Features of localization on the mandible
The clinical picture largely depends on where the inflammation started:
- Angle and ramus region: collateral edema is not very sharp, but it covers a significant area of soft tissues.
- Molar region: in this zone, the internal bone wall is thinner than the external one. Because of this, purulent exudate often breaks through to the lingual surface. Objectively, the physician observes hyperemia, edema, and a characteristic swelling of the mucous membrane, which can spread to the sublingual region.
Laboratory and instrumental diagnostics
The diagnosis is established primarily based on the clinical picture, since additional methods show only indirect signs:
- Complete blood count (CBC): reflects a moderate inflammatory reaction. The leukocyte count increases slightly (up to 10–11×10^9/L), and a shift in the leukocyte formula is observed due to an increase in the number of neutrophils (up to 70–78%). ESR rarely exceeds 12–15 mm/h.
- Jaw radiography: it is important to remember that there are no specific changes in the bone structure inherent specifically to periostitis. The radiograph is necessary exclusively to identify the primary disease: signs of granulating periodontitis, a radicular cyst, or the presence of a semi-impacted tooth.
Differential diagnosis
Acute odontogenic periostitis must be differentiated from a number of other maxillofacial pathologies:
- Periodontitis: inflammation is strictly limited to the projection of the root apex, soft tissue edema is insignificant. In periostitis, however, a subperiosteal abscess is formed, and pain upon tooth percussion paradoxically decreases.
- Acute osteomyelitis: proceeds with severe intoxication (chills, severe hyperthermia). The infiltrate covers the alveolar process from both sides (in a cuff-like manner), several healthy neighboring teeth become mobile at once, and numbness of the lower lip may appear (Vincent's sign).
- Acute sialadenitis: the salivary glands are intact in periostitis. If the gland is massaged in sialadenitis, cloudy saliva with purulent streaks will be released from the duct orifice.
- Acute sinusitis: gives diffuse pain radiating to the maxilla and is accompanied by unilateral nasal congestion.
- Pulpitis: there are no changes in the periosteum, and electric pulp testing (EPT) shows only a decrease in the sensitivity threshold (in periostitis, the pulp is completely non-viable).
Clinical rule (oncological alertness): if, after adequate surgical drainage and anti-inflammatory therapy, tissue infiltration continues to increase, it is necessary to purposefully search for a malignant tumor.
Principles of treatment
Treatment of acute periostitis is always comprehensive and begins with surgical intervention under local anesthesia with premedication.
First of all, incisions are made to open the subperiosteal abscess, taking into account its localization. Further tactics depend on the causal tooth:
- Extraction: most authors recommend extracting multi-rooted teeth that caused the infection.
- Preservation: indicated for single-rooted teeth with a well-patent canal that can be high-quality filled. If there is a focus of destruction at the root apex, a resection operation is performed, but strictly after the complete relief of acute symptoms.
- Delayed extraction: if extraction threatens major surgical trauma (for example, with a dystopic or impacted tooth), it is postponed for 7–10 days until the complete elimination of inflammation.
For rapid differential diagnosis of periostitis and osteomyelitis, use the "ONE — MANY" rule. In periostitis, one causal tooth is affected, and the infiltrate is unilateral. In osteomyelitis, many teeth are mobile, and the infiltrate is bilateral (cuff-like).
Class and exam questions
Is acute periostitis visible on an X-ray?
No, there are no specific radiological signs of inflammation of the periosteum itself. Only the cause of the disease (e.g., a cyst or granulomatous periodontitis) can be detected on the radiograph.
Does severe pain upon biting on the tooth persist when periodontitis transitions into periostitis?
No, the pain upon percussion and biting characteristic of periodontitis decreases significantly or disappears completely, as the purulent exudate breaks through under the periosteum and the pressure in the periodontium drops.
In which cases can the causal tooth in periostitis be preserved?
The tooth is preserved if it is single-rooted and its canal is well patent for endodontic treatment. In the presence of bone destruction, root apex resection is performed, but only after the acute inflammation subsides.
What else to study on this topic
- Acute odontogenic osteomyelitis of the jaws and Vincent's sign
- Differential diagnosis with suppurated jaw cysts
- Chronic recurrent multifocal osteomyelitis (CRMO) and LPIN2 gene mutation
- SAPHO syndrome: osteoarticular and skin manifestations
- Diagnostic imaging of intraosseous abscesses (contrast-enhanced MRI)
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