Jawbone infection (osteomyelitis): symptoms, and when is it an emergency?

Osteomyelitis means an infection of the bone. The NHS describes it as a painful bone infection and writes that it usually clears up with early antibiotics, but that if it is not treated it can lead to serious long-term problems such as permanent bone damage. In the jaw, bacteria usually reach the bone from the mouth: from a tooth with an infected root, a deep gum pocket, an extraction wound or a fracture. The symptoms resemble the NHS's general description: severe pain, swelling, a feeling of warmth in the area, redness of the skin and a high temperature.

Who is more prone to it is also clear. The NHS lists among the risk factors having had osteomyelitis before, diabetes, a fracture, an open wound, a previous infection or operation, and conditions that weaken the immune system, such as chemotherapy or HIV. In the jaw, the starting point is often a dental infection or extraction wound that has been left untreated.

With pain that will not settle after an extraction, the condition it is most often confused with is dry socket (alveolar osteitis). MSD Manuals writes that dry socket is pain coming from bone left exposed when the blood clot in the extraction site breaks down, and that it is seen mostly after removal of lower back teeth and wisdom teeth. The same source lists smoking, a weak immune system, older age and use of the contraceptive pill among its risk factors. The pain typically starts on the second or third day after the extraction, spreads to the ear and can last from a few days to a few weeks. It is self-limiting, but very painful, and often needs local treatment from the dentist.

The signs that separate the two are clear. MSD Manuals writes that osteomyelitis is distinguished from dry socket by fever, local tenderness and swelling. With dry socket there is pain but no fever or widespread swelling; the socket looks empty and there may be a bad smell. The same source states that when the symptoms have lasted a month, the piece of dead bone (sequestrum) that confirms a diagnosis of osteomyelitis should be looked for with a dental X-ray or a CT scan. What you can do at home is keep a timeline: the date of the extraction, the day the pain started, your temperature readings, and the days the swelling got bigger or smaller. MSD Manuals asks for the patient to be sent back to the dentist if swelling persists or increases beyond 3 days after the extraction, or if the pain gets worse.

Some medicines used for osteoporosis or in cancer treatment change the picture. In people taking medicines that suppress bone breakdown (bisphosphonates, denosumab) and some cancer medicines that suppress the formation of blood vessels, the jawbone can become exposed and fail to heal; this is called medication-related osteonecrosis of the jaw. MSD Manuals writes that the diagnosis is made when exposed dead bone in the upper or lower jaw has lasted at least 8 weeks in a person taking these medicines who has not had radiotherapy to the head and neck; in about 75% of cases it is in the lower jaw, which has a poorer blood supply than the upper jaw, and it can appear on its own or after an extraction or injury. The same source notes that some cases may be less a true necrosis than a persistent osteomyelitis that will not heal.

This risk is not the same for everyone. MSD Manuals writes that most cases are seen in cancer patients given high-dose bisphosphonates into a vein, that the overall risk in people taking bisphosphonates by mouth for osteoporosis is extremely low, and that they should therefore not be discouraged from appropriate bisphosphonate use. So if you take an osteoporosis medicine, do not stop it yourself; if a procedure such as an extraction or an implant is planned, tell your clinician the name of the medicine, how you take it and for how long. MSD Manuals recommends that any necessary oral surgery be done before the medicine is started where possible, and regular dental care while it is being taken.

In people who have had radiotherapy to the head and neck, there is a separate condition: radiation-related bone death (osteoradionecrosis). Radiation permanently reduces the blood supply to the bone, and even years later, after a small injury such as an extraction, the bone can become exposed and fail to heal. In a review that combined studies of patients given modern intensity-modulated radiotherapy for cancer of the oral cavity, the rate was about 8%; the authors note that the certainty of the evidence is very low, and that doses above 50 Gy and involvement of the lower jaw were associated with the risk. In someone with a history of radiotherapy, the clinician should be told this before every dental procedure.

What the four have in common is that they do not get better if left to themselves. The NHS writes that osteomyelitis is treated with antibiotics, usually for 4 to 6 weeks and for up to 12 weeks with a severe infection, and that if it is treated within 3 to 5 days of the infection starting, it often clears up completely. If an abscess has formed in the bone, or the infection has lasted a long time and damaged the bone, the damaged bone needs to be removed surgically. This is the concrete benefit of seeking help early: shorter treatment and less bone loss.

The items in the first list are the expected course after an extraction, or conditions that can be watched under a clinician's follow-up. If a single item from the second list applies to you, do not wait.

Jawbone infection falls within oral and maxillofacial surgery. The first visit is often to the dentist who did the extraction.

1. 1

   Emergency signs first

   If there is difficulty breathing, speaking or swallowing, swelling spreading to the eye or neck, or an inability to open the mouth, the assessment is done in A&E.

2. 2

   History and list of medicines

   You are asked about the date of the extraction or dental infection, the day the pain started, fever, diabetes, smoking and treatments that suppress the immune system. The name, route and duration of any osteoporosis and cancer medicines, and any history of head and neck radiotherapy, are always recorded; this information changes the diagnosis.

3. 3

   Examination inside the mouth

   Whether the extraction site has closed, whether there is exposed bone, a discharging hole in the gum (a fistula), looseness of the neighbouring teeth and the extent of the swelling are assessed.

4. 4

   Imaging

   Areas of bone loss and pieces of dead bone are looked for with a dental X-ray, a panoramic X-ray or a CT scan. MSD Manuals recommends looking specifically for this piece of bone when the symptoms have lasted a month.

5. 5

   Blood tests and a sample if needed

   The NHS writes that with osteomyelitis, blood tests, scans and a sample of bone may be taken. The sample shows which bacteria are responsible and which antibiotic will work.

6. 6

   Treatment and follow-up plan

   The length of the antibiotic course, removal of dead bone if needed and the intervals between check-ups are decided. If the source is a tooth, treating or removing that tooth is part of the plan.

Dry socket, osteomyelitis, medication-related osteonecrosis and radiation-related bone death are treated in different ways.

The following are the decisions that most often cost time and bone. We set them out so that, whichever clinician you see, you can ask the right questions.

The time varies a great deal depending on the condition. The sequence below is the framework in the sources; the plan of the surgeon treating you takes priority.

1. The first 3 days after an extraction

   Swelling and pain are the expected course. If they increase after the third day or the pain gets worse, MSD Manuals asks for you to go back to the dentist.

2. 3–5 days after the infection starts

   The NHS writes that if osteomyelitis is treated within this time, it often clears up completely. This window is the biggest gain from seeking help early.

3. 4–6 weeks

   According to the NHS, the usual length of antibiotic treatment; with a severe infection it can extend to 12 weeks.

4. One month

   When the symptoms reach this point, MSD Manuals recommends looking for a piece of dead bone with an X-ray or a CT scan.

5. 8 weeks

   If exposed bone in someone taking these medicines has lasted beyond this time, a diagnosis of medication-related osteonecrosis is made and treatment is planned accordingly.

We do not give a single figure here, because behind pain that will not settle after an extraction there may be a dry socket that clears up with one or two dressings, or a bone infection that calls for weeks of antibiotics and surgery. These are the items that determine the scope:

The diagnosis

Dry socket, osteomyelitis, medication-related osteonecrosis and radiation-related bone death are entirely different treatments.

Imaging and tests

A panoramic X-ray, a CT scan, blood tests and taking a bone sample are separate items.

The length and setting of treatment

Antibiotics by mouth at home and treatment into a vein in hospital with surgical clean-up are not the same scope.

The tooth plan after healing

Replacing lost teeth is planned separately, according to the state of the bone and your medicines and radiotherapy history.