Inflammatory diseases of the jaws. Odontogenic osteomyelitis of the jaw: clinical guidelines

List of Abbreviations

ABT – antibiotic therapy

HEI – higher educational institution

CT – computed tomography

WBCI – white blood cell intoxication index

PT – physical therapy

MSCT – multislice computed tomography

MRI – magnetic resonance imaging

MC – medical care

NSAID – group "Anti-inflammatory and antirheumatic products"

AR – adverse reaction

AIFD – acute infectious and inflammatory disease

ARF – acute renal failure

SARE – serious adverse reaction

ESR – erythrocyte sedimentation rate

US – ultrasound examination

MFR – maxillofacial region

OMFS – oral and maxillofacial surgery

EPT – electric pulp testing

EEG – electroencephalography

EchoCG – echocardiography

** – the trade name of a medicinal product is marked with two asterisks (**) if the recommendation thesis applies to a medicinal product for medical use included in the list of vital and essential drugs for medical use.

Terms and Definitions

• Sequestrum (odontogenic or otherwise) – a localized inflammatory and necrotic focus in bone tissue, accompanied by the death and detachment of jaw bone tissue areas with the formation of a sequestral capsule and subsequent bone tissue remodeling.

• Dentoalveolar segment – a conventional unit of volume of the alveolar part of the jaw used to assess the extent of the infectious and inflammatory process. The lower boundary of the dentoalveolar segments of the posterior mandible is the mandibular canal (canalis mandibulae), and of the anterior part, a virtual horizontal plane connecting the mental foramina (foramen mentale dex. et sin.). The upper boundary of the dentoalveolar segments of the maxilla is the floor of the nasal cavity and maxillary sinuses. The vertical boundaries are conventional lines drawn through the walls of the tooth sockets of adjacent teeth.

• Acute or exacerbation of chronic periostitis – an acute or exacerbation of a chronic infectious and inflammatory process in the jaw within a single dentoalveolar segment.

• Acute odontogenic periostitis – an acute odontogenic seropurulent or purulent inflammation of the periosteum, in which the zone of the primary infectious and inflammatory process in the jaw is limited to a single dentoalveolar segment that served as the entry gate for the causative agents of the disease, with the formation of a subperiosteal abscess.

• Acute odontogenic osteomyelitis – an acute odontogenic infectious and inflammatory process in which the lesion in the jaw extends beyond the dentoalveolar segment that served as the entry gate for the pathogen, to the periodontium of adjacent teeth or the body of the jaw.

• Secondary immune inflammatory response phenomenon – the phenomenon of organism sensitization by repeated contacts with an antigen (described in the early 20th century by Arthus), taking into account the role of organism sensitization in the development of AIFD of the maxillofacial region.

• Rehabilitation – a system of state, social, economic, medical, occupational, and other measures aimed at preventing the development of diseases and complications leading to temporary or permanent disability, and reintegrating patients and disabled individuals (adults and children) into society and socially useful labor.

• Periosteotomy – opening and drainage of a subperiosteal inflammatory focus.

• Sequestrectomy – removal of a sequestered bone area.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

• Periostitis – an inflammatory disease characterized by the spread of the inflammatory process from an odontogenic or non-odontogenic focus in the jaw within a single dentoalveolar segment, including the periosteum of the alveolar process.

• Acute odontogenic periostitis – an acute odontogenic seropurulent or purulent inflammation of the periosteum, in which the zone of the primary infectious and inflammatory process in the jaw is limited to a single dentoalveolar segment that served as the entry gate for the causative agents of the disease, with the formation of a subperiosteal abscess.

• Chronic periostitis of the jaw – chronic inflammation of the periosteum of the alveolar process of the jaw.

• Chronic odontogenic periostitis – a chronic odontogenic inflammation of the periosteum, in which the zone of the primary infectious and inflammatory process in the jaw is limited to a single dentoalveolar segment that served as the entry gate for the causative agents of the disease.

• Osteomyelitis of the jaw – a purulent-necrotic inflammatory disease of the jaw bone tissue (affecting all its structural components simultaneously) of an infectious-allergic nature of odontogenic or non-odontogenic origin.

• Acute odontogenic osteomyelitis – an acute odontogenic infectious and inflammatory process in which the lesion in the jaw extends beyond the dentoalveolar segment that served as the entry gate for the pathogen, to the periodontium of adjacent teeth or the body of the jaw.

• Chronic osteomyelitis – a purulent destructive or proliferative inflammation of bone tissue characterized by the formation of sequestra or the absence of a tendency to spontaneous recovery and an increase in resorptive and productive changes in the bone and periosteum.

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

Etiology.

Periostitis develops against the background of acute or exacerbation of chronic odontogenic diseases, most commonly chronic periodontitis, and less commonly periodontitis or pericoronitis.

Inflammatory diseases of the maxillofacial tissues, including bone tissue, occur as a result of their infection by the microbiota that vegetates in the oral cavity and on the skin.

Modern microbiological studies have revealed that the types of bacteria causing odontogenic infections include a wide range of facultative and strict anaerobic microorganisms considered part of the opportunistic human oral microbiota. In periostitis, the microbiota may be represented by: Peptococcus niger, Peptostreptococcus spp., Bacteroides spp., Prevotella oralis, Prevotella melaninogenica, Streptococcus anginosus, Porphyromonas gingivalis. The microbial composition in elderly individuals is represented predominantly by facultative anaerobes in combinations of 2–3 species, whereas in young age, obligate forms of microorganisms in monoinfection predominate. Chronic periostitis is characterized by the presence of a long-standing focus of odontogenic infection with frequent recurrent exacerbations against the background of immunodeficiency states of the organism. Rarefying periostitis occurs as a consequence of chronic trauma and most frequently in the central part of the mandible [21, 22, 23, 27, 32, 83, 103].

Opportunistic microflora of the oral cavity are also causative agents of odontogenic osteomyelitis. According to A.I. Yaremenko (2007), Staphylococcus aureus combined with anaerobes is detected in 50% of cases of maxillofacial inflammatory diseases. According to T.G. Robustova and V.V. Shulakov (2016), non-spore-forming anaerobes account for 65–75% of the microbiota. Actinomycetes and Veillonella are less commonly detected; facultative anaerobes and aerobic bacteria account for 35% [99]. The microbiota in jaw osteomyelitis can be represented by: Streptococcus pp., Peptostreptococcus spp., Bacteroides spp., Actinomyces israelii, Enterobacteriaceae, Staphylococcus aureus. According to Yaremenko et al. (2019), in inflammatory diseases of the jaws, the composition of the microbiota includes Candida albicans – 5,6 %, Candida krusei – 1,4 %, Candida spp. – 1,4 %, Enterobacter spp. – 1,4 %, Enterococcus faecalis – 2,8 %, Klebsiella pneumonia – 9,9 %, Proteus mirabilis  –  1,4 %, Pseudomonas aeruginosa – 1,4 %, Staphylococcus aureus – 4,2 %, 26,8 %, Staphylococcus saprophyticus – 2,8 %, Streptococcus spp. – 9,9 %, Streptococcus viridians group – 31%. As inflammation subsides, the microbiota becomes more diverse, and in the chronic course of osteomyelitis, its composition approaches the microbiocenosis of the periodontal pocket [21, 103].

General predisposing factors for the development of osteomyelitis include: anatomical and topographical features of the structure and blood supply of the bone area, decreased general nonspecific and immune resistance, background general somatic pathology (diabetes mellitus, blood disorders, chronic cardiovascular or hepatorenal failure, exposure to ionizing radiation, or the use of antiresorptive drugs [21, 23, 27, 32, 83].

Pathogenesis. Serous periostitis is regarded as a reactive inflammatory process in the periosteum that accompanies exacerbated chronic periodontitis.

In purulent periostitis, exudate from the tissues of the inflamed periodontium penetrates under the periosteum through Volkmann's and Haversian canals, via lymphatic vessels, or through a previously formed erosion in the socket wall. The phase of edema and exudation is followed by the phase of infiltration, causing the development of infectious-allergic inflammation with subsequent effusion of exudate under the jaw periosteum. In the onset of acute odontogenic periostitis of the jaws, the main predisposing factor is microbial sensitization to staphylococcus, the frequency and severity of which correlate with the severity and prevalence of the process.

In chronic periostitis the inflammatory process most frequently begins in the periosteum of the mandible and is characterized by a local hyperergic inflammatory reaction. Such a clinical course is observed in patients with primary or secondary immunodeficiency diseases or conditions, and is most often of a primary chronic character. Chronic periostitis is characterized by the presence of a chronic inflammatory focus in the periodontium, which causes low-grade localized inflammation of the periosteum with the formation of fibrous tissue (fibrous periostitis) and a predominance of a productive component in the underlying cortical bone. In simple chronic periostitis, the newly formed osteoid tissue undergoes regression after treatment. With a prolonged course, an osteoblastic reaction transforms the young bone tissue into mature, highly sclerotic bone, and the inflammatory process concludes with hyperostosis. Rarefying periostitis is characterized by superficial subperiosteal bone resorption. Trauma to the periosteum results in a hematoma, the organization of which leads to compaction of the periosteum with pronounced resorptive phenomena along the edge of the cortical bone and remodeling of the bone structures.

In the pathogenesis of odontogenic osteomyelitis, a decisive role is assigned to the impairment of the immune balance, which is based on sensitization against the background of long-standing multiple and chronic foci of odontogenic infection—intensified during exacerbations—and a decrease in the general reactivity of the body. The constant impact of microorganisms on the bone marrow disrupts its structure, cellular reactivity, and reparative capacities. The dilatation of numerous small blood vessels in the periapical region of the alveolus during an exacerbation creates favorable conditions for the spread of infection directly into the bone marrow spaces of the alveolar process and the body of the jaw. Microcirculatory disorders are based on the phenomenon of type II, III, and IV allergies. Increased vascular permeability, occurring as a consequence of the activation of cells participating in allergic reactions (mast cells, basophils, macrophages, etc.) and their release of a huge amount of allergy and inflammatory mediators, leads to impaired hemostasis and fibrinolytic activity, the formation of microthrombi in the bone marrow vessels, and their purulent melting. The nutrient canals of the osteon undergo purulent melting, and a zone of necrosis without demarcation inflammation forms in the affected area of the bone. The accumulation of pus in the bone marrow spaces leads to intraosseous hypertension and the involvement of extraosseous vessels. A collateral edema of the periosteum develops, along with its purulent melting and the release of pus into the perimaxillary soft tissues with the development of odontogenic phlegmons. The increase in the volume of damage and bone necrosis in osteomyelitis is facilitated by secondary mechanisms such as blood circulation disorders in the focus and increased hypoxia resulting from venous congestion and lymphostasis; damage to the extraosseous vessel system due to detachment of the periosteum from exudation, or during drainage of the focus, especially in the mandible.

1.3 Epidemiology of the Disease or Condition

Jaw periostitis occurs in 5.2–5.4% of outpatients. According to A.A. Timofeev (2010), complicated forms of periostitis are observed in 20–23% of patients hospitalized for inflammatory diseases. Acute periostitis occurs in 94–95% of cases, and chronic periostitis in 5–6%. The inflammatory process in periostitis is localized on one side of the jaw, most commonly on the vestibular surface, in 93.4% of patients. According to the literature, periostitis develops in the mandible in 61.3% of patients and in the maxilla in 38.7% [64, 66, 71].

Odontogenic osteomyelitis of the jaw accounts for up to 74.2% of all other jaw osteomyelitis cases. The disease occurs predominantly in middle-aged men. Regarding the localization of the "causative" tooth in osteomyelitis of the mandible, the first lower molar ranks first, the lower "wisdom tooth" ranks second—around which not only a periapical but also a marginal inflammatory process develops—and the lower second molar ranks third. In hospitalized patients, lesions of the mandible are registered in 85% of cases out of the total number of patients with jaw osteomyelitis, whereas in out-patient clinic appointments, lesions of the maxilla predominate [27, 64, 66, 71].

1.4 Features of Coding the Disease or Condition

K10.2 Inflammatory conditions of jaws.

Osteitis of jaw (acute) (chronic) (suppurative)

Osteomyelitis (neonatal) of jaw (acute) (chronic) (suppurative)

Osteonecrosis (medication-induced) (radiation) of jaw (acute) (chronic) (suppurative)

Periostitis of jaw (acute) (chronic) (suppurative)

Bone sequestrum

1.5 Classification of the disease or condition

Periostitis of the jaw

The following forms of periostitis of the jaw are distinguished [50, 64, 71, 74]:

Classification of jaw periostitis in adults:

1. Acute periostitis:

1.1. Serous form.

1.2. Purulent form: localized, diffuse.

2. Chronic periostitis:

1.1. Simple.

1.2. Ossifying.

1.3. Rarefying.

Osteomyelitis of the jaw.

