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    Move Forward Guide

    Physical Therapist's Guide to Osteomyelitis of the Jaw

    Osteomyelitis is an infection of the bone. The temporomandibular joint is rarely affected by osteomyelitis, but when it is, it requires immediate attention. Lack of jaw and neck mobility may occur during and after the infection, and physical therapy will help improve your jaw mobility to restore your ability to eat, speak, and brush your teeth.


     

    What Is Osteomyelitis of the Jaw?

    Osteomyelitis is an infection of the bone and most commonly affects the bones of the extremities, spine, and pelvis. The temporomandibular joint (TMJ) is rarely affected by this condition, but when it is, serious problems with the bones of the face and jaw can result.

    Usually, the infection is the result of bacteria entering the body through poor oral hygiene or oral surgery, such as a root canal procedure. It also may occur following a jaw fracture. Osteomyelitis in the jaw occurs more in men than women, and more commonly in the mandible (lower jaw bone) than the maxilla (bone where the top teeth are arranged). People with diabetes, have alcoholism, or other diseases that impact the immune system are at greater risk. Having had another recent surgery before oral surgery or jaw trauma may increase risk, also.

    To heal the infected bone, the body sends white blood cells to the area; however, persistent presence of white blood cells near the bone actually causes the bone to break down. The infection restricts blood flow to the area and causes bone death ("necrosis").

     

    Signs and Symptoms

    Osteomyelitis of the jaw can cause:

    • Fever
    • Jaw pain
    • Facial swelling
    • Tenderness to the touch
    • Jaw stiffness
    • Sinus drainage
    • Tooth loss
    • Pus (thick, usually yellow-white fluid)
    • A palpable bump on the bone of the jaw
    • Fatigue
    • Fever
    • Headaches or neck ache

    During the acute stage of osteomyelitis, you'll have increasing, constant jaw pain and sinus pressure that is not affected by movement of the jaw. If you have chronic osteomyelitis, you may have jaw and neck stiffness, and difficulty with eating and talking.

     

    How Is It Diagnosed?

    A series of blood tests usually is ordered to check for elevated white blood cell counts. This condition is often misdiagnosed because its symptoms are similar to other jaw, skull, or face problems. Bone changes and inflammation may be observed in medical images (x-ray, ultrasound, CT, or MRI) of the jaw, as well.

    If osteomyelitis is found to be the cause of your pain, your physician will prescribe antibiotics to clear up the infection. Occasionally, there is difficulty opening the mouth, normally due to tissue damaged by the inflammation. In these cases, physical therapy will help restore motion and decrease pain in the jaw area. Your doctor or dentist will inform your physical therapist what specific areas were impacted by the infection. The physical therapist then can help you restore the normal motion and mobility of those structures, reduce your pain, and gain the ability to speak, eat, and maintain oral hygiene.

     

    How Can a Physical Therapist Help?

    Your physical therapist can help restore the natural movement of your jaw and decrease your pain; but first, the antibiotics need to take effect. After you've finished your antibiotics, you might have pain and limited movement at the TMJ and cervical spine. You also might have headaches.

    During your first visit with your physical therapist, the therapist will:

    • Review your medical history, and discuss any previous surgery, fractures, or other injuries to your head, neck, or jaw
    • Conduct a physical examination of your jaw and neck
    • Evaluate your posture and how your neck moves
    • Examine the TMJ to find out how well your mouth can open and whether there are any abnormalities in jaw motion as a result of the osteomyelitis

    The therapist might place his or her hand in your mouth in order to examine your jaw movement.

    Following the examination, the physical therapist will select appropriate treatments to improve jaw movement and relieve pain.

    Improve Jaw Movement

    Physical therapists use skilled hand movements called manual therapy  to increase movement and relieve pain in tissues and joints. Your therapist also might use manual therapy to “stretch” the jaw to:

    • Restore normal joint and muscle flexibility (so that you won't feel "tight")
    • Break up the scar tissues ("adhesions") that may occur when disease or injury limits movement for a period of time

    Your physical therapist may teach you special "low-load" exercises. These are exercises that don't exert a lot of pressure on your TMJ but can strengthen the muscles of the jaw and restore a more natural, pain-free motion. The therapist will also teach you exercises that help you increase the opening of your jaw and improve the way your jaw works

    Relieve Your Pain

    In addition to manual therapy, if your pain is severe, your physical therapist might use treatments such as electrical stimulation or ultrasound to reduce pain.

     

    Can this Injury or Condition be Prevented?

