during meals and conversation.

Acute purulent periostitis of the jaw

This form of the disease is characterized by an inflammatory process in the periosteum or alveolar process (jaw area, place of attachment of the roots of the teeth). Acute inflammation with the formation of pus is more often differentiated on the jaw from below, mainly on large multi-rooted teeth. In second place in clinical practice are wisdom teeth and small molars (premolars), and the share of canines and incisors accounts for the smallest percentage of inflammations. Periostitis of the jaw from above is formed when the focus of infection spreads from the central teeth (molars and premolars).

Analysis of purulent contents indicates the presence of mixed flora with streptococci, staphylococci, putrefactive microorganisms, gram-negative and gram-positive bacteria. Therefore, it can be concluded that the cause of acute purulent inflammation lies in the defeat of pathogenic microflora.

Predisposing factors for the onset of the disease are:

• periodontal diseases;
• formation of pus in radicular cysts;
• problems associated with teething;
• benign tumors (odontomas);
• trauma to the tooth/jaw during extraction.

Acute purulent periostitis of the jaw is characterized by an increase in regional lymph nodes.

[ 10 ], [ 11 ]

Periostitis of the upper jaw

Pathogenic microflora in molars and premolars causes periostitis of the upper jaw. The upper lip, wings and bottom of the nose are involved in the inflammatory process, which is manifested by severe swelling. Often the eyelids swell, which causes a sharp narrowing of the palpebral fissure. When premolars are affected, the swelling spreads to the cheeks, cheekbones, parotid and temporal region.

Acute purulent inflammation of the upper jaw may have a palatine localization, resulting from the spread of infection from the incisors, roots of molars and premolars (the roots of these teeth are closest to the palate). Pus can penetrate under the mucous membrane, causing softening and exfoliation of tissue. Cases of palatine abscess are diagnosed by an increase in submandibular lymph nodes and the presence of a characteristic palatine swelling of an oval or hemispherical shape. Changes in the outline of the face, as a rule, are not detected. The growth of the purulent focus causes smoothing of the transverse folds on the upper palate. An abscess is characterized by the growth of the tumor area on the mucous membrane, tongue and pharynx, which provokes pain when swallowing. Unpleasant sensations increase as the purulent contents increase and soft tissues exfoliate, turning eating and communication into real torture. Spontaneous discharge of pus into the oral cavity alleviates the patient's condition. If the abscess does not open spontaneously, acute periostitis of the upper jaw requires immediate surgical intervention.

Periostitis of the lower jaw

In medical practice, this form of the disease is most often diagnosed as the following types:

• odontogenic in chronic form - occurs in patients with primary or secondary stage of immunodeficiency, with relapses of acute periodontitis;
• aseptic inflammation of the periosteum is a consequence of trauma to the lower jaw, the tissues of which are less protected from external influences;
• acute purulent process - affects the area of large multi-rooted teeth in middle or young age, often formed after advanced periodontitis, as well as against the background of a previous viral infection.

Inflammation in the lower incisors causes swelling of the lower lip, chin and chin area. Affected premolars and canines cause swelling of the corner of the mouth and the lower cheek area. In malar pathology, swelling is located at the bottom of the cheek, in the parotid-chewing and submandibular area. If the infection penetrates the periosteum, this is expressed in inflammation of the masticatory and pterygoid muscles.

Acute purulent periostitis of the lower jaw

Acute purulent inflammation of the periosteum is accompanied by severe, pulsating pain, a sharp deterioration in general condition, an increase in temperature, and loss of appetite. This pathology is detected mainly on the lower jaw.

As clinical practice shows, this form of pathology is formed as a result of:

• the spread of pathogenic microflora (often mixed type) from a diseased tooth in the lower jaw;
• complications of acute or chronic periodontitis, including marginal;
• problems associated with teething;
• formation of pus in radicular cysts;
• periodontal lesions;
• as a negative consequence of conservative therapy;
• injuries;
• unsuccessful tooth extraction or activation of pathogenic microorganisms after surgery.

Acute periostitis of the jaw with the formation of purulent exudate leads to the appearance of inflammatory swelling of soft tissues, the location of which depends on the affected tooth. Swellings are found on the lower lip, in the chin area, lower part of the cheeks, corners of the mouth. Acute purulent process occurs against the background of regional lymphadenitis. The hyperemic area and swelling of the alveolar process mucosa spread to adjacent teeth, forming a thickened fold, which is easily palpated. The diffuse ridge-shaped area is painful, purulent exudate shines through it. When the sublingual zone is involved in the inflammatory process, the patient complains of pain during swallowing and limited speech function.

[ 12 ], [ 13 ]

Diagnosis of periostitis of the jaw

A dentist can make an accurate diagnosis, and you should contact him/her if alarming symptoms appear. The classification of the disease is based on a thorough collection of anamnesis, clarification of the features of the course of the pathology, and an initial examination. If necessary, X-rays and laboratory tests are prescribed.

Diagnosis involves excluding conditions with similar clinical features:

• acute periodontitis, in which the inflammation is concentrated around the affected tooth (with periostitis, the swelling affects several teeth);
• acute sialoadenitis (pathology of the salivary glands) - the source of pus is the salivary ducts, not the teeth;
• other inflammatory processes - phlegmon, lymphadenitis, abscesses, which are dense neoplasms with characteristic tension and redness of the skin. Periostitis of the jaw, on the contrary, entails softening of tissues with characteristic swelling of the skin without hyperemia;
• osteomyelitis in acute form - characterized by general intoxication of the body, including fever, chills, headache, increased temperature, weakness. An important difference is that the alveolar process thickens on both sides, not on one.