The following classifications of jaw osteomyelitis are distinguished:

1. Classification of osteomyelitis based on the etiological factor and the route of infection penetration [21, 27, 36, 64]:

1. Odontogenic.

2. Hematogenous.

3. Traumatic, including gunshot wounds.

4. Contact osteomyelitis, arising when inflammation spreads to the bone from adjacent tissues or organs.

2. Lukyanenko V.I. classification (1968).

3. Classification of odontogenic osteomyelitis according to A.G. Shargorodsky (2002) [21, 27, 64]:

4. Clinical and radiological classification of osteomyelitis by M.M. Solovyov (2016), based on the classification by M.M. Solovyov and I. Khudoyarov (1979) [21, 59, 75, 103].

Due to the lack of a single unified classification of jaw osteomyelitis in Russia, these clinical guidelines propose a "consolidated working" classification of jaw osteomyelitis. This classification comprehensively incorporates etiological features, key links and mechanisms of pathogenetic processes in the jaw bone tissue, as well as the division into stages and phases of the process linked with the main clinical and radiological manifestations. This enables the determination of treatment tactics, including surgical intervention, at each stage (phase) of the inflammatory process.

*It should be noted that in accordance with the classification presented above, adopted at Pavlov First St. Petersburg State Medical University by M.M. Solovyov and I. Khudoyarov [21, 75, 103], the subacute phase of osteomyelitis is distinguished as a separate stage of the inflammatory process.

1.6 Clinical presentation of the disease or condition

Odontogenic periostitis.

The clinical picture of acute odontogenic periostitis is varied and depends on the state of the body's immunological reactivity. Complaints are dominated by pain in the area of the "causal" tooth and edema of the adjacent maxillofacial soft tissues. The "causal" tooth may cause moderate discomfort. The general condition is satisfactory or of moderate severity; body temperature is elevated within subfebrile values, less frequently febrile. General weakness, lack of appetite, and sleep disturbances are possible. A reaction from the regional lymph nodes is noted. Mouth opening is generally not impaired or is moderately restricted (grade I–II) due to pain, or due to the reaction of the masseter or medial pterygoid muscle when localized in the distal parts of the mandible on one side (vestibular or lingual). Characteristic local signs of odontogenic periostitis include collateral edema of the maxillofacial tissues, as well as edema, hyperemia, and bulging of the tissues along the transitional fold in the area of the "causal" and adjacent teeth on only one side of the jaw. The main sign is the presence of an inflammatory infiltrate, determined upon palpation, in the projection of the root apex of the "causal" tooth; at the stage of purulent inflammation, periosteal melting occurs and an abscess forms exclusively on one side of the alveolar part of the mandible or the alveolar process of the maxilla, with a positive fluctuation sign. There is a "positive" percussion of varying intensity and mobility of the "causal" tooth, whereas adjacent teeth are painless upon percussion and stable [21, 23, 24, 25, 59, 65, 75, 103]. When the inflammatory process is localized on the lingual side of the mandible, pain during swallowing is observed. When a palatal abscess develops, bulging of the palatal mucosa occurs, which is sharply painful corresponding to the projection of the "causal" tooth.

In the normergic type of course of the inflammatory reaction in periostitis, the inflammatory infiltrate is dense, but quickly demarcates from healthy tissues and an abscess forms. The hyperergic course of inflammation is characterized by a rapidly growing and pronounced inflammatory reaction that responds fairly well to treatment. The hypoergic course is more sluggish; the disease develops slowly, but tends to spread stubbornly with a weak tendency toward demarcation, despite ongoing treatment.

Chronic periostitis is characterized by the absence of clearly defined clinical symptoms. As a rule, there is no sharp pain, and the preceding acute inflammatory process subsides slowly. The general condition is satisfactory, there is no temperature reaction of the body, and subfebrile temperature is sometimes noted. External examination reveals minor changes in facial configuration. Palpation reveals a dense, painless bone thickening. Regional lymph nodes are enlarged, dense, painless, or slightly painful. The oral mucosa in the area of the "causal" tooth is edematous and hyperemic on only one side of the jaw [21, 23, 24, 25, 59, 65, 71, 75].

Odontogenic osteomyelitis.

The disease begins with toothache, which soon loses its localized character, spreading to neighboring teeth with radiation throughout the entire half of the jaw and along the branches of the trigeminal nerve. Throbbing pain when closing the teeth on the affected side is a frequent complaint. In the mandible, if the purulent-inflammatory process in the bone tissue spreads from the dentoalveolar segment zone to the mandibular body below the level of the mandibular canal, the Vincent's symptom appears (decreased sensitivity along the inferior alveolar nerve), and numbness of the skin of the lower lip, chin, and anterior teeth of the affected side is possible. The general condition is of moderate severity, with lethargy, pallor of the skin, fever up to 38°C and possibly higher, and tachycardia. External examination reveals a change in facial configuration due to soft tissue edema of the maxillofacial region. Regional lymph nodes are enlarged and painful upon palpation and head turns. Mouth opening is difficult when the masticatory muscle group is involved in the process.

In the oral cavity: percussion of several teeth in the affected area of the jaw is sharply painful, while percussion of the "causal" tooth may be less painful; mobility of the "causal" tooth and at least 2 adjacent teeth is pronounced. The transitional fold is hyperemic, smoothed out, and the mucous membrane is edematous on both sides of the jaw; if the purulent-inflammatory process in the bone tissue of the mandible spreads from the dentoalveolar segment zone not only vestibularly, but also lingually, or vestibularly and palatally in the maxilla, signs of a "sleeve-like" infiltration are determined upon palpation. When the purulent-inflammatory process is localized in the maxillary molar zone, parietal edema of the alveolar recess mucosa in the region of the maxillary sinus floor above the "causal" tooth may develop, which should also be regarded as the presence of a "sleeve-like" infiltrate.

Clinical manifestations of the disease largely depend on the variant of immunological reactivity. The normergic variant of the course of jaw osteomyelitis is characterized by moderately pronounced general and local clinical manifestations and is rare. The hyperergic type of inflammation is characterized by an extremely acute and rapid onset (within 1–3 days), hyperthermia above 38°C, and the appearance of the so-called "scissors" between body temperature and pulse rate. The inflammatory process manifests with pronounced local signs. The hypoergic variant of inflammation features a sluggish course, moderately pronounced pain syndrome, and local inflammatory reaction. Patients, as a rule, seek medical attention 3–5 days after the onset of the disease. The prevalence of the inflammatory process does not correspond to the general manifestations—body temperature does not exceed 37.5°C, leukocyte counts are normal or may be lower—5–6 – 9 × 10⁹/L, and the ESR is either sharply increased (≥ 30 mm/h) or sharply decreased (about 2 mm/h) [21, 23, 24, 25, 59, 65, 71, 75, 103].

The clinical picture of lesions of the mandible and maxilla has significant differences and is due to the anatomical and physiological features of the structure of the jaws and adjacent soft tissues, as well as the characteristics of blood supply and innervation. Maxillary osteomyelitis is characterized by a milder course, rapid convalescence, and a tendency toward limitation of the purulent-necrotic bone process. The clinical picture of mandibular osteomyelitis in the early period most often manifests as thickening of the margin and frequently the appearance of Vincent's symptom [21, 23, 24, 25, 59, 65, 71, 75, 103].

2. Diagnostics, medical indications and contraindications for diagnostic methods

Criteria for establishing the diagnosis (condition):

1. collection of complaints,

2. collection of anamestic data,

3. physical examination data,

4. instrumental examination data,

5. other research methods, including diagnostic imaging methods,

6. differential diagnosis of diseases.

2.1 Complaints and Anamnesis

Comments: performing an initial examination (assessment, consultation) by a maxillofacial surgeon and/or dental surgeon for patients with odontogenic inflammatory diseases of the jaws, preferably no later than 2 hours from the moment of hospital admission. If the medical facility (hospital) does not have a maxillofacial surgeon and/or dental surgeon on staff, the initial examination (assessment, consultation) may be performed by a general surgeon with subsequent patient routing.

Comments: for the correct establishment of a diagnosis and differential diagnosis between periostitis and osteomyelitis of the jaw, it is necessary to clearly understand their characteristic, typical, so-called "pathognomonic" symptoms. In acute serous periostitis of the jaw, patients most often complain of pain restricted to the region of the "causative" tooth, which intensifies when biting down on it, touching it with the tongue or an antagonist tooth; patients note a sensation of a "elongeated" tooth. In acute purulent periostitis, patients complain of intense pain localized to a single "causative" tooth, which gradually subsides, but intensifies upon palpation of the mucobuccal fold and when touching adjacent facial areas. Patients complain of soft tissue edema in the maxillofacial region and oral mucosa; symptoms of systemic intoxication (general weakness, fatigue, headache, loss of appetite, etc.) manifest depending on the body's reactivity and the virulence of the microbiota [40, 50, 64]. In chronic periostitis, patients may complain of jaw thickening in the area of inflammation, both from the skin and oral cavity sides [21, 23, 24, 25, 59, 65, 71, 75, 103].

In acute or exacerbation of chronic osteomyelitis of the jaw, the patient is disturbed by acute, throbbing pain increasing in intensity, initially localized to a single "causative" tooth, then extending to a number of adjacent teeth and further to a segment of the jaw, radiating along the branches of the trigeminal nerve. Patients note soft tissue edema in the maxillofacial region corresponding to the projection of the lesion in the jaw and oral mucosa. Complaints may also include limitation (due to edema) and painful mouth opening, pain when swallowing, speaking, or moving the tongue, nasal congestion or purulent nasal discharge upon development of maxillary sinus empyema if the primary odontogenic inflammatory "focus" is localized in the maxillary premolar or molar region. Patients note the progressive onset of tooth mobility in the area of the purulent-inflammatory process, purulent discharge from periodontal pockets or fistulous tracts. Reduced or lost sensation in the lower lip, chin skin (Vincent's symptom), or infraorbital region and maxillary teeth of the corresponding side may be observed. In addition, significant weakness, loss of appetite, sleep disturbances, fever, and headaches are noted [21, 23, 24, 25, 59, 65, 71, 75, 103, 109].

In subacute osteomyelitis of the jaw, patients report mildly expressed pain in the region of several teeth and/or a segment (half) of the jaw, tooth mobility, soft tissue edema of the perimaxillary tissues in the projection of the affected jaw area, and purulent wound discharge. Some alleviation of intoxication symptoms is noted, however, complete recovery does not occur. Fistulous tracts in the area of the extracted "causative" tooth socket and/or postoperative scars in the oral cavity with purulent discharge and/or the discharge of small sequestra may be detected [21, 23, 24, 25, 59, 65, 71, 75, 103].

In chronic osteomyelitis of the jaw, patients may complain of minor, intermittent pain in the region of the "causative" and adjacent teeth or the jaw, and tooth mobility within the inflammatory focus. Facial deformation due to jaw thickening, or the presence of postoperative scars or fistulous tracts both on the skin and in the oral cavity, which form later than 4–5 weeks in the upper jaw and 6–8 weeks in the lower jaw from the onset of the current exacerbation of the purulent-inflammatory process or following previous surgery (sequestrectomy) performed in the subacute phase, may be identified [19]. Complaints may include periodic fever within subfebrile ranges, episodes of general weakness, malaise, and excessive sweating [21, 23, 24, 25, 59, 65, 71, 75, 103, 109].

Comments: in purulent-inflammatory diseases of the jaw, for further planning of comprehensive treatment, the physician must first establish the relationship between the onset of this inflammatory process in the jaw and the symptoms preceding the disease. To this end, the physician determines: whether dental disease preceded the inflammatory process, the characteristics of the pain (restricted to the "causative" tooth or also involving adjacent teeth), their mobility; whether tooth extraction was performed; whether there were manifestations of inferior alveolar nerve neuritis (Vincent's symptom); whether the patient noted hypothermia or a recent cold-related illness, physical or emotional stress; what the patient personally associates the onset of the disease with; the dynamics of changes in the clinical picture and the treatment received or its absence: it is necessary to ascertain a subjective evaluation of the effectiveness of treatment administered at the pre-hospital stage [21, 23, 24, 25, 59, 65, 71, 75, 103, 109].

2.2 Physical Examination

Comments: the general condition of patients with acute periostitis of the jaw is most often satisfactory or, less frequently, of moderate severity; body temperature may be elevated within subfebrile ranges, rarely febrile; in rare cases, general weakness, loss of appetite, and sleep disturbances are noted. The general condition of patients with the chronic form of periostitis is generally undisturbed, and body temperature elevation is extremely rare.

Acute osteomyelitis of the jaw is characterized by a more pronounced disturbance of the patient's general condition due to more severe intoxication, elevation of body temperature up to 38.2–38.5 °C with a normergic type of inflammation, and up to 39^°C with a hyperergic type (with significant daily fluctuations), tachycardia, and is frequently accompanied by increased blood pressure and accelerated respiration. The patient's skin is pale and clammy. Patients experience decreased appetite and headaches. In the subacute stage of osteomyelitis, the patient's general condition improves, body temperature decreases, and its daily fluctuations diminish. Chronic odontogenic osteomyelitis is characterized by a satisfactory general condition of the patient, and body temperature most often normalizes or remains within subfebrile ranges [21, 23, 24, 25, 59, 65, 71, 75, 103].

