Osteomyelitis 1.introduction 2.Defination 3.Classification 4.Acute osteomyelitis 5.chronic osteomyelitis

1. OSTEOMYELITIS
DR SAGAR

2. Osteomyelitis
• Introduction
• Defination
• Classification
• Acute OML
• Chronic OML
• management

3. Osteomyelitis
Nelaton coined osteomyelitis in 1834
It includes three root words
• osteon (bone)
• myelo (marrow)
• Combination: itis (inflammation)to define the clinical state in which
bone is infected with microorganisms.

5. • o Infection of bone and marrow is known as
osteomyelitis.
•o It may remain localized, or it may spread
through the bone to involve the marrow,
cortex, periosteum, and soft tissue
surrounding the bone.

6. Defination
• Inflammatory condition of bone that begin as an infection of medullary
cavity and haversian system of the cortex and extends to involve the
periosteum of affected area.

7. • CLASSIFICATION
• Duration
• o Acute / Subacute / Chronic
• Mechanism
• o Heamatogenous (tonsil, lungs, ear/ GIT)
• o Exogenous (injection, open fractures)
• Host response
• Pyogenic / Granulomatous

8. • Osteomyelitis is divided into 3 forms as per
duration:
• 1. Acute osteomyelitis
• 2. Subacute osteomyelitis
• 3. Chronic osteomyelitis

10. •Three basic mechanisms allow an infection to
reach the bone;
•1 Haematogenous spread
•2. Contagious source of infection
•3.Direct implantation

11. • HAEMATOGENOUS OSTEOMYELITIS
• Primary haematogenous osteomyelitis is characterized
by an acute infection of bone caused by seeding of
bacteria within the bone from a remote source
• Haematogenous osteomyelitis usually occurs during
period of growth and thus occur primarily in children.
However, all ages may be affected and cases are even
found in old age.

12. Etiology
• Osteomyelitis of the jaw is caused by
1. Odontogenic Infections
• Primarily odontogenic infection originating from pulpal or periodontal
tissues,
• pericoronitis, infected socket, infected cyst, tumor, etc.
• 2.Trauma: It is the second leading cause:
• (a) Especially, compound fracture, and
• (b) Surgery-iatrogenic cause.

13. • Infections of orofacial regions derived from:
• Periostitis following gingival ulceration
• Lymph nodes infected from furuncles
• Lacerations
• Peritonsillar abscess.
• Infections derived by hematogenous route:
• wound on the skin,
• upper respiratory tract infection,
• middle ear infection,
• , systemic tuberculosis.

14. •TYPE OF ORGANISMS
• o Bacteria, viruses and fungi can all infect bone, soft
tissues and joints. Generally, bacterial infections are more
destructive and move rapidly.
• o Fungi tend to produce slow and chronic infections
• o Tuberculosis and brucellosis range from aggressive to
reparative

15. Pathogenesis
1. Osteomyelitis is initiated from a contiguous focus of infection or by
hematogenous spread.
2. Primary hemato genous osteomyelitis is rare in the maxillofacial region,
generally occurring in the very young patients.
3. The adult process is initiated by an inoculation of bacteria into the jaw bones.
4. The initial causative insult results in a bacteria induced inflammation or
cascade.
5. In normal healthy patient, this process will be self-limiting. However, some
times, in the normal host and mostly in the compromised host, the
pathological process will start.

17. 1. The important factor in the establishment of OML is the
compromise in the blood supply. It is worth considering the blood
supply and venous drainage of mandible
2. Blood Supply of Mandible
3. Primary supply:
4. The mandible is supplied by inferior alveolar artery, except coronoid
process, which is supplied by temporalis muscle vessels
5. . Secondary supply: It is the periosteal supply, which generally runs
parallel to cortical surface of bone, giving off nutrient vessels, those
penetrate cortical bone and anastomose with the branches of inferior
alveolar artery

18. Venous drainage of mandible:
There are two routes:
(1) Via inferior alveolar vein; it runs upwards, and joins pharyngeal plexus, and
(2). It runs downwards, and joins External jugular vein
• Osteomyelitis in Maxilla
• A true osteomyelitis infectious process does not occur in the maxilla despite the presence of tooth follicle or
anatomic respiratory sinus cavities, including the nose.
• It is rare, due to: (1) Extensive blood supply and signi ficant collateral blood flow in midface,
• (2) Porous nature of membranous bone,
• (3) Thin cortical plates, and (4) Abundant medullary spaces.
• These preclude confine ment of infections within bone; and permit dissipation of edema and pus into soft
tissues and paranasal air sinuses.

20. • Acute Pyogenic OML
• It may have the appearance of a typical odontogenic
infection.
• It can be localized and widespread
Microbiology
• It is caused by pyogenic organisms.
• OML in the tooth bear ing area, is polymicrobial in
nature. The most commonly found organisms in
odontogenic OML is Staphylococcus aureus; and
Streptococcus pyogenes.

