osteomyelitis of the jaws classification and clinical presentation. management and possible complications

1. OSTEOMYELITIS
Discussant; Don Chiwaya

2. Contents
• Definition
• Predisposing factors
• Classification
• Suppurative osteomyelitis
• Non suppurative

3. Definition
• Basically inflammation of the bone marrow
• However an almost all cases infection spread
to involve the cortical bone and periosteum.

4. Predisposing factors
• Poor nutrition
• Impaired immunity
• Untreated dental diseases
• Exposure to radiation

5. Classification
• Roughly divided into suppurative and non
suppurative based on clinical features.
• Suppurative
1. Acute
2. Subacute and chronic
• Infantile osteomyelitis
• Non suppurative
1. Chronic diffuse sclerosing
2. Garre’s sclerosing

6. SUPPURATIVE OSTEOMYELITIS
• The dominant form
• Characterised by pus formation and necrosis of
bone
• Has two distinct forms;
a) Acute ; infection whicch includes systemic
effects
b) Chronic; induce minimal systemic effects
• Primary chronic; no acute episode
• Secondary chronic; involves prolonged
inflammatory process

7. Etiology
• Odontogenic infection; most common cause
• Infected cyst/tumor
• Surgical wound/trauma infection
• Hematogenous seeding; rare

8. Pathogenesis
• Inflammation triggered by bacterial invasion into
marrow induces a compromised microcirculation
and increased pressure in the intramedullary site.
• Leads to vascular collapse, venous stasis and
ischemia and eventually bone necrosis
• Further multiplication of microorganisms and the
resultant inflammation induce further necrosis of
the surrounding bonny tissue and resulting in
extensive spread of infection

9. Factors involved in the onset, severity
and persistence of osteomyelitis
a) Blood supply to the bone
b) Virulence of the pathogens
c) Host defense mechanism
• Therefore the mandibular cancellous bone is
more likely to become ischemic and more
sensitive to infection than maxillar
• Any disease that will impair the blood flow
will increase the risk eg; paget’s disease,
osteoporosis, osteopetrosis, tumors

10. Microbiology
• Similar to those of odontogenic infections
• Viridan streptococci and strict anaerobes such
as Prevotella, Fusobacterium and
Peptostreptococci species are predominant
isolates.

11. Clinical features and stages
Acute
• Initial phase characterized by deep and intense
pain
• High intermittent fever ( 38-40C )
• Other systemic symptoms;
Chills
Malaise
Headache
Decreased appetite

12. • Swelling is minimal and fistulae are absent
• Infection is localized only in the intramedullary
site- adequate antibiotic treatment at this
stage may prevent further progression
• With spread of infection systemic toxic
symptoms become more severe and sepsis
may occur

13. • Regional lymph nodes become enlarged and
tender
• Later purulent exudates erode the cortical
bone and periosteum resulting into facial and
submandibular cellulitis
• If masticatory muscles are affected, trismus
may occur
• A throbbing pain in the jaw, severe tenderness
and a feeling of extrusion of teeth

14. • Vicent’s symptom as the infection affects the
inferior alveolar nerve
• Subsequently pus discharge from gingival
sulcus,
• Multiple mucosal fistulae become apparent
• There is little or no radiographic changes in
this stage
• The acute stage usually continues for 1-
2weeks

15. Subacute and Chronic stage
• If the disease is neglected or does not respond
to treatment
• However some cases primarily develop a
chronic form without an acute episode
• Temperature falls to the normal range
• Symptoms disappear or become minimal
• Affected teeth are mobile and tender to
percusion

16. • Swelling becomes localized
• An involucrum forms
• In some extreme cases pathologic fracture
occurs due to significant bone loss from
sequestration

17. Diagnosis
• Diagnosis of acute osteomyelitis is based on
history, clinical findings and results of blood
examination
• Chronic osteomyelitis; bony destruction can
be confirmed with plain radiographs