Comments: in acute periostitis, clinical signs include the presence of minor collateral edema of the perimaxillary tissues or its absence, along with symptoms of acute serous regional lymphadenitis.

In subacute periostitis, clinical signs may also include the presence of minor collateral edema of the perimaxillary tissues and acute serous regional lymphadenitis.

In chronic periostitis, changes in the patient's facial contour upon external examination are usually minor.

Upon examination, "thickening" of the bone is detected, most frequently on the vestibular surface (when the purulent inflammation "focus" is localized in the apex region of the root of the second incisor, first premolar, or palatal roots of the molars, formation of a subperiosteal abscess from the palatal surface of the alveolar process of the maxilla or the lingual surface of the alveolar part of the mandible is more likely), at the level of the dentoalveolar segment of only a single "causative" tooth that served as the entry gate for the infection. Regional lymph nodes are enlarged, dense, painless, or slightly painful [21, 23, 24, 25, 59, 65, 71, 75, 109].

When examining a patient in the acute stage of odontogenic osteomyelitis of the jaw, facial contour abnormalities are often revealed due to pronounced soft tissue edema localized in the area of the bone inflammatory process. The skin is of physiological color or slightly hyperemic, and can be gathered into a fold. Bone "thickening" is detected, extending beyond the boundaries of the dentoalveolar segment of the "causative" tooth that served as the "entry gate" for the infection, by at least 2 adjacent teeth (potentially more—at the level of several adjacent teeth, up to half of the mandible corresponding to the localization of the primary inflammation "focus"), with the possible formation of a "muff-like" infiltrate (when the inflammatory process spreads within the bone structures of the jaw in the linguo-vestibular or linguo-palatal direction), or a unilateral infiltrate from the vestibular surface (when the purulent inflammation "focus" is localized in the apex region of the root of the second incisor, first premolar, or palatal roots of the molars, subperiosteal abscess formation from the palatal surface of the alveolar process of the maxilla or the lingual surface of the alveolar part of the mandible is more likely). Enlarged, painful regional lymph nodes are determined. Signs of inflammatory contracture of the mandible may be noted when the purulent process is localized in the area of the masticatory muscles. Eating and swallowing may be difficult.

In the subacute phase of osteomyelitis, inflammatory changes are minor: soft tissue edema and purulent discharge from wounds decrease, wounds granulate, or fistulous tracts form. Regional lymph nodes are slightly enlarged, mildly painful, and dense. However, purulent discharge from the socket of the extracted "causative" tooth and/or the postoperative wound along the mucobuccal fold may appear. A "wave-like" course of the process is possible, alternating between periods of remission and exacerbation, within timeframes not exceeding 4–5 weeks in the upper jaw and 6–8 weeks in the lower jaw from the onset of the current exacerbation of the purulent-inflammatory process, which requires determining the indications and timing for a control radiological examination (if technically feasible, computed tomography of the maxillofacial region or computed tomography of the facial skull with intravenous bolus contrast enhancement) to resolve the issue of whether sequestrum formation is complete and to determine indications for surgical intervention in the volume of sequestrectomy at the end of the subacute phase. The formation of fistulous tracts in the area of the socket of the extracted "causative" tooth and/sought postoperative scars in the oral cavity with purulent discharge is possible.

On external examination of patients with chronic osteomyelitis of the jaws, changes in the facial contour are determined as a result of minor infiltration of the surrounding soft tissues and periosteal thickening of the jaw; the skin color is unchanged. The presence of fistulous tracts extending to the bone is characteristic, from which pus is discharged or lush bleeding granulations protrude, which form within timeframes exceeding 4–5 weeks in the maxilla and 6–8 weeks in the mandible from the onset of the current exacerbation of the purulent-inflammatory process or following a previously performed surgical intervention (sequestrectomy) in the subacute phase [21, 75, 103]. Upon probing the fistulous tract, a mobile area of bone tissue with an uneven surface can be detected. A number of fistulas may scar over. Lymph nodes are slightly enlarged, dense, and mildly painful on palpation [21, 23, 24, 25, 59, 65, 71, 75].

Comments: in patients with a suspected diagnosis of acute periostitis, hyperemia of the mucosal membrane and smoothing of the mucobuccal fold in the area of the "causative" tooth and adjacent teeth are detected. A clinical sign is the presence of a painful inflammatory infiltrate determined on palpation in the projection of the root apex of the "causative" tooth and adjacent teeth; in purulent cases, a positive fluctuation sign is present. A characteristic symptom of periostitis is the location of the inflammatory infiltrate on one side of the jaw (vestibular or lingual/palatal). When the purulent inflammation focus is localized on the palatal side of the maxilla, a palatal abscess forms. In chronic periostitis, oral cavity changes are minor: purplish-cyanotic mucosal membrane in the area of the "causative" tooth.

In acute osteomyelitis, oral cavity examination reveals mucosal hyperemia, gingival edema, and smoothing of the tissues of the oral vestibule in the projection of the purulent-inflammatory focus in the jaw. Palpation reveals a dense, painful infiltrate in the projection of the root apex of the "causative" tooth and at least 2 adjacent teeth (or more); a bilateral ("muff-like") infiltrate is possible when the inflammation spreads within the bone structures of the jaw in the linguo/palato-vestibular direction, and the fluctuation sign may be positive. Signs of inferior alveolar nerve neuritis (Vincent's symptom) may develop if the inflammation spreads vertically within the bone structures of the mandible (from the alveolar part of the mandible below the level of the mandibular canal). When inflammation spreads vertically within the bone structures of the maxilla (upwards from the alveolar process of the maxilla into the maxillary sinus), clinical signs of maxillary sinusitis may develop (most often acute serous, but in cases of maxillary osteomyelitis with primary purulent inflammation focus localization in the premolar or molar region against the background of underlying chronic odontogenic or mixed-genesis maxillary sinusitis—an exacerbation of chronic purulent sinusitis), which requires an otorhinolaryngologist consultation and a control radiological examination of the paranasal sinuses (if technically feasible, computed tomography of the paranasal sinuses, larynx, or computed tomography of the facial skull with intravenous bolus contrast enhancement) to resolve the issue of indications for diagnostic sinus puncture.

In subacute osteomyelitis, oral mucosal edema is mildly pronounced. However, the appearance of purulent discharge and/or discharge from the socket of the extracted "causative" tooth and/or postoperative wound along the mucobuccal fold is possible, as well as the discharge of small sequesta [21, 75, 103].

A "wave-like" course of the process is possible, alternating between periods of remission and exacerbation within timeframes not exceeding 4–5 weeks on the upper jaw and 6–8 weeks on the lower jaw from the onset of the given exacerbation of the purulent-inflammatory process. This requires determining the indications and timing for a control radiological examination (if technically feasible: computed tomography of the maxillofacial region or computed tomography of the oral cavity and teeth or computed tomography of the facial skull with intravenous bolus contrast enhancement) to resolve the issue of whether sequestration formation is complete and to determine indications for performing surgery in the volume of sequestrectomy at the end of the subacute phase of osteomyelitis. At the same time, fistulous tracts in the area of the socket of the extracted "causal" tooth and/or postoperative scars in the oral cavity with purulent discharge or the release of small sequestra are identified [21, 75].

In chronic osteomyelitis, the mucous membrane in the projection of the affected area of the jaw is loose, hyperemic, or cyanotic, sometimes edematous, and, as a rule, there is a "muff-like" thickening of the jaw. Exacerbation of chronic osteomyelitis is characterized by deterioration of the general condition, fever, increase in clinical signs of inflammation, and the formation of fistulas with purulent discharge, which form in timeframes exceeding 4–5 weeks on the upper jaw and 6–8 weeks on the lower jaw from the onset of the given exacerbation of the purulent-inflammatory process or after a previously performed surgical intervention (sequestrectomy) in the subacute phase [21, 75, 103].

Comments: in lower jaw periostitis, limitation of mouth opening may be due to the localization of the inflammatory process in the molar region, to a greater extent due to the development of collateral edema of the perimaxillary soft tissues, and with the further spread of the purulent-inflammatory process into the fascial spaces — due to inflammatory contracture of the masticatory muscles. In the acute stage and subacute phase of osteomyelitis in the lower jaw area, limitation of mouth opening may also be associated with the spread of inflammation to the region of the masticatory muscles. In chronic osteomyelitis, limitation of mouth opening may be due to the localization of the inflammatory process in the angle and ramus of the mandible.

Comments: in acute periostitis of the jaw, "positive" percussion of varying intensity and mobility of only the "causal" tooth are noted.

In acute osteomyelitis, percussion is painful not only for the "causal" tooth, but also for at least 2 adjacent teeth and/or a group of neighboring teeth. There is an increasing pathological mobility of the "causal" tooth and 2 or more neighboring teeth, while the "causal" tooth, which is the source of infection, is more mobile than the others.

In subacute osteomyelitis of the jaw, tooth mobility in the area of the affected bone persists, while teeth located along the periphery become less mobile.

In chronic osteomyelitis of the jaw, tooth mobility in the area of the affected bone is significant.

Comments: one of the early, but not mandatory, local symptoms in acute odontogenic osteomyelitis of the mandible is hypoesthesia of soft tissue areas innervated by nerves passing through the affected area of the jawbone. Hypoesthesia is due to the fact that in the inflammatory focus, the nerve is in a state of hyper-irritation, which is similar to parabiosis (inflammatory neuritis). Very rarely, hypoesthesia is observed in the upper jaw (in the innervation zone of the infraorbital nerve), and much more frequently in the lower jaw (in the innervation zone of the inferior alveolar nerve). In the latter case, this sign almost always confirms the diffuse or focal nature of the lesion of the mandibular body and is known as Vincent's sign [21, 23, 24, 25, 29, 32, 33, 34, 59, 65, 71, 75, 103].

Comments: the general practitioner assesses the patient's general somatic status, clarifies the diagnosis regarding comorbid diseases, determines indications for additional diagnostic methods taking into account the technical capabilities of the medical institution (echocardiography, electrocardiographic monitoring, Holter heart rhythm monitoring, 24-hour blood pressure monitoring, remote monitoring of external respiration function indices (ERF), esophagogastroduodenoscopy, ultrasound diagnostics taking into account the patient's individual pathology (e.g., comprehensive ultrasound examination of the abdominal organs, ultrasound examination of the kidneys, ultrasound duplex scanning of lower extremity vessels (arteries and veins), etc.), coordinates medication regimens for existing/newly diagnosed concomitant (comorbid) pathology, and coordinates the protocol of perioperative patient management with the attending dentist [3, 31, 34, 35, 40, 54, 57, 60].

Comments: fundus examination is a non-invasive method that allows detecting signs of intracranial hypertension. The ophthalmologist identifies signs of optic atrophy and optic disc edema, as well as visual impairments that may indicate the development of intracranial complications [64].

Comments: the neurologist assesses the neurological status, determines indications for EEG and brain MRI when neurological complications are suspected (taking into account the technical capabilities of the medical institution). In the event of neuropathy of the trigeminal nerve branches, they perform additional examination, clarify the diagnosis, and prescribe pathogenetic treatment [36, 50, 71].

Comments: the otorhinolaryngologist assesses the state of ENT organs, clarifies the diagnosis, determines indications for maxillary sinus puncture, adjusts complex treatment including local therapy, and/or coordinates the treatment protocol with the attending dentist to prevent complications from ENT organs [25, 27, 36, 104-107].

Comments: the choice of anesthesia technique is determined by the patient's general condition and the volume of the dental intervention [1, 3, 27].

2.3 Laboratory Diagnostics

Comments: in order to clarify the diagnosis and the nature of the inflammatory process, determine the scope and coordinate the tactics of preparation for surgery, a set of laboratory tests is indicated in accordance with the medical and economic standard. Among them, in the absence of concomitant (comorbid) pathology in the patient, with a normergic type, favorable prognosis of the inflammatory process, and absence of risks of developing complicated forms of purulent-inflammatory processes (PIP), the mandatory tests [109] are: determination of a subgroup and other minor blood groups A-1, A-2, D, Cc, E, Kell, Duffy; determination of antibodies to Rhesus system antigens (if a subgroup is present - determination of the phenotype for C, c, E, e, C, K, k antigens and determination of anti-erythrocyte antibodies); complete blood count (CBC) ("comprehensive") including erythrocyte sedimentation rate (ESR), urinalysis, general somatic blood biochemistry: alanine aminotransferase, urea, creatinine, glucose, electrolytes: potassium, sodium; coagulogram (exploratory hemostasis test): APTT, determination of prothrombin (thromboplastin) time in blood or plasma, if the patient is taking warfarin** - determination of the international normalized ratio (INR), determination of blood fibrinogen level. Comparison of these parameters with the clinical picture of the disease makes it possible to objectively assess the initial severity of intoxication and the body's reactivity [27, 32, 45, 61]. It should be taken into account that the volume of performed laboratory tests should be planned taking into account the technical equipment and capabilities of the medical institution.