21. Etiology
(1)Odontogenic infections,
(2) Local traumatic injuries,
(3) Peritonsillar abscess
(4) Hemato infections,
(5) Compound fractures of jaws are genous complicated
by OML

22. .Odontogenic infections
: These are the common local cause of OML. These infections
may result from:
• Periapical disease secondaryto pulp pathology,
• Periodontal disease
• Pericoronitis of long duration,
• Infected odontogenic cyst, and. Infection of an extraction
wound or fracture site.
• • Local traumatic injuries:(a) Injuries of gingiva are
usually insignificant; however, may become serious in patient
with low resistance

23. ACUTE OML DUE TO
ODONTOGENIC INFECTION

24. Clinical Features
Occurrence:
• In adults, it is more common in mandible and involves
alveolar process,
• angle of mandible,
• posterior part of ramus and coronoid process.
• OML of condyle is reportedly rare

25. 1.More common in adult with mandibular infection
2.Osteomyelitis of maxilla more common in neonate
3.Sever throbbing pain, deeply sited pain
4.Swelling malaise and pyrexia
5.Gingiva red swollen and tender
6.involved teeth tender and moble.
7.Intraand extra-oral pus discharge
8.RegionaL.N enlargement
9.trismus

27. Early cases are characterized by
Generalized constitutional symptoms:
• High intermittent fever,
• malaise,
• nausea, vomiting, anorexia
• Deep seated boring, continuous intense pain in the affected area
• paresthesia or anesthesia of the lower lip, which helps the clinician to
differentiate this condition from alveolar abscess.
• Teeth are tender to percussion and loose, and trismus

28. Established cases are characterized by:
• Deep pain, malaise, fever, dehydration, anorexia
• Teeth in involved area begin to loosen and
become sensitive to percussion
• Purulent discharge through sinuses: (a)
Intraorally; (i) around gingival sulcus: or (ii)
through buccal vestibule, and (b) Extraorally
on the face, through cutaneous fistulae
• Fetid odor is often present
• Trismus may be present
• Dehydration, acidosis and toxemia
• Regional lymphadenopathy is usually present

29. Chronic Osteomyelitis
It can be
(a) primary: resulting from organisms which are less
virulent, and
(b) secondary: occurring after acute OML, when the
treatment did not succeed in eliminating the infection

30. CHRONIC OML DUE TO PERIODONTAL
DISEASE

31. clinical features
(1)Pain and tenderness: the pain is minimal,
(2)Nonhealing bony and overlying soft tissue wounds with
induration of soft tissues,
(3)Intraoral or extraoral draining fistulae,
(4)Thickened or "wooden" character of bone,
(5) Enlargement of mandible, due to deposit of new bone
(6)Teeth in the area tend to become loose and sensitive to
palpation and percussion

32. Managaement
• Conservative management
• Surgical management

33. Conservative Management
• Complete bed rest
• Supportive therapy: It includes-nutritional
support, in the form of high protein and high
caloric diet; and adequate multivitamins
• Dehydration: Hydration orally or through adminis tration of IV fluids
• Blood transfusion: In case, RBCs and hemoglobin islow
• Control of pain: It is controlled with analgesics.
• Sedation may be employed for keeping patient comfortableand allow to
sleep.

34. Antimicrobial therapy
antibiotic regimens for OML of jawsare as follows:
• Regimen I (1st choice):
• penicillin (Penicillin V) is given.Oxacillin: 1 g IV every 4 hourly
• Regimen II: It is based on culture and sensitivity results. Penicillinase-
resistant penicillins, such as oxacillin,cloxacillin, dicloxacillin, may be given.
• In case of allergy to penicillin, the following antibiotics are prescribed, (i)
Clindamycin 300-600 mg orally 6 hourly,
• (ii) Cephalosporin 250 500 mg orally every 6 hourly:

35. • 2nd choice Clindamycin: It is effective against penicillinase
producing staphylococci, streptococci and anaerobic bacteria
including Bacteroides.
• It is used because of its ability to diffuse widely in bone.
• It is not recommended as first choice; as it is bacteriostatic, and
causes diarrhea
• Third choice: Cefazolin or Cephalexin:

36. Hyperbaric oxygen in treatment of OML

37. • It has entered as
• A potential alternative to surgical reperfusion
• As an adjunct in hospital immune response
• Increase wound healing
• Therefore its use has been increased in treatment of OML

38. HYPER (increase) + BARIC(pressure)
• Hyperbaric oxygen therapy (HBOT) involves the"intermittent,
usually daily, inhalation of 100 percent humidified oxygen
under pressure, greater than 1 atmospheric absolute pressure
ATA
• Hyperbaric oxygen therapy(HBOT) is defined as
administration of 100% oxygen to a patient placed inside a
chamber pressurized to greater than 1 atmosphere.•

39. • Effects
• ENHANCED LEUCOCYTIC LYSOSOMAL ACTIVITY
• NEUTRALISATION OF BACTERIAL TOXINS
• INCREASED WOUND HEALING
• Increased oxygen PERFUSION TO ISCHEMIC AREAS
• Applications
• ORN
• OML
• CO POISONING
• TO PROMOTE BONE GRAFTS HEALING AND FLAP UPTAKE

40. Contraindication
• Immunosuppressive disorders
• Claustrophobia
• COMPLICATIONS
• Oxygen toxicity
• Visual changes
• Tooth and sinus pain

41. Surgical Management
The surgical treatment modalities include:
(1)Incision and drainage,
(2)Extraction of loose or offending teeth,
(3)Debridement, of affected area
(4)Immediate or delayed reconstruction with bone graft.

42. Thankyou