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  2. 2. DEFINITION• The word “osteomyelitis” originates from the ancient Greek words osteon (bone) and muelinos (marrow)• Inflammation process of the entire bone including the cortex and the periosteum, recognizing that the pathological process is rarely confined to the endosteum.
  3. 3. PREDISPOSING FACTORS• Fractures due to trauma and road traffic accidents• Gun shot wounds• Radiation damage• Paget`s disease• Osteoporosis• Systemic disease : Malnutrition, Acute Leukemia, Uncontrolled diabetes, sickle cell anemia, Chronic alcoholism
  5. 5. Classification based on clinicalpicture, pathology, etiology andradiology:The two major groups:•Acute•Chronic
  6. 6. Acute suppurative osteomyelitisChronic suppurative osteomyelitis Chronic focal sclerosing osteomyelitis (pseudo-paget,condensing osteomyelitis) Chronic diffuse sclerosing osteomyelitisChronic osteomyelitis with proliferative periostitis(Garres chronic nonsuppurative sclerosing osteitis,ossifying periostitis) Specific osteomyelitis:1. Tuberculosis osteomyelitis2. Syphilitic osteomyelitis3. Actinomycotic osteomyelitis
  7. 7. The Zurich classification of osteomyelitis of the jaws Acute Secondary Chronic Primary Chronic Osteomyelitis Osteomyelitis Osteomyelitis • Neonatal, tooth germ •Early onset associated (juvenile chronic • Trauma/fracture related osteomyelitis) • Odontogenic • Adult onset • Foreign body, • Syndrome associated transplant/implant induced • Associated with bone pathology and/ or systemic disease
  8. 8. I. Suppurative osteomyelitis:1. Acute suppurative osteomyelitis2. Chronic suppurative osteomyelitisII. Nonsuppurative osteomyelitis1. Chronic focal sclerosing osteomyelitis2. Chronic diffuse sclerosing osteomyelitis3. Garres chronic sclerosing osteomyelitis(proliferative osteomyelitis)III. Osteoradionecrosis /Radio osteomyelitis
  10. 10. (I) INTRODUCTION• Serious sequela of periapical infection that often results in diffuse spread of infection throughout the medullary spaces , with subsequent necrosis of variable amount of bone.• Poly microbial• Most common cause : Dental infection• Other causes : Infection due to fracture of jaw, gun shot, or hematogenous spread
  11. 11. (II) CLINICAL FEATURES• Maxilla : localized ; Mandible : Diffuse and widespread• Sever pain• Trismus• Parasthesia of lips in case of mandibular involvement• Elevation of temperature• Regional lymphadenopathy• Loosening of teeth and exudation of pus from gingiva• No swelling and redness till periostitis develops
  12. 12. (III) ROENTGENOGRAPHIC FEATURES• Roentgenographic evidence of its presence until the disease has developed for atleast one to two weeks• Trabeculae becomes fuzzy and indistinct• Ill defined margins• MOTH EATEN APPEARANCE
  13. 13. Raggedness of inferior border
  14. 14. (IV) PATHOLOGY Spread of Thrombosis Lifting of Acute exudate Liquefaction periosteuminflammation of vessels Necrosis along the of necrotic causing of marrow due to of bone marrow tissues further tissues spaces compression necrosisFinally ,Osteoclastic activity >>> SEQUESTRUM
  15. 15. (V) HISTOLOGIC FEATURES• The inflammatory cells are chiefly neutrophilic polymorphonuclear leukocytes but may show occasional lymphocytes and plasma cells• Osteoblasts bordering the bony trabeculae are destroyed• Trabeculae may lose their viability and begin to undergo slow resorption
  16. 16. (VI) TREATMENT AND PROGNOSIS• 3D >> Debridement , Drainage and Drugs [Anti- microbial]• Sequestrum >> If small, exfoliates through mucosa >> If large, surgical removal• Involucrum : When Sequestrum is surrounded by new living bone• Untreated cases may proceed to development of periostitis , soft tissue abscess or cellulitis
  19. 19. CHRONIC SUPPURATIVE OSTEOMYELITIS• Inadequately treated acute osteomyelitis• Clinical features similar to acute forms but milder• Acute exacerbations of chronic stage may occur• Fistulous tract may form which open to surface
  20. 20. Chronic osteomyelitis of the left mandible(a)Extraoral fistula and scar formation(b) large exposure of infected bone and sequestra(c) Large sequester collected from surgery
  21. 21. CHRONIC FOCAL SCLEROSING OSTEOMYELITIS ( CONDENSING OSTEITIS)• Unusual reaction of bone to infection• High degree of tissue reaction and tissue reactivity
  22. 22. (I) FEATURES OF CONDENSING OSTEITIS• Commonly affects young adults and children• Mandibular molar is affected commonly• Symptoms : mild pain due to infected pulp• Tissues reacts to the infection by proliferation rather than destruction , since the infection acts as a stimulus rather than a irritant• Treatment : Extraction or endodontic treatment