If the patient has concomitant (comorbid) pathology, a hypo- or hyperergic type of PIP course, a doubtful or unfavorable prognosis of the inflammatory process, or identified risks of developing complicated forms of PIP, an "extended" volume of laboratory testing is indicated: determination of blood group and Rh factor; comprehensive complete blood count (with ESR), urinalysis, general somatic blood biochemistry (total protein and protein fractions (albumin), determination of aspartate aminotransferase, alanine aminotransferase, bilirubin, urea, creatinine, glucose, electrolytes: potassium, sodium, calcium, chlorides); prescription of an "extended" coagulogram additionally including: D-dimer level (quantitative), as clinically indicated - determination of blood antithrombin III activity. In atypical courses of purulent-inflammatory processes, hypo- or hyperergic forms, and risks of developing complications, determination of CRP level should be performed in all patients with PIP, along with procalcitonin as clinically indicated (in consultation with an anesthesiologist-resuscitologist) [21, 50, 73, 92, 96, 108, 109].

Data from the "extended" volume of laboratory tests are especially important when there is a mismatch between the severity of the general and local clinical picture of purulent-inflammatory diseases of the jaws, in cases of complications, and for an objective assessment of treatment dynamics in patients [21, 50, 73, 92, 103, 109]. In addition, when determining the list of laboratory tests, it is necessary to take into account not only the presence and nature of concomitant (comorbid) pathology, but also the fact of taking medications for the concomitant pathology that require laboratory monitoring during their use (e.g., Warfarin** (ATX: B01AA03), heparin sodium** (ATX: C05BA03), Insulin soluble (human genetically engineered) - ATX: A10AB01).

2.4 Instrumental Diagnostics

Comments: if there is no technical capability to perform the listed types of X-ray examination, radiovisiography is acceptable as a screening test.

If there is no technical capability to perform the listed types of X-ray examination, radiovisiography is acceptable as a screening test [147-154].

In acute periostitis of the jaw, the radiographic picture is non-specific and only allows identifying the primary odontogenic source of infection in the form of a chronic destructive focus of periapical tissues, odontogenic cyst, periodontitis, or tooth retention. In chronic periostitis at the beginning of the disease, an additional shadow of the fibro-thickened or ossified periosteum is detected along the lower edge of the jaw, under which signs of marginal thickening of the bone tissue appear. As it remodels, it acquires a pronounced trabecular structure. The primary odontogenic focus is detected.

X-ray examination of a patient in the acute stage of odontogenic osteomyelitis of the jaws also helps identify the "primary" pathological focus: chronic apical periodontitis, odontogenic cyst, periodontitis, tooth retention. It should be borne in mind that if a patient has multiple foci of chronic odontogenic infection in the area of teeth adjacent to the "causative" tooth, radiological signs of chronic destructive foci of periapical tissues (chronic apical periodontitis, odontogenic cyst, periodontitis) may be detected, which will require not only the removal of the "causative" tooth and periosteotomy, but also the extraction of adjacent teeth with periapical changes. On days 10–14 of the disease, the radiological picture of osteomyelitis manifests as areas of uneven bone tissue resorption, and a pronounced periosteal reaction in the form of periosteal thickening may be determined along the edge of the jaw. In the case of a hypoergic course of inflammation and/or diffuse bone lesion, and/or the presence of a comorbid history in patients (especially diabetes mellitus), and/or the use of bisphosphonates, the clinical manifestations of the local picture of the purulent-inflammatory process in the jaw may last longer, and radiological signs of alternating areas of uneven bone resorption and pronounced periosteal reaction in the form of periosteal thickening may be detected for up to 21 days. The radiological picture of the subacute form of osteomyelitis, if the process continues for more than 21 days from the onset of the disease, but within periods not exceeding 4–5 weeks for the maxilla and 6–8 weeks for the mandible from the onset of the current exacerbation of the purulent-inflammatory process, may be characterized by the formation of one or more bone resorption foci, most often irregular in shape, in the center of which shadows of sequestra of various shapes are determined. Importantly, the demarcation of sequestra with the formation of a demarcation zone ("sequestral capsule") must necessarily be completed within periods not exceeding 4–5 weeks for the maxilla and 6–8 weeks for the mandible from the onset of the current exacerbation of the purulent-inflammatory process [21, 59, 75, 103]. It is this fact that confirms the completion of the inflammatory process in the bone structures with the formation and demarcation of sequestra, the formation of a "sequestral capsule" as a demarcation zone, and, in combination with appropriate clinical signs, serves as a criterion for determining the surgical treatment tactics for the patient, namely: determining the timing of surgical intervention in the volume of sequestrectomy, performed at the end of the subacute stage of osteomyelitis [21, 59, 75, 103].

The radiographic picture of the chronic form of osteomyelitis is characterized by significant diversity: in the sequestering variant (when forming within a period exceeding 4-5 weeks in the upper jaw and 6-8 weeks in the lower jaw, at the end of the subacute stage of osteomyelitis or after a surgical intervention previously performed in the subacute phase (sequestrectomy)[21, 59, 75, 103]. One or several bone resorption foci, mostly of irregular shape, in the center of which "shadows" of sequestra of various shapes are determined, can be seen on the radiograph. Along with the separation of sequestra, areas of bone tissue новообразования (new formation) are revealed. In the hyperplastic form, productive changes are characterized by endosteal and periosteal remodeling of bone tissue [21, 48, 50, 59, 65, 73, 75, 77, 83, 90, 103].

Comments: in the comprehensive examination for more accurate diagnosis of inflammatory diseases of the jaws and the development of their complications, based on the results of CBCT or MSCT examination, it is possible to establish the "primary" odontogenic focus of inflammation and determine changes in the bone tissue (for example, to determine the completeness of the sequestration demarcation process, the formation of the sequestral capsule, and to assess the state of the periosteum). This research method makes it possible to obtain a clear image of the cortical layer, assess the condition of the surrounding soft tissues, determine the presence of sequestra and periosteal layers, and visualize in detail the osteolysis of the cortical layer and bone trabeculae [21, 50, 59, 65, 75, 83, 93, 94]. It is important to take into account that the radiation dose during CBCT of the jaws does not exceed that of an orthopantomogram.

Comments: the ultrasound method allows detecting the presence of edema and infiltrative changes in the muscles, as well as the accumulation of fluid/gas in the tissues at an early stage of the disease. The ultrasound method is successfully used for differential diagnosis in acute hematogenous osteomyelitis with soft tissue abscesses, infectious arthritis of the temporomandibular joint, and malignant bone tumors [32, 50].

2.5 Other Procedures

Comments: if necessary, biological material (biopsy specimen) can be sampled intraoperatively from the wound to study the microbiota and its susceptibility to antibacterial drugs and antiseptics in order to monitor the ongoing treatment and subsequently adjust targeted antibacterial therapy dynamically [10, 21, 65, 75, 83, 103]. These data are especially important in case of a discrepancy between the severity of the general and local clinical presentation of purulent-inflammatory jaw diseases, atypical course of the purulent-inflammatory process, hyperergic forms of the clinical course, development of complications, as well as for an objective assessment of treatment dynamics in patients [10, 21, 65, 75, 83, 103].

Comments: morphological examination of tissues obtained during surgery (biopsy specimen) is necessary not only to clarify the diagnosis and perform differential diagnosis with other non-specific, specific inflammatory diseases and maxillofacial neoplasms [21, 65, 75]. Histological examination of biopsies from affected tissues has been and remains the "gold standard" of diagnostics. Significant advancements in microscopy techniques over recent decades make it possible to perform modern microscopic examination methods as a modality for non-invasive intravital diagnostics in dental diseases [113].

Comments: differential diagnosis in patients with acute jaw periostitis is carried out with acute periodontitis, periapical abscess without a fistula, acute osteomyelitis, lymphadenitis of non-odontogenic origin, suppurated jaw cysts, abscesses and phlegmons, and Ewing's sarcoma [25, 27, 50, 64, 74].

Comments: differential diagnosis in patients with acute jaw osteomyelitis is carried out with acute periodontitis, acute periostitis, lymphadenitis of non-odontogenic origin, suppurated jaw cysts, abscesses and phlegmons, and Ewing's sarcoma [25, 27, 50, 64, 74, 103].

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

The main components of treatment for patients with inflammatory jaw diseases include:

Etiotropic treatment:

• Surgical treatment (removal of the causal tooth, opening and drainage of the purulent focus);

• Antibacterial therapy: antibiotic therapy, local application of antiseptics (general and local treatment);

1. Pathogenetic treatment (targeting various links of the inflammation pathogenesis) – general and local treatment;

2. Symptomatic treatment (elimination of disease symptoms);

3. Therapy for concomitant (comorbid) conditions.

Conservative therapy in patients with purulent-inflammatory jaw diseases is largely aimed at suppressing the etiological factor, normalizing the main pathogenetic mechanisms, relieving intoxication, and correcting the body's immunological reactivity. Restoring impaired blood circulation is of particular importance, as circulatory disorders affect oxygen and energy supply, as well as the metabolic and immune responses of the body.

Treatment goals:

• Elimination of the source of inflammation (removal of the cause of the disease, achieved by opening and draining the purulent "focus" of inflammation).

• Prevention and treatment of complications.

Treatment of inflammatory diseases of the jaws should be comprehensive and have a pathogenetically substantiated basis that takes into account the patient's age, disease duration, presence of comorbidities, functional state of all organs and body systems, as well as the localization, stage, form, and extent of the purulent-necrotic process in the bone tissue.

Comments: providing medical care for jaw periostitis in a dental clinic setting is indicated in most cases for patients of "young" (18 to 45 years) and "middle" age (46 to 60 years) according to the WHO classification (2017 revision).

Comments: when treating patients with odontogenic osteomyelitis of the maxilla or mandible, the likelihood of the inflammatory process spreading to the perimaxillary soft tissues (with the development of phlegmon) should be taken into account. Furthermore, if the "causal" tooth is a premolar or molar, the development of odontogenic maxillary sinusitis is possible. In this regard, medical care for patients with odontogenic jaw osteomyelitis must be provided in a multidisciplinary hospital setting where it is possible, if necessary, to consult a general practitioner and subspecialists (neurologist, otorhinolaryngologist, ophthalmologist, etc.), and in the event of a purulent-inflammatory process in the perimaxillary soft tissues with indications for surgery under general anesthesia — an anesthesiologist-resuscitator.

Comments: medical care for patients with odontogenic periostitis or jaw osteomyelitis in the presence of comorbidities should be provided in a multidisciplinary hospital setting where it is possible to conduct an initial appointment (examination, consultation) by subspecialists (cardiologist, pulmonologist, neurologist, nephrologist, cardiovascular surgeon, etc.), and if signs of decompensation are detected — by an anesthesiologist-resuscitator.

3.1 Surgical Treatment

Surgical treatment for inflammatory jaw diseases is the main method and is performed in accordance with the key principles of treating patients with purulent infection, including surgical debridement of the purulent "focus" by eliminating the odontogenic cause of the disease (most often, extraction of the "causal" tooth and drainage of the subperiosteal abscess if present), as well as local drug therapy.

When patients present with inflammatory jaw diseases, surgical intervention must be performed on an emergency basis. The stage and nature of the clinical development of the inflammatory process, its localization, extent and prevalence, individual characteristics of the body (age, duration of the disease, nature and specifics of previous treatment, presence of concomitant pathology, etc.) must be taken into account [2, 21, 29, 55, 59, 75, 103].

Principles of treatment for purulent-inflammatory jaw processes:

1) Opening and drainage of the purulent inflammatory "focus" (most often by extracting the "causal" tooth, if not already extracted, and performing periosteotomy). When opening a purulent focus (in an outpatient setting prior to hospitalization in a specialized inpatient facility), a thorough wound revision is performed, with repeat surgical intervention if necessary.

2) The choice of anesthesia method is determined jointly with anesthesiologists-resuscitators and other related specialists (in the presence of comorbid pathology) after a thorough examination of the patient, taking into account indications and contraindications for the type of anesthesia.

Surgical access must correspond to the localization of the purulent focus. Opening of the purulent focus can be performed via an external or intraoral approach, or a combined approach if indicated. When choosing surgical treatment, preference should be given to the method that ensures:

√ the shortest path to the purulent inflammatory "focus",

√ the lowest probability of damage to organs and functionally important structures (vessels, nerves) during tissue dissection along the path to the purulent inflammatory "focus",

√ the best conditions for the outflow of purulent exudate, wound revision, and removal of pathologically altered tissues.

Comments: surgical intervention should ideally be performed no later than 2 hours after diagnosis establishment. In patients with odontogenic inflammatory diseases of the jaws against the background of severe comorbid pathology, additional extended examination and preoperative preparation for surgery are indicated [21, 27, 50, 59, 75, 103].

Comments: teeth that have no functional or aesthetic value and whose root canal cannot be adequately shaped to ensure proper exudate outflow are subject to immediate extraction [21, 50, 59, 64, 71, 73, 75, 103, 109].

