The word “osteomyelitis” originates from
the ancient Greek words:
Meaning inflammation of medullary
portion of the bone caused by infection.
This disease is now rare due to the value of
antibiotics and early treatment but the
importance of predisposing factors such as:
Untreated dental diseases
Exposure to radiation…
It is quite rare but seen particularly in
those patients whose defense
against infection is compromised
because of local or systemic factors.
There are many various causes of osteomyelitis:
Acute periapical infection
Acute periodontal lesions (postsurgical)
Trauma-fractures and extraction of teeth
Acute infection of the maxillary sinus
Infection from skin(boils-skin abcess)
Middle ear infections
Osteomyelitis of the jaws induced by
hematogenous spread has become rare
since the introduction of antibiotics;
however, in regions of limited medical
access these forms may still be noted.
For osteomyelitis to occur exudate must
spread through the cancellous spaces of the
bone producing thrombosis of the nutrient
vessels with ischemia, infarction, and
Until old age the main blood supply to the
mandible is the inferior alveolar artery with
its centrifugal distribution anastamosing
with the peripheral vessels which enter
through Volkmann's canal.
Parts of the ramus and coronoid processes
are supplied by additional small nutrient
arteries but are dependent to a substantial
extent upon small vessels entering the
cortex from muscle attachments.
In most incidences periapical and periodontal infections
are localized by a protective pyogenic membrane or soft
tissue abscess wall which serves as a certain barrier.
This condition represents a carefully balanced equilibrium
between microorganisms and host resistance preventing
further spreading of the infection. If the causative
bacteria are sufficient in number and virulence, this
barrier can be destroyed. Furthermore, permanent or
temporary reduction of host resistance factors for various
reasons mentioned previously facilitate deep bone
invasion by microorganisms.
Bacterial invasion induces a cascade of inflammatory host
responses causing hyperemia, increased capillary permeability,
and local inflammation.
Proteolytic enzymes are released during this immunological
reaction creating tissue necrosis, which further progresses as
destruction of bacteria and vascular thrombosis ensue.
Accumulation of pus inside the medullary cavity, consisting of
necrotic tissue and dead bacteria within white blood cells,
increases intramedullary pressure. This leads to vascular
collapse, venous stasis, thrombosis, and hence local ischemia.
Pus travels through the haversian and nutrient canals and
accumulates beneath the periosteum, elevating it from the
cortical bone and thereby further reducing the vascular supply
Chronification of bone infection
The chronification of the disease reflects the
inability of the host to eradicate the pathogen
due to lack of treatment or inadequate
treatment, resulting in failure to reestablish the
carefully balanced equilibrium between host
factors and pathogens found in a healthy oral
After the acute inflammatory process occurs
and local blood supply is compromised,
necrosis of the endosteal bone takes place.
The bone fragments die and become
Chronic osteomyelitis at the molar region
and region of first premolar of the left side of
Osteomyelitis is a rare problem in the
maxilla because it has predominantly
cancellous alveolar bone with a thin
cortex and a rich plexiform blood supply.
Complete blood count
Erythrocyte sedimentation rate
Needle aspiration or bone biopsy
Radionuclide bone scans
Symptoms of Acute
Osteomyelitis Severe pain
Tenderness in the affected area
Swelling in the affected area
Regional lymphadenopathy(lymph nodes enlarged & tender)
If the infection involves the mandibular canal near premolar
region, a paresthesia of the lip is common.
Problem opening jaw (trismus)
An important symptom is a developing numbness over the
chin as a result of mental nerve involvement.
Percussion is painful over involved teeth
Some teeth involved can become loose and mobile
A fetid oral odor caused by anaerobic pyogenic
bacteria often is present.
Fever (sub-febrile) and weakness
Can be seen on x-ray only after 1-3 weeks
The typical feature is a rarefying of the bone. This may
extend through a large area of bone, involving the
inferior dental canal and lower cortex of the mandible.
decreased density of trabeculae
multiple small radiolucent areas become
sequestra - irregular calcified areas separate from remaining
Clinical course lasting over a month.
Painful exacerbations and swelling are
always present, although this is likely to be
less severe than in the acute form.
Preservation of mental and labial sensation
One or more soft tissue sinuses are
typically present, draining pus. The affected
bone may become enlarged owing to
A- Patient with a clinically extensive secondary chronic
osteomyelitis of the frontal region with multiple fistula and abscess
formations. The patient was treated with i.v. bisphosphonates for
metastatic breast cancer.
B- CT scan corresponding to a: The bone and periosteal reaction is
not as strong as would have been expected from the clinical picture
and compared with cases of secondary osteomyelitis of the
mandible with no underlying bone pathology.