    Prevention of infection starts with maintaining a healthy lifestyle. Your body fights infections best when you have proper rest, nutrition, and hygiene, such as hand washing and tooth brushing.

    If you need oral surgery, the dentist or doctor’s technique can be the start of avoiding infection. However, you should take antibiotics as prescribed after any surgery, as everyone’s mouth has a significant amount of bacteria present. These bacteria do not pose a threat in normal circumstances.

    After any procedure, you will be given instructions about how to care for the healing area. For instance, after wisdom tooth removal you can prevent infection by following directions for how and when to clean the area, and using gauze to pack the wound. You may need to alter your diet to protect the area, while allowing open wounds in the mouth to heal.

    If you notice any signs and symptoms of infection, or something doesn’t seem correct with your mouth and jaw, calling the office can avoid progression of any problems.

     

    Real Life Experiences

    About 2 weeks following an oral procedure to remove her wisdom teeth, Dana begins to notice an increase in jaw stiffness, with pain and pressure in front of her ear. She assumes that it is related to the fact that her mouth was held open for a prolonged period of time during the procedure. As time passes, however, her pain worsens. Dana develops a low-grade fever and fatigue. Concerned, she calls her oral surgeon.

    The oral surgeon consults Dana’s family physician, who orders blood tests. The results show an elevated white blood cell count. The physicians want to see the condition of the bone, and an x-ray demonstrates significant bone and joint swelling in the area of her left jaw. They diagnose Dana with osteomyelitis, and place her on antibiotics. After a few days, Dana no longer is in pain or feels ill. However, her jaw stiffness increases, and she is frustrated that she cannot chew and open her mouth very far. When she calls her physician, he sends her to a physical therapist.

    Dana makes an appointment with Jennifer, a physical therapist who specializes in jaw and neck problems. The physical therapist asks questions about her recent medical and surgical history, and reviews the imaging to note the affected tissues. Jennifer takes measurements of how well and how much Dana’s jaw and neck move. The physical therapist feels Dana’s neck, the side of her face, and inside her mouth to determine why the jaw is stiff. Jennifer moves Dana’s jaw and applies pressure to her muscles.

    The therapist asks her to perform specific stretching techniques and strengthening exercises at home.   Appointments were a couple times a week for the first 2 weeks, and once her jaw started to get more flexible, Dana did more jaw exercises at home and followed up every 10-14 days.

    Now, Dana can eat a sandwich at the deli or brush her teeth without any problems.

    This story was based on a real-life case. Your case may be different. Your physical therapist will tailor a treatment program to your specific case.

     

    What Kind of Physical Therapist Do I Need?

    All physical therapists are prepared through education and experience to treat patients who have osteomyelitis. You may want to consider:

    • A physical therapist who is experienced in treating people with orthopedic or musculoskeletal problems. Some physical therapists have a practice with a craniofacial focus, meaning that they focus on movement disorders related to the skull and facial structures, and often specialize in treating the temporomandibular joint (jaw joint).

    You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

    General tips when you're looking for a physical therapist (or any health care provider):

    • Get recommendations from family and friends or from other health care providers.
    • When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people with osteomyelitis.
    • During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.
     

    Further Reading

    The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for their visit with their health care provider.

    APTA has determined that the following articles provide some of the best scientific evidence about physical therapist treatment of osteomyelitis of the jaw. The articles report recent research and give an overview of the standards of practice for treatment of TMJ both in the United States and internationally. The article titles are linked either to a PubMed abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.

    Furto ES, Cleland JA, Whitman JM, Olson KA. Manual physical therapy interventions and exercise for patients with temporomandibular disorders. Cranio. 2006;24:283-291. Article Summary on PubMed.

    Uche C, Mogyoros R, Chang A, et al. Osteomyelitis of the jaw: a retrospective analysis. The Internet Journal of Infectious Diseases. 2009;7(2) Free Article.

    Ertas U, Tozoglu S, Gursan N. Chronic osteomyelitis: 20 years after mandible fracture. Dent Traumatol. 2004;20:106–108. Article Summary on PubMed.

    Michelotti A, De Wijer A, Steenks M, Farella M. Home exercise regimes for the management of non-specific temporomandibular joint disorders. J Oral Rehabil. 2005;32:779–785. Article Summary on PubMed.

     *PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.

    Revised by Jennifer Miller, PT, MPT, SCS.  Authored by Eric S. Furto, PT, DPT, MTC, FAAOMPT. Reviewed by the MoveForwardPT.com editorial board.