Comments: optimal drainage ensures full outflow of wound exudate, creates the best conditions for the rapid sloughing of necrotic tissues, and transitions the process from the inflammatory phase to the regeneration phase. The primary means of drainage in purulent-inflammatory diseases of the jaws are rubber strip drains and tubular polyvinyl chloride drainage tubes of various configurations. If necessary, to prevent the drain from being dislocated into the wound, it can be fixed to one of the wound edges using an interrupted suture with any suture material, which is removed when the drain is removed. It is possible to use various instrumental methods for debridement of a purulent wound: laser, plasma, vacuum, ultrasonic cavitation, and irrigation of the wound with a pulsating stream of antiseptic solution [56]. In the hyperergic form of acute osteomyelitis, to reduce intraosseous hypertension and prevent the progression of the osteonecrotic process, drainage must be performed via intraosseous bone lavage [14, 16, 21, 25, 43, 59, 75, 103, 109]. In acute periostitis, the drain is left in the wound for 1-2 days if the tooth was extracted, or up to 4-5 days if the tooth was preserved, until acute inflammatory symptoms subside and purulent discharge from the wound ceases [16, 21, 27, 59, 75, 103]. Preservation of the tooth is possible only in cases of acute serous periostitis of the jaw, provided there is a well-patent root canal [21, 59, 75], a "favorable" prognosis for the course of the purulent-inflammatory process, no risk of complications, a normergic form of the inflammatory process, no burdened somatic status, no focus-dependent diseases, and the possibility and/or expediency of preserving this tooth from the standpoint of conservative treatment and its subsequent use as a denture abutment [21, 59, 75, 103]. If the "causal" tooth is preserved after performing a periosteotomy, it is advisable to perform osteoperforation in the projection of the periapical focus, followed by planning a tooth-sparing procedure after the acute inflammatory symptoms subside (granulomectomy, cystectomy, or cystostomy with root-end resection) [21, 59, 75, 103].

Comments: in acute serous odontogenic periostitis, tooth extraction generally leads to recovery; in such cases, in young patients with a normergic type of inflammatory reaction, no risk of complications, and no history of comorbid pathology, periosteotomy may be omitted. If the tooth is preserved (provided the coronal part of the tooth is preserved, root canals are patent to allow and justify endodontic treatment, and it is possible thereafter—following the resolution of acute inflammation and healing of the postoperative wound—to perform a tooth-sparing surgery within timeframes dictated by the normal course and completion of the purulent wound process), then surgical tactics do not depend on the stage of the inflammatory process, and the incision must be performed.

During periosteotomy, the mucosal incision must be made strictly along the mucobuccal fold for a length of at least three teeth, spanning the entire width of the infiltrate (at the level of the "causal" tooth and at least adjacent teeth, dissecting the entire thickness of soft tissues—mucosa, submucosa, and periosteum down to the bone), after which the subperiosteal abscess is opened and emptied bluntly. Next, mechanical debridement of the wound is performed to eliminate free pus and any necrotic tissue, and biomaterial is collected for microbiological (culture) testing. Then the wound is rinsed with local antiseptic solutions. A rubber strip or semi-tubular drain (or tubular drain, if necessary) is inserted into the wound, which should be fixed to the upper edge of the postoperative wound with a suture (polyamide thread or silk).

When opening a subperiosteal abscess during periostitis on the lingual side of the mandible in the region of the 2nd–3rd molars, the incision is made above the transition site of the alveolar process mucosa into the sublingual region, holding the scalpel almost perpendicular to the jaw to avoid injuring the vessels and organs of the sublingual region. All other manipulations are performed according to the blunt protocol described above. On the hard palate, the mucosal incision line should be parallel to the alveolar ridge and run along the line connecting the incisive foramen and the greater palatine foramen. To prevent premature adhesion of the wound edges and ensure drainage, a section of the mucosa is excised using two converging semi-oval incisions or in the form of a triangle whose base is parallel to the alveolar process [10, 21, 25, 59, 73, 75, 103].

Comments: preservation of central teeth according to indications is possible only in case of acute serous periostitis of the jaw [25, 50, 71, 73, 103], provided there is a well-patent root canal, a normergic type of inflammatory response, a "favorable" prognosis of the purulent-inflammatory process, no risk of complications, in patients without a "burdened" somatic status and "foci-related" diseases, subject to the following conditions: mandatory performance of "osteoperforation" in the projection of the periapical "focus" of inflammation during periosteotomy, integrity of the crown part of the tooth, good root canal patency, the possibility of subsequent adequate endodontic treatment [21, 25, 50, 59, 71, 73, 75, 103], if it is possible and/or advisable to preserve this tooth from the standpoint of conservative treatment and its subsequent use as a denture abutment [21, 25, 50, 59, 71, 73, 75, 103]. In case of preservation of the "causative" tooth and drainage of the "focus" of purulent inflammation in the jaw bone exclusively through periosteotomy and "osteoperforation" in the projection of the periapical focus, it is important to ensure the technical capability and mandatory compliance with the staging of treatment in a medical facility, with the possibility of providing "support" for complex treatment involving a general dentist, who must perform the opening of the tooth cavity, removal of the anesthetized pulp, endodontic and medicinal treatment of the root canals of the "causative" tooth, create conditions for adequate outflow of exudate (preferably at the first visit before surgical manipulations and incisions), followed by mandatory planning of a "tooth-preserving" operation (gallemectomy, cystectomy, or cystostomy with root-end resection) as scheduled after the relief of acute inflammatory symptoms and wound healing [21, 59, 75, 103].

Comments: in jaw periostitis in patients with concomitant diseases in the stage of decompensation and/or receiving medications leading to drug-induced hypocoagulation, in case of delayed extraction of the "causative" tooth, it is necessary to drain the "focus" of purulent inflammation in the bone with minimal tissue trauma against the background of ongoing conservative treatment and only after stabilization of the patient's condition, with preoperative examination (additional laboratory and instrumental studies). Extraction of the "causative" tooth can be performed as a second stage only after preparation in agreement with subspecialty internists (general practitioner/cardiologist, endocrinologist, etc.) [21, 25, 27, 36, 50, 59, 71, 73, 75, 103].

Comments: delayed extraction of the "causative" tooth in the presence of objective technical difficulties is possible only with a "favorable" prognosis of the purulent-inflammatory process, absence of complication risks, normergic form of the inflammatory process, absence of "burdened" somatic status and/or "foci-related" diseases. The timing of delayed extraction of the "causative" tooth is determined individually, taking into account the dynamics of the local inflammatory process and the systemic response of the body, optimally after the relief of acute inflammatory symptoms against the background of ongoing conservative treatment [21, 27, 50, 59, 75, 103].

Comments: treatment of patients with acute or acute exacerbation of chronic osteomyelitis of the jaws should begin with resolving the issue of removing the "causative" tooth, which is mandatory. In the vast majority of cases, tooth extraction must be performed simultaneously with the opening of purulent foci.

In patients with acute or acute exacerbation of chronic osteomyelitis of the jaws, the opening of subperiosteal abscesses by periosteotomy must be performed from both sides of the "muff-like" jaw infiltrate - vestibular and lingual/palatal. An extraoral surgical approach is used in the event of purulent "foci" in the perimaxillary soft tissues or in the presence of functioning fistulous tracts on the skin [10, 21, 50, 59, 64, 71, 75, 103].

Comments: radical surgery – sequestrectomy, is the only correct treatment method for the subacute or chronic form of osteomyelitis, which is performed only after confirmation of sequestrum formation based on CBCT examination of the jaws (computed tomography of the maxillofacial region) within the following timeframes: in the subacute stage of osteomyelitis, not exceeding 4–5 weeks in the upper jaw and 6–8 weeks in the lower jaw from the onset of the current exacerbation of the purulent-inflammatory process; in chronic osteomyelitis of the jaws, more than 4–5 weeks in the upper jaw and 6–8 weeks in the lower jaw, or following surgery (sequestrectomy) previously performed in the subacute phase of the process [21, 59, 75, 103].

The etiopathogenetic features of surgical treatment in patients with odontogenic osteomyelitis of the jaws are: extraction of the "causative" tooth, electric pulp testing (EPT) of adjacent teeth and those located in the focus of inflammation, endodontic treatment of affected teeth (at values ≥ 64 µA) in the preoperative period followed by their treatment, and immobilization of mobile teeth using various methods.

Depending on the localization of the sequestrum, intra- and extraoral surgical approaches are used. In case of an osteomyelitic process in the upper jaw, it is rational to use intraoral approaches. If osteomyelitis of the maxilla is complicated by maxillary sinusitis or sequestration of the maxillary sinus walls, it is advisable to perform sequestrectomy in the manner of a radical sinusotomy (Caldwell-Luc operation). External approaches are used more frequently on the lower jaw; in particular, an external surgical approach is indicated in cases of subtotal jaw osteomyelitis, as well as in the presence of fistulae at a significant distance from the affected bone area. In such cases, typical approaches are used with a skin incision following Langer's lines (where possible) for aesthetic reasons, and the principles of the anatomical arrangement of vessels and nerves.

Surgical intervention consists of opening the sequestration cavity, removing the pathological focus, excising fistulous tracts, scarred, and non-viable tissues [25]. Surgical material must be sent for histological examination. Part of the material is sent for microbiological examination. The question of the urgency and scope of surgical intervention has a clear rationale—it is performed only after the formation of the sequestration cavity and complete demarcation of the sequestrum based on clinical and radiological findings within the following timeframes: in the upper jaw – 4–5 weeks, in the lower jaw – 6–8 weeks from the onset of the current exacerbation of the purulent-inflammatory process [21, 25, 27, 36, 59, 73, 75, 103].

In the postoperative period, following the opening and drainage of purulent inflammatory "foci" and the elimination of the primary cause of the disease, an important role in prevention is assigned to local wound management. Local wound treatment includes pharmacotherapy for the purulent wound, complements surgical treatment, and should be carried out taking into account the phase of the purulent wound healing process [6, 21, 24, 31, 32, 33, 43, 49, 53, 54, 65, 75, 103].

Comments: systemic antibiotic therapy in the treatment of patients with periostitis and jaw osteomyelitis is discussed in section 3.2. "Conservative treatment". Local treatment must be carried out taking into account all principles of therapy for purulent-inflammatory diseases, and conducted depending on the phase of the purulent wound healing process. General surgical principles of a differentiated approach in choosing medications for the local treatment of purulent wounds must be followed [4, 6, 33, 35, 56, 103]. The first phase of the purulent wound healing process is divided into 2 periods: 1 – vascular changes (duration 1–3 days) and 2 – wound cleansing (from 3 to 5–6 days). In phase I of the wound healing process, active local medical treatment should be carried out with an emphasis on the local antimicrobial action of the main component of the drug, and where indicated – necrolytic, as well as dehydrating and, if possible, analgesic effects.

Comments: daily irrigations, instillations, and intraosseous lavage are performed using antiseptic solutions in accordance with the pharmacological product instructions: Chlorhexidine** 0.05–0.2% aqueous solution, Hydrogen peroxide** 3% (ATC: D08AX01), Hexetidine 0.2% (ATC: A01AB12), Potassium permanganate** (ATC: D08AX06), Hydroxymethylquinoxalinedioxide 0.5% solution (ATC: J01XX), Povidone-iodine** as a 10% solution (ATC: D08AG02) diluted 10 or 100 times.

Intraoral thermal procedures are indicated starting from the 2nd day of treatment – oral "baths" with a 1–2% Sodium bicarbonate solution (ATC: B05CB04), followed by – antiseptics: chlorine-containing detergents (Chlorhexidine** 0.05–0.2% (ATC: D08AC02), and Hexetidine (ATC: A01AB12) 0.2%, and chlorine-containing phenols: Benzyldimethylmyristoylaminopropylammonium, Nitrofural at a dilution of 1:5000 (ATC: D08AF01) several times a day, as well as Sodium deoxyribonucleate 0.25% solution (ATC: L03AX) to optimize tissue repair [4, 73].

Comments: when prescribing topically applied drugs in the 2nd period of phase I of the inflammatory wound process when draining a "focus" of purulent inflammation via an external approach, ointments containing antibacterial drugs (e.g., Dioxomethyltetrahydropyrimidine (methyluracil) + chloramphenicol ointment, ATC: D06C) have become widespread; furthermore, they have low toxicity and pronounced osmotic properties, which allows dressings to be performed once a day [27, 50].

In phase II of the wound healing process – the regeneration phase, the formation and maturation of granulation tissue occurs. This period is characterized by the appearance of islands of granulation tissue in the wound, which, developing, completely covers the wound surface. Healthy granulation tissue is always bright, succulent, and bleeds easily. At the slightest deterioration of biosynthetic processes in the wound, the appearance of the granulations changes: they lose their bright color, become small, and are covered with a mucous coating. Any slowdown in the development of granulations leads to a delay and cessation of the epithelialization process. During this period of the wound healing process, there is no need for drainage.

