Osteomyelitis of the jaw: what it is and how it manifests itself

Osteomyelitis of the jaw is an infectious inflammation of the bone marrow and bone with destruction (sequestra), periosteal reaction, and the risk of chronicity. It is most often odontogenic: complicated caries/periapical infection, peri-implantitis, infection after tooth extraction, trauma, or open fracture. Less common causes include hematogenous mole, actinomycosis, and systemic factors (diabetes, immunodeficiency, smoking). Without timely drainage and debridement of the lesion, osteomyelitis can become chronic (fistulas, sequestra, sclerosis) and require more extensive surgery. [1]

It is important to distinguish “classic” infectious osteomyelitis from conditions with a similar picture:

• MRONJ (drug-related osteonecrosis of the jaw) in patients receiving antiresorptive/antiangiogenic drugs; often associated with secondary osteomyelitis. Management and prognosis are different. [2]
• Osteoradionecrosis after irradiation of the head and neck (bone lesion with necrosis and frequent infection).
• Rare sclerosing forms (primary chronic sclerosing osteomyelitis, diffuse sclerosis, CRMO) - occur without obvious pus, with painful outbreaks. [3]

Table 1. Types of osteomyelitis of the jaw (briefly)

View	Clinic/tips	Notes
Acute purulent	Pain, fluctuation/abscess, fever, tooth mobility, early radiographic image is poor	Urgent: drainage + sanitation + antibacterial therapy
Chronic purulent	Fistulas, sequesters, intermittent pain, bone thickening	Sequestrectomy/decortication + course of AB
Sclerosing (diffuse/primary)	Dense pain, little pus, extensive sclerosis on CT	Often without overt infection; individual regimen, NSAIDs/surgery as indicated [4]
Actinomyces-associated	Long fistula process, "granular granules" in the discharge	Long-term penicillin therapy + surgery is required [5]

Symptoms and red flags

Typical symptoms: localized pain/distension, soft tissue swelling, pain when biting, pus discharge through a pocket/fistula, fever (not always), trismus, and an unpleasant odor. In chronic cases, fistulas, "chips" of necrotic bone (sequesters), and numbness of the chin (Numb chin syndrome) may occur. [6]

Refer immediately to hospital if: rapidly growing, dense swelling of the floor of the mouth/neck (risk of Ludwig's angina), difficulty breathing/swallowing, high fever, ocular symptoms (swelling of the eyelid, pain behind the eye), signs of sepsis. These are situations where airway priority, surgical decompression, and intravenous therapy are required. [7]

Diagnostics: What is really needed?

1. Clinic and dental source. We examine the causative tooth/implant, sinus tracts, and pulp vitality; we evaluate soft tissues and spread.

2. Visualization.

• Start with a panoramic shot;
• To assess the prevalence and sequestration - CT/CBCT;
• In case of soft tissue complications and early bone changes - MRI (better able to see bone marrow/abscesses). [8]

3. Microbiology and histology (if possible before antibiotics): pus culture/bone biopsy during surgery → targeted therapy; if Actinomyces is suspected, we ask the laboratory to specifically look for actinomycete filaments. [9]

4. Differential diagnosis with MRONJ/n-MRONJ. MRONJ and "non-drug-induced osteonecrosis" have similar radiographic features; medication history (bisphosphonates, denosumab, antiangiogens, and, less commonly, biologics) is always clarified, as this determines the treatment strategy and prognosis. [10]

Table 2. Osteomyelitis vs. MRONJ: Key Differences

Sign	Infectious osteomyelitis	MRONJ
Drug history	Not required	Common: antiresorptives/antiangiogens (onco/osteoporosis)
The root cause	Odontogenic infection, trauma, surgery	Extraction with medications or spontaneously
Tactics	Drainage/source removal + debridement + AB course	Gentle pre-aggressive debridement + long-term control; risk of delayed healing is higher [11]

Treatment: "First surgery, then antibiotics - but the right way"

1) Source control and drainage are the cornerstone

• Opening and drainage of abscesses, wound revision;
• Sanitation of the causative tooth (endodontics) or removal if the prognosis is poor;
• In chronic cases, sequestrectomy, decortication/sauce, and, if necessary, resection with reconstruction are performed. This reduces the bacterial load, improves antibiotic penetration, and improves blood supply. [12]