18. Imaging
• Radiographic changes are generally detected
after losing 30-50% of bony calcified
constituents
• Changes are detected 1-3 weeks after onset of
acute form

19. • Once enough bone destruction has set in,
characteristics features will be see;
 Increased radiolucency, uniform pattern or
patch with moth-eaten appearance
 Sequestrum is seen as islands of bone
 There may be an area of increased
radiodensity surrounding the radiolucency as
a result of inflammatory reaction

21. CT
• Bony changes are detectable earlier
• Particularly useful in visualizing the actual
extent of the lesion
Radionuclide scan
• More sensitive than others
• Gallium scan images depicts lesions since they
tend to accumulate at inflammatory sites

22. TREATMENT
• Consists of ; Conservative and Surgical
management.
Antibiotic Therapy
• Osteomyelitis occurs mostly in bone with an
inadequate blood supply or
immunocompromised patients
• Therefore high doses and also adequate
serum level have to be maintained,

23. A. Conservative
• Complete bed rest
• Supportive therapy; nutritional- high protein
and caloric diet
• Hydration; orally or IV
• Blood transfusion; in case of low Hb
• Pain control
• IV antimicrobial agents;

24. Recommended antibiotic regimes
• Aqueous Penicillin 2MU IV 4hourly
• Metronidazole 500mg IV 4hourly
for 2 – 4 weeks
• Based on culture and sensitivity; Penicillinase
resistant penicillins; oxacilin, cloxacillin of
flucloxacillin

25. • In case of penicillin allergy use;
• Clindamycin 300-600mg 6hourly or
• Cephalosporin 250-500mg 6hourly or
• Erthromycin 2g 6hourly IV

26. Surgery
• The purposes are;
1. To improve the blood supply in the involved
area thereby allowing adequate penetration
of antibiotics
2. To maximize the host defense mechanisms
and self healing ability

27. Surgical management
• Incision and drainage
• Extraction of the loose or offending tooth
• Debridement
• Continuos or intermittent indwelling closed
catheter irrigation
• Sequestrectomy
• Saucerization
• Decortication
• Resection and reconstruction

28. I and D
• Intraorally or extraorally depending on the
location
• Various methods employed;
o Opening up pulp chamber
o Making fenestration through cortical plate
over apical area with a drill
o Edentulous area; make an incision over the
crest and make a window

29. • Extraction of the loose teeth; sometimes
drainage is achieved
• Debridement; following I and D, irrigation with
hydrogen perioxide and then normal saline.

30. Sequestrectomy
• once full formation of sequestrum has been
confirmed
• removal can be performed by simple incision
and small surgical

31. Saucerization
• After incision, the buccal mocoperiosteal flap is
reflected to expose the infected bone.
• Then, loose teeth, pus, sequestrum, necrotic
tissue and granulation in the bone marrow and
cancellous bone are removed with sharp
curettes.
• The procedure should be performed carefully to
avoid damage to the inferior alveolar nerve and
vessel.

32. • Bone in affected areas is reduced using burs or
rongeurs until vital bleeding of the area is
encountered at all margins.
• Any sharp bony portion and undercut portion
are removed using burs and bone files to
produce a saucer-like depression of the bone.

33. • After the surgical area is thoroughly irrigated
with copious amounts of saline solution,
• buccal flap is trimmed and a medicated gauze
pack is inserted for hemostasis and to
maintain the flap in a retracted position.
• The pack is placed firmly and slightly
overfilling the defect but should not put
pressure on the defect.

34. • If necessary, several sutures are tied over the
pack to maintain its position.
• The sutures should be removed 5–7 days after
surgery.
• The gauze pack should be replaced every 7–10
days.

36. Decortication
• surgical procedure that aims to encourage an
increased blood supply to bone from the
blood vessels of buccal periosteum
• The buccal mucoperiosteal flap is reflected to
the inferior border of mandible
• The lateral cortical plate is removed to form a
window.
• If loose teeth are presented, they should be
removed.

