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  1. 1. Plan  Definition  Etiology  Classification  Pathogenesis  Symptoms
  2. 2. Definition The word “osteomyelitis” originates from the ancient Greek words:  osteon (bone)  muelinos (marrow) Meaning inflammation of medullary portion of the bone caused by infection.
  3. 3. This disease is now rare due to the value of antibiotics and early treatment but the importance of predisposing factors such as:  Poor nutrition  Untreated dental diseases  Impaired immunity  Exposure to radiation…
  4. 4. It is quite rare but seen particularly in those patients whose defense against infection is compromised because of local or systemic factors.
  5. 5. Etiology There are many various causes of osteomyelitis:  Acute periapical infection  Pericoronitis  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  Haematogenic origin  Vascular Insufficiency
  6. 6. 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.
  7. 7. Classifications
  8. 8. Pathogenesis
  9. 9. Pathogenesis For osteomyelitis to occur exudate must spread through the cancellous spaces of the bone producing thrombosis of the nutrient vessels with ischemia, infarction, and sequester formation.
  10. 10.  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.
  11. 11.  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.
  12. 12.  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
  13. 13. 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 environment.  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 sequestra.
  14. 14. Chronic osteomyelitis at the molar region and region of first premolar of the left side of the mandible
  15. 15.  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.
  16. 16. Diagnosis  Clinical Picture  X-ray  Complete blood count  Erythrocyte sedimentation rate  Needle aspiration or bone biopsy  Radionuclide bone scans  CAT scans  MRI  Ultrasound  C-reactive Protein
  17. 17. Signs and Symptoms
  18. 18. 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  Puss discharges  A fetid oral odor caused by anaerobic pyogenic bacteria often is present.  Fever (sub-febrile) and weakness
  19. 19. On Radiographs:  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 apparent  sequestra - irregular calcified areas separate from remaining bone.
  20. 20. Chronic Osteomyelitis Clinical features  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 periosteal reaction.
  21. 21. 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.
  22. 22. To Be Continued…….