Comments: in the regeneration phase, it is necessary to use drugs with a certain anti-inflammatory effect, since the fight against infection continues, and it is necessary to improve tissue microcirculation, cellular and tissue metabolism, thereby promoting granulation growth and rapid wound epithelialization. To prevent secondary infection, it is indicated to use water-soluble wound-healing and antibacterial ointments. Such drugs include: plant-based tissue repair stimulants, sea buckthorn oil (ATC: D11A), TN Kombutek-2 (ATC: D08AF), Hydrocortisone + Oxytetracycline (ATC: D07CA01 - Hydrocortisone in combination with antibiotics), Dioxomethyltetrahydropyrimidine (ATC: L03AX), Povidone-iodine** as a 10% ointment (ATC: D08AG02 Povidone-iodine), silver-containing ointments, for example, Sulfadiazine ointment, tissue repair stimulants for external use that have antimicrobial and anti-inflammatory effects and simultaneously improve tissue regeneration, for example, Diethylbenzimidazolium triiodide ointment (ATC: D08AG) and other agents [56, 73]. Recently, a new trend in improving local treatment has been developing – the development of drug carriers with immobilized drugs [117, 118].

Comments: Phase III of the wound healing process is the phase of scar reorganization and epithelialization. The main objective of treating patients in phase 3 is to normalize reparative processes and epithelialization and protect the wound from mechanical damage. Therefore, the use of drugs with low osmotic activity is indicated: TN Solcoseryl dental adhesive paste, Dioxomethyltetrahydropyrimidine (ATC: L03AX), sea buckthorn oil (ATC: D11A), as well as other drugs used in dermatology (ATC: D11AX).

3.2 Conservative treatment

Comments: one of the most important principles of antibiotic therapy is its administration based on strict indications after establishing a precise diagnosis and identifying the etiological factor of the disease. Stereotyped, routine use of antibiotics is unacceptable.

Rational antibiotic therapy is only possible when the choice of drug is based on pathogen identification and susceptibility testing of the microbiota according to antibiogram data, knowledge of the drug's pharmacodynamics and pharmacokinetics, and the clinical presentation of the disease. Empirical antibiotic therapy is initiated within the first hours of admission to the maxillofacial inpatient unit, even before antibiogram results are available. Broad-spectrum systemic antimicrobial agents are prescribed empirically. Once the species and susceptibility of the given strain are determined, definitive correction of the antibacterial therapy is performed, and the regimen is switched to targeted antibiotic therapy. The efficacy of antibacterial therapy should be evaluated 2-3 days after drug initiation, accompanied by mandatory serial microbiological monitoring. It must be taken into account that the microbiota may change during the course of the disease and as a result of ongoing empirical antibacterial therapy, which necessitates treatment correction based on serial bacteriological analyses of purulent discharge from the patients' wounds [5, 21, 48, 60, 72, 78, 103].

Comments: the AMR Control program (Antimicrobial Stewardship Strategy in Inpatient Medical Care, 2018) is the standard for prescribing antibiotic therapy during surgical interventions. Clinical guidelines by the «Alliance of Clinical Chemotherapists and Microbiologists» on AMR Control are reviewed annually [48, 103]. Based on them, local formularies for antibacterial drug prescription are developed for specific practical healthcare institutions for various nosological forms of purulent-inflammatory processes (local orders issued by the head physician of the medical institution), which must also be reviewed annually and are based on the results of annual monitoring of the microbiota composition and its resistance to used antibacterial drugs in that specific department [21, 48, 103].

Comments: the results of bacteriological examination should be interpreted in accordance with the principles set out in the documents of the European Committee on Antimicrobial Susceptibility Testing (EUCAST) of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and in similar Russian guidelines [21, 103, 120].

The choice of drugs and the determination of empirical ABT tactics in patients with purulent-inflammatory processes of the maxillofacial region within local protocols of an individual medical institution in each region should be carried out taking into account the stratification of patients by the risk of resistant pathogens and the type of infection, as well as in accordance with the list of drugs presented in the relevant clinical guidelines.

Each medical institution must establish an interdisciplinary team of specialists, including: "narrow-profile" specialists (maxillofacial surgeon), clinical microbiologist, clinical pharmacologists, specialists in clinical pharmacology and evidence-based medicine, department heads, and relevant deputy chief physicians of the clinic. Based on the annual analysis of the departments' work (including maxillofacial surgery), protocols for empirical antibacterial therapy (ABT) with recommended algorithms for inpatient care should be developed for each department, including maxillofacial surgery (MFS).

When conducting empirical therapy, antibacterial drugs are divided into two levels: therapy of choice ("first-line drugs") and alternative agents. Therapy of choice refers to drugs whose use, from the standpoint of clinical pharmacology and evidence-based medicine, provides the maximum clinical effect with the highest probability. Preference is given to antibacterial agents with a narrower and more targeted spectrum of action, whenever possible. Alternative drugs are classified as agents that also have proven efficacy against the most probable pathogens for a given pathology. These drugs are prescribed secondarily for various reasons, including treatment cost, individual tolerability, and probable microbial resistance.

Due to the fact that in each region, and in some cases in different medical institutions of the same region, there are differences in the microbiota composition in patients with purulent-inflammatory diseases of the maxillofacial region, empirical ABT regimens should be formulated individually as local protocols (orders of the head physician of the medical institution) taking into account the results of microbiological monitoring and pathogen resistance to antibacterial drugs. In this regard, within each specific profile department (including maxillofacial surgery), the AMR Control guidelines should be supplemented by local protocols of the medical institution, compiled on the basis of annual monitoring of the microbiota composition and its resistance to used antibacterial drugs, featuring recommended algorithms that regulate the implementation of the empirical antibacterial therapy (ABT) protocol. At the same time, it is necessary to take into account the varying financial capabilities of the region and the level of financing of the medical institution depending on its tier. The recommended algorithm for empirical antimicrobial therapy (AMT) in the maxillofacial surgery (MFS) clinic when providing inpatient care to patients with odontogenic periostitis and osteomyelitis of the jaws at the MFS clinic of the Pavlov University of the Russian Ministry of Health, taking into account stratification for risk factors of multidrug-resistant pathogens and invasive candidiasis and within the framework of AMR Control recommendations (2018), is presented in Appendix A3.1. [103].

Comments: microbiological monitoring must be performed, and, according to indications and if technically feasible, intraoperative sampling of material (biopsy) from the wound (sampling of biological material from oral organ lesion sites) should be carried out to study the microbiota and its susceptibility to antibacterial drugs and antiseptics in order to monitor the ongoing treatment and subsequently correct the antibacterial therapy [21, 103].

Antibacterial therapy is administered until stable positive dynamics of the patient's general condition are achieved, the purulent wound is cleansed, and the main local symptoms of infection and intoxication disappear. Due to the lack of pathognomonic signs of a bacterial infection, absolute criteria for stopping antibacterial therapy do not exist; the decision is made individually based on a cumulative assessment of the dynamics of the patient's general condition, the local course of the purulent-inflammatory process, and laboratory parameters characterizing the inflammatory response. The general criteria for the sufficiency of antibacterial therapy are as follows: 1) stable normalization of body temperature; 2) positive dynamics of the main symptoms of infection; 3) absence of signs of systemic inflammatory response; 4) normalization of blood leukocyte count, leukocyte formula, ESR, and CRP (if necessary, procalcitonin level); 5) negative blood culture; 6) normalization of gastrointestinal function. It is important that the persistence of only a single sign of bacterial infection (fever or leukocytosis), as well as the presence of a granulating wound, is not an absolute indication for continuing antibacterial therapy. The average typical duration of antibacterial therapy for purulent-inflammatory processes ranges from 5 to 10 days. Prolongation of antibiotic therapy may lead to potential complications, increased microbial resistance, and the development of superinfection [21, 48, 97, 103]. In the absence of a stable clinical and laboratory response to adequate antibacterial therapy within 1-3 days, additional examination is necessary (e.g., Ultrasound examination of oral cavity tissues - Medical Services Nomenclature Code: A04.07.003, and Soft tissue ultrasound (one anatomical zone) - Medical Services Nomenclature Code: A04.01.001, in case of risks of purulent-inflammatory processes spreading to adjacent fascial spaces; Duplex scanning of maxillofacial vessels - Medical Services Nomenclature Code: A04.12.009 in case of risks of thrombotic complications; computed tomography of the maxillofacial region, etc.) to detect complications or the formation of a secondary "focus" of infection in another localization, to prescribe serial wound discharge cultures to determine the species composition of the microbiota and its susceptibility to antibacterial drugs and antiseptics, and to test body fluids (blood, urine) for sterility [21, 28, 51, 82, 87, 103].

In the absence of positive dynamics in the patient's condition despite ongoing antibacterial therapy, the treatment regimen should be revised, the purulent-necrotic "focus" should be re-explored, and the spread of the purulent-inflammatory process and/or the formation of blind pockets must be ruled out.

Upon stabilization of the general condition, transition of the local purulent inflammatory process to phase II, positive dynamics or normalization of laboratory parameters, antibiotic therapy is discontinued, and the focus of subsequent treatment is shifted to local intervention against the microbiota using local antiseptics [21, 48, 97, 103].

It is necessary to coordinate the duration of antimicrobial therapy — in most cases 5–7 days, except for patients with immunodeficiency including neutropenia, infective endocarditis, purulent meningitis, infections caused by non-fermenting multidrug-resistant Gram-negative microorganisms, S. aureus bacteremia, candidemia, or the development of invasive candidiasis [21, 48, 102, 103, 120].

When choosing the drug, dosage, frequency, route of administration, and duration of therapy, the following data must be considered: weight, age, severity and localization of the inflammatory process, presence of chronic "foci" of infection and immunodeficient states, organ and system diseases capable of affecting the drug's pharmacokinetics, and previous therapy [56, 65, 72, 103].

Comments: risk factors for community-acquired infections caused by multidrug-resistant pathogens (ESBL and carbapenemase producers, MRSA, fluoroquinolone-resistant pathogens) and risks of candidiasis in hospitalized patients include: 1) history of medical care in healthcare facilities (outpatient day hospital, hemodialysis units, long-term care facilities) or hospitalization within the last 90 days; 2) use of antibacterial drugs in the last 90 days (regardless of the reason); 3) history of severe comorbid pathology in the patient (acute kidney injury or chronic kidney disease, diabetes mellitus, liver cirrhosis, alcoholic visceropathy, drug addiction, HIV). Stratification helps identify patients suspected of harboring multidrug-resistant pathogens and at high probability of a more severe course of the infectious disease, which will require prescribing broader-spectrum antibacterial drugs for empirical therapy and conducting microbiological monitoring for a timely switch to targeted antibiotic therapy. The detailed principles of patient stratification into risk groups and antibiotic therapy strategies are outlined in the SCAT Program (2018).

An individualized antibiotic therapy protocol, along with the scope and timing of additional laboratory tests, in patients with burdened somatic status, a hyperergic response of the body to the local inflammatory process, or an unfavorable prognosis of the purulent-inflammatory process with high risks of complications, should be coordinated with a clinical microbiologist and clinical pharmacologist.

Comments: in pharmacotherapy for elderly patients, the risk of adverse drug reactions (ADRs) is higher, which requires additional attention and may necessitate dose adjustments of antibacterial drugs and course duration. The most frequent ADRs are digestive system disorders, intestinal dysbiosis, allergic reactions, and mucosal candidiasis. Serious adverse drug reactions (SADRs) manifesting as nephro-, neuro-, hemato-, or hepatotoxicity may rarely occur (the instructions for the administered medicinal products must be consulted). Antibacterial therapy in patients with renal¹ or hepatic² impairment should be administered taking into account the severity of the organ function impairment. For this purpose, the serum creatinine clearance is calculated using the Cockcroft-Gault formula¹ (or an approximate estimation method is used)¹, and serum bilirubin and transaminase levels are monitored². Currently, there is a wide range of drugs available for antibacterial therapy. More than 30 different groups of antibacterial drugs are used in Russia [7, 9, 11, 21, 46, 48, 51, 59, 66, 102, 103], including the most frequently used beta-lactam antibiotics (including penicillins, cephalosporins, carbapenems, and monobactams), aminoglycosides, quinolones/fluoroquinolones, tetracyclines, macrolides, lincosamides, and glycopeptides.

Comments: Active detoxification of the body is most commonly performed via infusion therapy. The primary objectives of infusion therapy in patients with odontogenic inflammatory processes are: correction of hypovolemia, improvement of microcirculation, restoration of adequate tissue perfusion, normalization of cellular metabolism, correction of homeostasis disorders and blood rheological properties, and reduction of the concentration of inflammatory mediators and endotoxins in the blood [9, 19, 21, 20, 29, 103]. When selecting drug groups, administration routes, single and daily doses for infusion therapy, it is advisable to take into account the recommendations set forth in the product labeling, guidelines of specialized associations of anesthesiologists-intensivists and surgeons, specialists of the Russian Federation Association of Anesthesiologists-Intensivists (RAR), and the Russian Sepsis Forum regarding intensive care [1, 13, 22, 36, 51, 72, 99, 103]. In accordance with the recommendations of specialized associations of anesthesiologists-intensivists, surgeons, and RAR specialists on intensive care within the framework of targeted intensive care for inflammatory processes of the maxillofacial region, solutions classified as electrolytes and agents influencing water-electrolyte balance and acid-base balance (ATC: B05BB) are used [1, 13, 14, 36, 41, 72, 99]. The composition of infusion therapy should be determined by the following factors: patient age, comorbid conditions, extent of the process, severity of the disease course, and severity of endogenous intoxication. It is necessary to consider the degree of hypovolemia, the absence/presence of consumption coagulopathy, the nature of changes in biochemical parameters and blood acid-base balance characterizing the specific clinical situation, and the compatibility of the drug's physicochemical properties with them. A component of detoxification therapy must be controlled hemodilution. To date, for the correction of fluid and electrolyte loss, the use of balanced solutions for intravenous administration (ATC: B05B) is justified, including: Electrolytes (ATC: B05BB01). It is possible to use drugs belonging to the pharmacological group of water-electrolyte balance and acid-base balance regulators in combinations, plasma substitutes and other blood components in combinations, for example, complex sodium lactate solution [potassium chloride + calcium chloride + sodium chloride + sodium lactate], complex sodium lactate solution (potassium chloride + calcium chloride + sodium chloride + sodium lactate) [1, 13, 14, 36, 41, 72, 99, 103].