2) Antibacterial therapy - how much and how

• The classic approach to osteomyelitis is 4-6 weeks of systemic antibiotics after adequate surgical control, with possible transition to oral forms once the condition stabilizes. There is growing evidence that oral regimens with good bioavailability are as effective as long-term, purely intravenous courses if surgery has been comprehensive and there is a clinical response. [13]
• If the entire infected bone area is removed (complete sequestrectomy/clean margin resection), a shorter course is acceptable (up to 10-14 days in some models) - the decision is individual after discussion with the surgeon/infectious disease specialist. [14]
• Empirical therapy is aimed at mixed oral flora (aerobes/anaerobes): amoxicillin/clavulanate; in severe cases, parenteral beta-lactams ± metronidazole, with culture-based correction. Current reviews on dental infections emphasize de-escalation based on results. [15]

A special case is actinomycus (Actinomyces spp.): it requires long-term high-dose penicillin therapy (weeks to months) in conjunction with surgical debridement. In real-life series, the duration varies from 6 weeks to several months, depending on the prevalence and response. [16]

3) Pain relief and support

NSAIDs and local measures (cold for the first 48-72 hours, then as needed) reduce pain and trismus. The combination of NSAIDs ± paracetamol is often more effective than opioids and safer. [17]

Table 3. Scheme of actions (simplified algorithm)

Stage	What are we doing?	For what
1. Evaluation and visualization	Examination, OPG → CT/MRI as indicated	Determine the prevalence, sequesters, abscesses
2. Emergency surgery	Drainage + sanitation/removal of the causative tooth; in chronic cases - sequestrectomy/decortication	Reduce the bacterial load, restore blood flow
3. Antibiotics	Start empirically → correction by culture; usually 4-6 weeks, shorter with complete removal of infected bone	Eradication of infection, prevention of relapse [18]
4. Control	48-72 hours and further according to the clinic; if worsening - revision of surgery/scheme	Early detection of treatment failure

What the patient should do: postoperative care

• Ice on the cheek for 10-20 minutes with breaks in the first 1-2 days, sleep with your head elevated.
• Pain relief: NSAIDs ± paracetamol as prescribed by the doctor.
• Rinsing: from 24 hours - warm salt water 3-5 times a day, without vigorous shaking.
• Hygiene and nutrition: soft brush, gently; soft warm food, plenty of fluids; no smoking/vaping.
• Antibiotics - strictly as prescribed and for the required duration; do not stop "as soon as you feel better."
• Monitor: Contact clinic within 48-72 hours or sooner if worsening (increasing pain/swelling, fever, new weakness/numbness, foul odor). [19]

Table 4. When to urgently return to the doctor/hospital

Sign	Why is it dangerous?
Progressive, dense swelling of the floor of the mouth/neck, difficulty swallowing/breathing	Risk of deep phlegmon (Ludwig's angina)
High fever, chills, increasing pain despite antibiotics	Inadequate surgical debridement/resistance is possible
Swollen eyelids, pain behind the eye, blurred vision	Risk of orbital/intracranial complications
Lip/chin numbness, new asymmetry	Nerve lesion/spread into the bone canal

Prevention and risk reduction

• Oral cavity sanitation before traumatic interventions; periodontal and peri-implantitis control.
• In patients on antiresorptive/antiangiogenic therapy, discuss dental tactics and MRONJ prevention before/during treatment; minimize trauma during extractions, plan closed suturing, and long-term monitoring. [20]
• Glycemic control, smoking cessation, dietary and hygiene correction improve healing and reduce the risk of chronicity. [21]

Table 5. Frequently asked questions (short answers)

Question	Answer
"Can it be cured without surgery using antibiotics alone?"	No: if there is an abscess/sequestra, surgery is required, otherwise there is a high risk of failure and chronicity. [22]
"How long does a course of antibiotics last?"	Usually 4-6 weeks after adequate surgery; if all infected bone is removed, the course may be shorter - at the discretion of the doctor. [23]
"Is it necessary to administer antibiotics intravenously?"	Not always: current evidence supports oral regimens (with good bioavailability) after stabilization and with full surgical control.[24]
"If Actinomyces was found?"	Long-term penicillin therapy + surgery will be required; timeframe - weeks/months depending on the response. [25]
"How to distinguish from MRONJ?"	They look at the drug history and the nature of the bone; with MRONJ, management is more gentle, healing is slower. [26]

Results

• Osteomyelitis of the jaw is a predominantly odontogenic bone infection. The mainstay of treatment is surgical control of the lesion (drainage/sequestrectomy/decortication) + rational antibacterial therapy, usually 4-6 weeks, with possible transition to oral regimens upon stabilization. [27]
• Complete removal of the infected bone may allow a shorter course of antibiotics; this is an individual decision.[28]
• Special scenarios (eg, actinomycosis) require longer and more targeted treatment. [29]
• Always exclude and consider MRONJ: in patients on antiresorptive/antiangiogenic therapy the management and prognosis are different. [30]