37. • The lateral cortical plate and a portion of the
inferior cortical plate are removed
• debridement of the bone bed should be
performed thoroughly.
• Any bleeding areas should be included in the
margin of the uninvolved area.

38. • The flap is primarily closed, and use of a
pressure bandage or insertion of a tube drain
is employed to eliminate dead space.
• An additional blood supply to the exposed
bony tissue from the periosteum side is
expected and may contribute to healing.

40. Resection and reconstruction
• Resection of infected areas
• Immediate or delayed reconstruction
• Considered if an involved area is extremely
extensive or less aggressive surgical
procedures have failed.

41. Continuous/ intermittent indwelling
catheter irrigation
• Employed after sequestrectomy, saucerization
or decortication
• 2 small pediatric nasogastric tubes or
catheters
• Placed against the bony bed through separate
skin incisions at some distance and secured
with sutures

42. • One tube connected to low pressure suction
to allow drainage of pus
• Another kept patent to provide a route
through which locally antibiotics may be
instilled in very high concentrations
• Daily, first normal saline followed by antibiotic
instillation

43. • Repeat until negative cultures are obtained
• Systemic antibiotics are continued for at least
2-3months following cessation of clinical
evidence of disease

44. Supportive care
• Patients should be hospitalized for any aggressive
surgery
• provided with intravenous antibiotic therapy and
managed for correct fluid balance and nutrition.
• As mentioned previously, the patient is likely to
have an underlying compromise of their host
defenses.
• The factors that may delay recovery should be
assessed and corrected.

45. Infantile osteomyelitis
• Occur few days after birth
• Commonly involves the maxilla
Etiology
• Remains unclear
• Thought to involve;
Perinatal trauma
Infection of the maxillary sinus
Hematogenous spread

46. • Disease could spread to involve the eye and
brain
• Potential risk for serious optic and cerebral
sequelae, facial deformities, serious damage
to jaw growth and loss of teeth.

47. Sign and symptoms
• Swelling of the face and eye lid
• Subperiosteal abscesses on the alveolar
mucosa and palate
• High fever
• Rapid pulse rate
• Vomiting delirium and postration

48. Treatment
• Prompt and aggrassive
• Use of intravenous antibiotics and drainage of
abscesses
• S. aureus is the most common pathogen
involved

49. NON SUPPURATIVE OSTEOMYELITIS
CHRONIC DIFFUSE SCLEROSING.
• Usually affects mandible
• Characterized by;
Recurrent pain and swelling
No suppuration or abscess formation
paraesthesia

50. Etiology
• Unclear
• Possibly due to;
Hyperactive immunologic response
hyperostosis

51. Radiography;
• Intermingled sclerotic and osteolytic lesion
with a solid periosteal reaction
• External bone resorption
Treatment
• Difficult to eradicate- may persist for years
• Asymptomatic; NSAIDs, corticosteroids

52. Garre’s sclerosing osteomyelitis
• Named after a Swiss surgeon, Dr Carl Garre
• Characterized by;
Active periosteum proliferation
Formation of subperiosteal bone
No purulent exudate

53. • Believed to result from over inflammatory
reaction of the periosteum
• Commonly in children and adults
• Usually on the lateral surface of body of
mandible

54. Etiology
• Periapical abscess
• Post extraction infection
Clinical features
• Localized, unilateral and hard mandibular
swelling with little tenderness
• Pain can be episodic
• No apparent systemic signs

55. Radiological findings
• Thickened cortical bone
• Onion skin appearance due to new bone
formation
Treatment
• Elimination of cause

56. Complications of osteomyelitis
• Neoplastic transformation; SCC, reported
incidence of 0.2 – 1.5%
• Deformation of the face
• Pathological fractures
• Progressive diffuse sclerosis
• Spreading infection; cellulitis, carvenous sinus
thrombosis, Ludwig angina, DIC

57. referrences
• Oral and maxillofacial surgery, L Andersson, KE
Kahnberg, MA Pogrel
• Textbook of Oral and Maxillofacial Surgery 3rd
ed, NA Malik