The modern ideology of infusion therapy in patients with a severe course of purulent-inflammatory processes involves: 1) the use of crystalloid solutions affecting water-electrolyte balance (ATC: B05BB), which are the drugs of choice as "starting" fluids; 2) omission of dextran-based drugs (due to high allergogenicity, increased bleeding tendency, and the risk of acute renal failure ²) and hydroxyethyl starch (HES) (results of the VISEP, CRYSTMAS, 6S, and CHEST trials); 3) administration of 10% Albumin (ATC: B05AA01) only in patients requiring significant volumes of solutions regulating water-electrolyte balance and acid-base balance (ATC: B05BB), under the monitoring of blood total protein and albumin levels. 4) initial fluid challenge in patients with tissue hypoperfusion and suspected hypovolemia must be at least 30 ml/kg of a solution affecting water-electrolyte balance (ATC: B05BB) (part of this dose may be replaced with 10% Albumin (ATC: B05AA01)); 5) monitoring of hemodynamic parameters during infusion therapy using dynamic (pulse pressure variation, stroke volume variation) and static parameters (blood pressure and heart rate) [1, 13, 14, 20, 36, 41, 70, 72, 99, 103].

The volume and composition of drugs for infusion therapy in patients with burdened somatic status, a hyperergic body response to a local inflammatory process, or an unfavorable prognosis of the purulent-inflammatory disease course with high risks of complications should be coordinated with an anesthesiologist-intensivist.

Comments: When performing surgical interventions in the head and neck region, all patients must be provided with an adequate enteral nutrition regimen using enteral and parenteral nutrition products (ATC: B05BA Solutions for parenteral nutrition) planned in accordance with the instructions for use of the medical nutrition product and administered within the maxillofacial surgery department. If enteral nutrition is impossible, as well as in debilitated and severe patients, various regimens of parenteral or mixed nutrition may be considered. The energy value on average should be about 3000 kcal based on energy requirements of 25–30 kcal/kg/24 h, specifically [155, 156]]:

- when providing nutritional support, calculations must be made based on: energy requirements — 25–30 kcal/kg/24 h, reduced in the acute phase of the process, in the phase of stable hypermetabolism — glucose — < 6 g/kg/24 h, lipids — 0.5–1 g/kg/24 h, proteins — 1.0–1.5 g/kg/24 h (0.20–0.30 g nitrogen/kg/24 h) monitored by nitrogen balance, vitamins — "standard" daily composition + K⁺ (10 mg/24 h) + B₁ and B₆ (100 mg/24 h) + A, C, E, trace elements — "standard" daily composition + Zn⁺ (15–20 mg/24 h + 10 mg/L in case of loose stools), electrolytes — Na⁺, K⁺, Ca²⁺ taking into account balance calculations and plasma concentrations + P²⁺ (> 16 mmol/24 h) + Mg²⁺ (> 200 mg/24 h);

- early initiation of nutritional support within 24–36 hours of intensive care is indicated (early enteral tube feeding protocols);

- in patients with a severe course of purulent-inflammatory processes, the administration of the full nutritional dose should be avoided during the first week; one should start with low-dose feeding (up to 500 kcal/day), increasing the volume only upon normal tolerance.

During infusion-transfusion therapy, it is necessary to provide not only homeostasis correction and detoxification [1, 13, 14, 19, 22, 36, 51, 70, 99], but also the determination of indications for prescribing additional parenteral nutrition according to the standard protocol for debilitated patients, the energy value of which should be 1500–2000 kcal/day, and together with enteral nutrition — up to 3000–3500 kcal/day [155, 156].

Implementation of the standard enteral nutrition protocol must be carried out subject to mandatory laboratory monitoring. If a patient is diagnosed with moderate or severe malnutrition of a mixed type (regarding visceral and somatic protein pools) requiring an expanded diagnostic workup, individual calculations, and the compilation of an individual medical nutrition chart for a specific patient, when it is necessary to address the insufficiency of enteral nutrition alone and the additional prescription of parenteral nutrition, as well as in the absence of an effect from nutritional therapy according to the standard scheme, a consultation with specialists of the interdisciplinary nutritional support team (for organizing and conducting therapeutic enteral and parenteral nutrition), which should be established in each healthcare facility, is required.

When treating patients with odontogenic inflammatory diseases of the maxillofacial region, it is advisable to be guided by the generally accepted Methodological Guidelines of the Federation of Anesthesiologists and Intensivists for patients on perioperative nutritional support (2021) and the recommendations of the Association of Parenteral and Enteral Nutrition Specialists when performing surgical interventions in the head and neck region [103, 157, 158].

Comments: when prescribing antithrombotic agents (ATC group: B01A), adverse factors should be assessed to predict the patient's risk of venous thromboembolism (VTE), using the thromboembolic risk assessment scale based on the score obtained (Appendix G2), following the standard procedure for perioperative thromboprophylaxis in surgical patients outlined in the Clinical Guidelines for the Diagnosis, Treatment, and Prevention of Venous Thromboembolism in Traumatology and Orthopedics by the Society of Specialists in Emergency Cardiology and the Association of Trauma Surgeons of Russia, adopted in 2025 [144, 167].

In osteomyelitis of the upper jaw and in complications (abscesses and phlegmons of the infraorbital, zygomatic regions, orbit), there is a risk of thrombosis of the facial veins and cerebral sinuses. To prevent the development of facial vein thrombophlebitis, as well as for pharmacological prevention of DIC syndrome, it is necessary to use antithrombotic agents (anticoagulants) in accordance with the instructions for the pharmacological drug. For this purpose, both unfractionated heparin preparations (Heparin sodium**) (ATC: B01AB01) and low molecular weight heparin preparations (Heparin group - ATC: B01AB) can be used. When planning surgical intervention or other invasive procedures, patients with superficial vein thrombosis should not receive the drugs, for at least 24 hours before surgery, with resumption of their use no earlier than 6 hours after hemostasis is restored, at prophylactic doses [166]. Drug administration should be carried out under coagulogram monitoring (once every 2-3 days when using unfractionated heparin (ATC: B01AB01) at prophylactic doses, and once daily when prescribing unfractionated heparin (ATC: B01AB01) at therapeutic doses) [98].

An individualized antithrombotic therapy protocol in patients with purulent-inflammatory diseases of the jaws, as well as the scope and timing of additional laboratory tests, should be coordinated with a clinical laboratory diagnostics physician.

Comments: antihistamines are used to relieve adverse effects of biologically active substances produced as a result of catabolic processes in the inflammation "focus", and are particularly indicated for the hyperergic type of inflammation. Therefore, the use of systemic antihistamines (ATC: R06A) is pathogenetically justified [7, 20, 73].

Comments: in the treatment of patients with odontogenic inflammatory diseases of the jaws, it is possible to prescribe NSAIDs: Metamizole sodium (ATC: N02BB02), Paracetamol** (ATC: N02BE01), Acetylsalicylic acid (ATC: N02BA01), Ibuprofen** (ATC: M01AE01), Indometacin (ATC: M01AB01), Ketoprofen** (ATC: M01AE03), Ketorolac** (ATC: M01AB15) [7, 73].

When prescribing medications for pain relief, it is advisable to use the visual analogue scale (VAS) for pain [127-130] Appendix G1.

Comments: currently, the positive effect of immunomodulators on the course and outcome of inflammatory diseases of the maxillofacial region and neck with parenteral administration has not been proven. The decision to prescribe this group of drugs to individual categories of patients must be approved by the medical panel only after performing an immunological blood test and local biomaterial testing, consultation with a clinical immunologist, and in the absence of general and local contraindications [21, 23, 26, 39, 47, 56, 90, 103]. There are isolated clinical and experimental studies substantiating the efficacy of topical application of immunomodulatory drugs, for example, based on human recombinant interleukin-1 beta (IL-1 beta) – Interleukin-1 beta (ATC: L03AX) [103]. However, multicenter clinical trials are required to implement this technique.

Comments: hyperbaric oxygenation reduces tissue hypoxia, exerts pathogenetically substantiated antibacterial, anti-acidotic, and reparative effects, including on the course of purulent-inflammatory processes of maxillofacial localization [47, 74, 122, 123].

Comments: medical ozone possesses antibacterial, detoxifying, antihypoxic, dose-dependent immunomodulatory, mediated antioxidant, and antiplatelet pathogenetically substantiated effects. Therefore, these methods are actively used in the treatment of jaw osteomyelitis, especially in patients with a sluggish and chronic inflammatory process. However, they are contraindicated in the hyperergic variant of the course of the purulent-necrotic process of the jaws. Routes of ozone administration: intravenous or local application, their combination is possible [40, 55].

¹ This equation allows calculating creatinine clearance provided that the serum creatinine level is stable (https://www.msdmanuals.com/medical-calculators/CreatinineCl_CG-ru.htm).

² Hohl MK, Lüscher KP, Tichý J, Stiner M, Fridrich R, Gruber UF, Käser O. Prevention of postoperative thromboembolism by dextran 70 or low-dose heparin. Obstetrics and Gynecology. 1980;55(4):497-500. 121. Krüger K, Seifart W, Freudenberg R. Infusion incidents with dextran. Anaesthesiologie und Reanimation. 1988;13(5):259. 122. Laxenaire MC, Charpentier C, Feldman L. Anaphylactoid reactions to colloid plasma substitutes: incidence, risk factors, mechanisms. A French multicenter prospective study. In Annales Francaises d’Anesthesie et de Reanimation. 1994;13(3):301-310. 123. Matheson NA, Diomi P. Renal failure after the administration of dextran 40. Surgery, Gynecology & Obstetrics. 1970;131(4):661. 124. Rasmussen KC, Hoejskov M, Johansson PI, Kridina I, Kistorp T, Salling L, Nielsen HB, Ruhnau B, Pedersen T, Secher NH. Coagulation competence for predicting perioperative hemorrhage in patients treated with lactated Ringer’s vs. Dextran — a randomized controlled trial. BMC Anesthesiology. 2015; 15(1):178.

4. Medical Rehabilitation and Sanatorium-Resort Treatment

To ensure full rehabilitation of patients with inflammatory diseases of the jaws, especially jaw osteomyelitis, coordinated work of a multidisciplinary team is necessary: a maxillofacial surgeon, dental surgeon, general dentist, prosthodontist, neurologist, general practitioner (internist), anesthesiologist-resuscitologist, physical and rehabilitation medicine physician, and medical rehabilitation specialist. Rehabilitation measures are carried out based on specific clinical manifestations (dental, neurological, functional, etc.) and are subject to consideration in the relevant clinical guidelines.

Comments: timely and appropriate prescription of physiotherapy procedures in the complex treatment of patients with purulent-inflammatory diseases of the jaws helps to relieve acute inflammatory symptoms, improves tissue microcirculation, and promotes the reduction of purulent exudate and wound regeneration. Physiotherapy can be included in the complex of therapeutic measures, but only under the condition and after a timely and adequately performed surgical intervention ensuring effective wound drainage, after a comprehensive examination of the patient and against the background of drug therapy, in the absence of contraindications regarding concomitant diseases (primarily of oncological genesis), and necessarily taking into account the phase of the wound healing process. In acute periostitis and acute osteomyelitis of the jaw, it is possible to perform low-frequency magnetotherapy (Magnetotherapy for oral cavity and dental pathology) - exposure of the purulent "focus" to an ultra-high-frequency electric field in athermal or oligothermal doses, ultraviolet irradiation of the affected area with a helium-neon laser, followed by drug electrophoresis (Drug electrophoresis for oral cavity and dental pathology), ELF therapy (Exposure to millimeter-range electromagnetic radiation (ELF therapy)), fluctuarization, etc. In chronic forms of inflammatory diseases of the jaws, the following may be performed: drug electrophoresis for microcirculation disorders, combined exposure to pulsed currents and ultrasound, paraffin therapy for diseases of the peripheral nervous system [27, 50, 67].