  23. 23. (II) ROENTGENOGRAPHIC FEATURES• Pathognomic ,well circumscribed radiopaque mass of sclerotic bone surrounding and extending below the apex of one or both roots• PDL space widening {violet arrow mark} (distinguishes from cementoblastoma)
  24. 24. (III) HISTOLOGIC FEATURES• Dense bony trabeculae with little interstitial marrow tissue• Many reversal and resting lines giving pagetoid appearance• If interstitial soft tissue is present , it is generally fibrotic and infiltrated with small amount of lymphocytes• Osteocystic lacunae appears empty
  25. 25. Residual chronic focal sclerosing osteomyelitis ( BONE SCAR)
  26. 26. CHRONIC DIFFUSE SCLEROSING OSTEOMYELITIS• In contrast to focal type , it may occur at any age group , no gender predominance• Common in edentulous mandible• Insidious in nature , no clinical indications of its presence• Acute exacerbation can result in : vague pain , unpleasant taste , mild suppuration , many times drainage through fistulous tract
  27. 27. (I)ROENTGENOGRAPHIC FEATURES• Cotton wool appearance• Indistinct borders because of its diffuse nature• Mimic Pagets disease or fibro osseous proliferation
  28. 28. (II) HISTOLOGIC FEATURES• Dense , irregular trabeculae of bone bordered by active layer of Osteoblasts ; focal Osteoclastic area may be present• Mosaic pattern appearance• Interstitial soft tissue is fibrotic• Proliferating fibroblasts and occasional small capillaries as well as small focal collection of lymphocytes and plasma cells• Burned – out appearance leaving only sclerotic bone and fibrosis
  29. 29. (III) TREATMENT AND PROGNOSIS• Lesion is too extensive to be removed surgically• Sclerotic bone is hypovascular and resistant to antibiotics• Bell has recommended extraction of tooth as a last option utilizing a surgical approach with removal of liberal amounts of bone to facilitate extraction and increase bleeding.• Antibiotic administration during acute exacerbation may help
  30. 30. SCLEROTIC CEMENTAL MASSES• Multiple symmetric lesions producing pain, drainage or localized expansion• Common in black females• Roentgenographic features similar to chronic diffuse type
  31. 31. HISTOLOGIC FEATURES• Cemental masses have tissues interrupted by the cementum unlike diffuse type which mostly have sclerotic bone• In some instances ,the cementum is in the form of large solid masses with smooth, lobulated margins often with a globular accretion pattern• Only significant difference was in microscopic appearance which is radiopaque lesional tissue in cemental masses
  32. 32. CHRONIC OSTEOMYELITIS WITH PROLIFERATIVE PERIOSTITIS [Garre`s chronic nonsuppurative sclerosing osteitis periostitis ossificans]
  33. 33. (I) INTRODUCTION• Distinctive type of chronic osteomyelitis in which there is focal gross thickening of the periosteum , with peripheral reactive bone formation resulting from mild reaction or infection• Periostel osteosclerosis analogous to endosteal osteosclerosis in chronic focal and diffuse sclerosing types
  34. 34. (II) CLINICAL FEATURES• Common : Children and young adults; Mandible ; especially in bicuspids and molars• Toothache or pain in the jaws• Bony hard swelling on the outer surface of jaw , which may last for several weeks• May develop only due to dental infection but also from soft tissue infection or cellulitis
  35. 35. (III) ROENTGENOGRAPHIC FEATURES• ONION PEEL APPEARANCE : Focal overgrowth of bone on the outer surface of cortex ,which may be described as duplication of the cortical layer of bone (Image B)• IOPA often reveals a carious tooth opposite to bony hard mass• This mass of bone is smooth rather well calcified which itself shows a thin but definite cortical layer
  36. 36. A .Intense periosteal B. One year after extractionreaction in first molar ; Remodeling occurs
  37. 37. (III) HISTOLOGIC FEATURES• Supracortical but subperiosteal mass is composed of much reactive new bone and osteoid tissue , with Osteoblasts bordering many of trabeculae• Trabeculae is perpendicular to cortex and parallel to each other• Connective tissue is fibrous and shows sprinkling of lymphocytes and plasma cells
  38. 38. (III) TREATMENT AND PROGNOSIS• Extraction or endodontic treatment of the teeth• No surgical intervention except biopsy to confirm diagnosis• After extraction the jaws undergo remodeling and facial symmetry is restored• Neoperiostitis or new periosteum formation may occur in certain conditions.