[ 14 ], [ 15 ]

Treatment of periostitis of the jaw

Therapy for acute purulent inflammation of the periosteum is a combination of surgical and conservative methods, the purpose of which is the mandatory opening of the suppuration with rapid stabilization of the patient's condition.

Treatment at the beginning of its formation (serous stage) can be done without making an incision. In this case, the dental canals are cleaned of purulent exudate. Drainage in the cavity of the tooth may be required for spontaneous outflow of purulent contents or removal of the affected tooth. Dental manipulations are performed using conduction and infiltration anesthesia.

Local anesthesia is relevant for conditions requiring dissection of the periosteum. Moreover, the drug is injected into the mucosa along the line of the intended incision, but not into the suppuration zone. After opening the abscess, the patient rinses his mouth with a solution of sodium or manganese bicarbonate and the wound surface is treated with chlorhexidine or gramicidin. The decision to remove a tooth is made by a doctor based on its functional and aesthetic characteristics. Removal facilitates the outflow of pus and significantly reduces pain. Treatment with preservation of the affected tooth requires careful treatment of the cavity cleared of pus and high-quality filling.

In cases of acute inflammatory process with removal of pus on the second day, physiotherapeutic procedures are appropriate: light-thermal treatment, laser therapy, warm rinsing of the mouth with special antiseptics, UHF, sea buckthorn/rosehip/camphor oil in the form of dressings, fluctuation.

Antibiotics for periostitis of the jaw

Medicines are divided into groups:

• nitrofurans – furazolidone, furadonin;
• antihistamines – diazolin, suprastin, diphenhydramine;
• sulfonamides - norsulfazole, sulfadimethoxine;
• substances with calcium;
• vitamins and multivitamins.

In recent years, sulfonamides have been replaced by broad-spectrum antibiotics (lincomycin, macrolide group, and metronidazole-based drugs). Antibiotics are prescribed to suppress pathogenic microflora and prevent the spread of the infection to adjacent tissues. Taking antibiotics is possible upon agreement with the attending physician, after identifying the causative agent of the pathology. The dosage and duration of treatment are selected individually based on the patient's age, severity and characteristics of the inflammatory process.

It should be remembered that periostitis of the jaw is amenable to complex methods of therapy, the main one of which is surgical intervention. Antibacterial treatment alone does not bring the desired result in most cases.

[ 16 ]

Treatment of periostitis of the lower jaw

Treatment at the beginning of formation is reduced to opening the suppuration of the tooth area, if necessary, the affected tooth is subject to removal. To reduce inflammation and prevent relapses, subsequent therapy includes taking antibiotics, vitamins, and treating the wound surface with anesthetics.

Acute inflammation in the periosteum of the lower jaw requires mandatory surgical intervention. The operation is performed under local anesthesia with free outflow of purulent exudate. Surgeons have their own special techniques: using a sickle scalpel when cutting the periosteum along the inner surface of the jaw branch. The abscess of the subperiosteal region is cut vestibularly to the bone along the 2nd and 3rd molars, then the dissector is moved to the angle of the lower jaw, avoiding the masseter muscle. The wound is drained, the result of which is checked the next day.

The next stage will be drug treatment, including washing the wound with antiseptics, taking antibiotics, dressings with special ointments (vaseline, camphor/sea buckthorn oils, etc.). Physiotherapeutic treatment – microwave, laser treatment, fluctuation and other methods – gives good results. Final recovery usually occurs on the second or third day after surgery.

Treatment of periostitis of the upper jaw

Surgical treatment is performed in the molar area along the transitional fold; when using a raspatory/grooved probe, the incision is made along the upper tubercle, moving backwards and inwards. Excision in case of inflammation that has covered the lingual surface is made in the place of the greatest accumulation and protrusion of pus. An abscess of the upper palate after dissection requires drainage of the wound with thin rubber (glove latex is often used) in order to completely drain the purulent exudate. In this case, triangular excision of a section of soft tissue of the mucous membrane allows for the maximum removal of purulent contents.

After the incision, the patient must rinse the oral cavity with a solution of potassium permanganate or sodium bicarbonate, followed by treatment of the infection site with an antiseptic. Irrigation with distilled water with oxacillin and dimexide, as well as applications using the latter substance, may be indicated.

If the effect of the surgical treatment is not observed on the following day, this serves as grounds for placing the patient in hospital.

Prevention of periostitis of the jaw

Without proper and timely treatment, periostitis of the jaw is dangerous due to consequences such as the spread of pus into nearby soft tissues and bone structures, osteomyelitis, and blood poisoning (sepsis). The inflammatory disease is characterized by a rapid progression and a severe clinical picture. That is why prevention plays an important role in dental practice, including:

• regular and thorough oral care;
• mandatory brushing of teeth twice a day with toothpaste or tooth powder;
• use of floss, mouthwashes, special products (for example, if there are problems with bleeding gums, etc.);
• visiting the dentist at least once every six months, as well as following all doctor’s recommendations;
• timely treatment of any dental problems (caries, trauma, etc.);
• correction of bite and crooked teeth;
• compliance with hygiene rules while wearing braces and removable plates;
• avoiding cases of self-medication, which can aggravate the problem and lead to irreparable consequences.

Prognosis of periostitis of the jaw

The duration and effectiveness of therapy, the absence of complications and relapses of periosteitis largely depend on the timeliness of the patient's request for qualified help, as well as the correctness of the prescribed treatment.

It can be said with confidence that the prognosis for periostitis of the jaw at the initial stage of development is favorable, and noticeable relief occurs already on the fifth day after dental intervention.

Periostitis of the jaw with the formation of a palatine abscess, which does not open on its own, threatens the necrosis of the bone parts of the jaw or the development of osteomyelitis. It should be remembered that errors in treatment can lead to the inflammation developing into a chronic form, the formation of an abscess and phlegmon.