Comments: in the acute period of inflammation, it is necessary to perform exercises for muscles not associated with damaged tissues; the exercises should be dosed and aimed at improving tissue microcirculation and preventing the formation of coarse scars. Therapeutic exercise in the subacute and chronic stages is aimed at preventing the development of contractures, restoring the mobility of the temporomandibular joint and the functions of various muscle groups, and completing scar formation and epithelization of wounds [6, 40].

The prescription of a general health-improving regimen contributes to the optimal recovery of the body [6].

5. Prevention and Dispensary Observation

Comments: oral hygiene, educational outreach, and teaching oral hygiene to children and adults play a major role in the prevention of caries and its complications, and periodontal diseases [13]. A dentist visit should be carried out at least once a year, and professional oral hygiene at least once every 6 months. Timely endodontic treatment of complicated forms of caries is of great importance [146].

Indications for preventive measures:

1. Low level of oral hygiene;

2. Presence of hard dental tissue and periodontal diseases in the patient;

3. Presence of decompensated concomitant pathology in the patient.

Contraindications to preventive measures: there are no absolute contraindications.

6. Organization of Medical Care

Type of care: medical care (MC) profile "maxillofacial surgery":

• specialized MC.

• emergency, including emergency specialized MC.

Conditions of MC provision: outpatient, inpatient.

Indications for emergency hospitalization to a medical organization:

Acute serous or purulent periostitis in the presence of sub- or decompensated concomitant pathology in the patient; hyperergic form of the inflammatory process course; malignant neoplasms of any localization; conditions accompanied by immunodeficiency of the body.

Indications for planned hospitalization in a medical organization:

1) Osteomyelitis in the subacute phase and chronic osteomyelitis of the jaw in the presence of a formed sequestrum.

2) Chronic osteomyelitis of the jaw in case of a protracted, torpid, or progressive course of the disease and prolonged formation of sequestra.

Indications for patient discharge from the hospital:

1) Uncomplicated course of the early postoperative period, satisfactory patient condition, controlled pain syndrome with the possibility of its relief by oral medications, the possibility of taking antibacterial drugs on an outpatient basis under the supervision of a maxillofacial surgeon, dental surgeon, or surgeon.

2) Need to transfer the patient to another medical institution or department;

3) At the request of the patient or their legal representative;

4) In cases of non-compliance by the patient with prescriptions or internal hospital regulations, if this does not threaten the patient's life and the health of others.

Further follow-up and treatment of the patient is carried out on an outpatient basis by a maxillofacial surgeon, and in their absence, by a dental surgeon or a surgeon.

7. Additional Information

Factors negatively affecting treatment outcomes:

1. Inadequate opening and drainage of the purulent "focus", which can lead to the progression of the inflammatory process and its spread to surrounding tissues.

2. Non-compliance with the local contact hypothermia regimen in the early postoperative period.

3. Non-compliance with oral hygiene.

4. Non-compliance with physiotherapy and physical therapy recommendations in the postoperative period.

5. Absence of dispensary follow-up.

6. Non-compliance with other recommendations of the attending physician (general and local treatment, diet, etc.).

7. Presence of decompensated forms of somatic diseases in the patient.

Criteria for Evaluating the Quality of Medical Care

References

Appendix A1. Working Group Composition

1. Durnovo, E. A. – MD, Professor, Board Member of the Association of Maxillofacial Surgery Specialists LLC.

2. Yaremenko A.I. – MD, Professor, Vice-President of the LLC "Society of Maxillofacial Surgery Specialists".

3. Solovyov M.M. – Honored Scientist of the RF, MD, Professor of the Department of Surgical Dentistry and Maxillofacial Surgery, Pavlov First Saint Petersburg State Medical University of the Russian Ministry of Health.

4. Grigoryants A.P. – PhD, Associate Professor of the Department of Propaedeutics of Dental Diseases, Pavlov First Saint Petersburg State Medical University of the Russian Ministry of Health.

5. Marusov I.V. – PhD, Associate Professor of the Department of Pharmacology, Pavlov First Saint Petersburg State Medical University of the Russian Ministry of Health.

6. Spiridonova A.A. – Head of the Department of Clinical Microbiology, Pavlov First Saint Petersburg State Medical University of the Russian Ministry of Health.

7. Petropavlovskaya O.Yu. – PhD, Associate Professor of the Department of Surgical Dentistry and Maxillofacial Surgery, Pavlov First Saint Petersburg State Medical University of the Russian Ministry of Health.

8. Vyseltseva Yu.V. – Cand. of Med. Sci., Associate Professor, Member of the LLC "Association of Maxillofacial Surgeons".

9. Khomutinnikova N.E. – Cand. of Med. Sci., Associate Professor, Member of the LLC "Association of Maxillofacial Surgeons".

10. Bespalova N.A. – Cand. of Med. Sci., Associate Professor, Member of the LLC "Association of Maxillofacial Surgeons".

11. Kulakov, A. A. – Academician of the Russian Academy of Sciences, MD, Professor, President of the Association of Maxillofacial Surgery Specialists LLC.

12. Drobyshev A.Yu. – Dr. of Med. Sci., Professor, Vice-President of the LLC "Association of Maxillofacial Surgeons".

13. Bagnenko A.S. – Candidate of Medical Sciences, Associate Professor, Member of the "Association of Specialists in Maxillofacial Surgery".

14. Bayrikov, I. M. – Corresponding Member of the Russian Academy of Sciences, MD, Professor, Member of the Association of Maxillofacial Surgery Specialists LLC.

15. Braylovskaya T. V. – MD, Professor, Executive Secretary of the Association of Maxillofacial Surgeons.

16. Ivanov, S. Yu. – Corresponding Member of the Russian Academy of Sciences, MD, Professor, Board Member of the Association of Maxillofacial Surgery Specialists LLC.

17. Epifanov, S. A. – MD, Associate Professor, Member of the Association of Maxillofacial Surgery Specialists LLC.

18. Tarasenko S. V. – MD, Professor, Member of the Association of Maxillofacial Surgeons.

All members of the working group are members of the All-Russian Public Organization "Association of Maxillofacial Surgeons", * except for specialists from other fields.

There is no conflict of interest.

Appendix A2. Methodology for Developing Clinical Guidelines

Methods used for collecting/selecting evidence: electronic database search, library resources. Description of methods used for collecting/selecting evidence: the evidence base for the recommendations includes publications from the Cochrane Library, EMBASE, and MEDLINE databases, as well as monographs and articles in leading specialized peer-reviewed domestic medical journals on the subject. Methods used for assessing the quality and strength of evidence: significance assessment in accordance with the rating scale.

Target audience for these clinical guidelines:

1. Maxillofacial surgeons.

2. Oral and maxillofacial surgeons.

3. Surgeons.

4. Pediatric dentists.

5. Pediatric surgeons.

6. Medical students, residents, and postgraduate students.

Table 1. Levels of Evidence (LE) rating scale for diagnostic methods (diagnostic interventions).

Table 2. Levels of Evidence (LE) rating scale for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitation interventions).

Table 3. Grades of Recommendation (GR) scale for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitation interventions).

Procedure for updating clinical guidelines

The mechanism for updating clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data on the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.

Appendix A3. Reference Materials

These clinical guidelines were developed taking into account the following regulatory legal documents:

Federal Law No. 323-FZ of November 21, 2011, "On the Fundamentals of Healthcare Protection in the Russian Federation".

Order of the Ministry of Health of the Russian Federation No. 203n dated April 14, 2025, "On approval of criteria for assessing the quality of medical care".

Order of the Ministry of Health of the Russian Federation No. 804n dated October 13, 2017, "On approval of the nomenclature of medical services".

Order of the Ministry of Health of the Russian Federation No. 103n dated February 28, 2019, "On Approval of the Procedure and Timeframes for the Development of Clinical Guidelines, Their Revision, the Standard Form of Clinical Guidelines, and the Requirements for Their Structure, Content, and Scientific Validity of Information Included in Clinical Guidelines."

Order of the Ministry of Health of the Russian Federation No. 422n dated June 14, 2019, "On approval of the Procedure for providing medical care in the specialty 'maxillofacial surgery'".

Decree of the Government of the Russian Federation No. 2406-r dated October 12, 2019, "On Approval of the List of Vital and Essential Drugs, as well as Lists of Medicinal Products for Medical Use and the Minimum Assortment of Medicinal Products Required for the Provision of Medical Care."

AMR Control Strategy (AMRCS) program in inpatient medical care / Russian Clinical Guidelines, Moscow – 2018.

EUCAST European Committee on Antimicrobial Susceptibility Testing http://www.eucast.org (European Committee on Antimicrobial Susceptibility Testing).

Appendix A3.1 Recommended algorithm for empirical antimicrobial therapy (AMT) in maxillofacial surgery (MFS) during inpatient care for patients with odontogenic periostitis and jaw osteomyelitis at the MFS Clinic of the Pavlov First Saint Petersburg State Medical University of the Russian Ministry of Health, stratified by the presence of risk factors for multidrug-resistant pathogens and invasive candidiasis (AMRCS, 2018) [46, 103, 120, 131, 132]

Appendix B. Physician Action Algorithms

Appendix C. Patient Information

Acute inflammatory diseases of the jaws, such as periostitis or osteomyelitis, are quite common in dental surgeon practice. The patient must be aware that if acute tooth or jaw pain occurs, followed by the development of facial soft tissue edema and fever, self-medication must be avoided, and medical assistance should be sought immediately at a medical organization or by calling an ambulance. Surgical intervention is the primary treatment for acute inflammatory diseases of the jaws, and untimely specialized medical care can lead to severe complications and even death.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

Appendix G1.

Russian title: - Visual Analog Scale (VAS) for pain.

Original title (if any): ____________________________________

Source (official developer website, validation publication): [127-130].

Type (underline):

- rating scale

- index

- questionnaire

- other (specify): __________________________________________________

Purpose: assessment of pain intensity in the patient.

Content (template):

Visual Analog Scale

No pain Excruciating pain

I___________________________________________________________________I

Numerical Rating Scale

No pain Excruciating pain

I______I______I______I______I______I______I______I______I______I_____I

0           1           2            3           4           5            6           7            8           9         10

Key (interpretation):

The patient marks their perception of pain over the past 24 hours on the provided scale (from "minimal" to "excruciating"), which is quantified by the physician in millimeters on the VAS or in points on the NRS.

The degree of pain intensity is determined after comparing the obtained data with the clinical picture and instrumental examination methods, using the following grading:

- no pain: 0–4 mm on the VAS or 0 points on the NRS;

- mild pain: 5–44 mm on the VAS or 1–3 points on the NRS;

- moderate pain: 45–74 mm on the VAS or 4–6 points on the NRS;

- severe pain: 75–100 mm on the VAS or 7–10 points on the NRS.

Notes: treatment outcomes are interpreted depending on the genesis of the pain syndrome:

- a reduction in pain intensity on the NRS by 2 points or 30% is considered clinically significant;

- changes greater than 3 points on the NRS or 50% on the VAS are considered substantial;

- a change of more than 20 mm is considered substantial.

Appendix G2.

Russian title: Thromboembolic risk assessment scales.

Original title (if any): ____________________________________

Source (official developer website, validation publication): [126].

Type (underline):

- rating scale

- index

- questionnaire

- other (specify): __________________________________________________

Purpose: assessment of adverse risk factors to predict the patient's probability of developing VTE based on the score.

Content (template):

1-point risk factor group:

✓ Planned minor surgeries;

✓ History of major surgeries (< 1 month ago);

✓ Varicose veins;

✓ History of inflammatory bowel disease;

✓ Lower extremity edema (at the time of examination);

✓ Obesity (body mass index > 25 kg/m²);

✓ Acute myocardial infarction;

✓ Congestive heart failure (< 1 month);

✓ Sepsis (< 1 month);

✓ Pulmonary diseases, including pneumonia (< 1 month);

✓ Pulmonary dysfunction;

✓ Medical patients on bed rest.

2-point risk factor group:

✓ Arthroscopic surgical procedures;

✓ Malignant tumors (current or past);

✓ Major surgical interventions (> 45 minutes);

✓ Laparoscopic surgeries (> 45 minutes);

✓ Strict bed rest (more than 72 hours);

✓ Cast immobilization (less than 1 month);

✓ Central venous access.

3-point risk factor group:

✓ History of deep vein thrombosis or pulmonary embolism;

✓ Family history of thrombosis;

✓ Factor V Leiden mutation;

✓ Prothrombin G20210A mutation;

✓ Elevated blood homocysteine levels;

✓ Presence of lupus anticoagulant;

✓ Elevated anticardiolipin antibody titer;

✓ Heparin-induced thrombocytopenia (HIT);

✓ Other types of congenital or acquired thrombophilia.

5-point risk factor group:

✓ Elective major lower extremity joint arthroplasty;

✓ Femoral, pelvic, and tibial bone fractures (< 1 mo);

✓ Stroke (< 1 mo);

✓ Multiple trauma (< 1 mo);

✓ Acute spinal cord injury (paralysis) (< 1 mo).

Key (Interpretation): Risk grades based on the total score:

✓ 0–1 points – low; ✓ 2 points – moderate; ✓ 3–4 points – high;

✓ 5 or more points – very high.

Notes: _____________________