This document discusses osteomyelitis of the jaw, including its definition, etiology, classification, clinical features, microbiology, and management. It defines osteomyelitis as an inflammatory bone infection that begins in the medullary spaces and spreads to involve the periosteum. Common causes include odontogenic infections, trauma, infections of nearby regions, and hematogenous spread. The document classifies osteomyelitis and describes the features of acute suppurative, chronic suppurative, nonsuppurative, infantile, and other specific types. Treatment involves antibiotics, surgical drainage and debridement, hyperbaric oxygen therapy, and reconstruction in severe cases. Complications like necrosis and pathological fractures are also mentioned

1. Osteomyeltis of
jaw
Instructor – Dr. Jesus George
1

2. Definition
 It is an inflammatory condition of bone,
that begins as an infection of medullary
spaces and harvesian systems of the
cortex & extends to involve the
periosteum of the affected area.
2

3. Etiology
 1-Odontogenic infections-
 Infections originating from pulpal or
periodontal tissue
 Pericoronitis
 Infected socket
 Infected cyst
 Tumor
 2.trauma-
 Compound fracture
 Surgery
3

4. cont.
 3-Infections of orofacial regions
 Periostitis following gingival ulceration
 Lymph nodes infected from furuncles
 Lacerations
 Peritonsillar abscess
 4-Infection from hematogenous route
 Upper respiratory tract infection
 Middle ear infection
 Systemic TB
 Furuncle of face
 Wound on the skin
4

5. Microbiology
 Strep.Viridans
 Peptostreptococci
 Fusobacteria
 Bacteriodes
 Klebsiella
 Pseudomonas
 Mycobacterium tuberculosis
 Actinomyces
5

6. Classification
 Suppurative osteomyelitis
 A/c suppurative
 C/c suppurative
 Infantile
 Nonsuppurative osteomyelitis
 C/c sclerosing
○ Focal sclerosing
○ Diffuse sclerosing
 Garre`s Sclerosing Oml
6

7. CONT.
 Actinomycotic Oml
 Radiation Oml
 Specific Infective Oml
○ Tb
○ Syphilis
7

8. A/c suppurative Oml
 Microbiology
 Staph.Aureus
 Strep.Pyogenes
 Spirochetes
 E.Coli
 Etiology
 A-Odontogenic Infections
 Periapical Pathology Secondary To Pulpal
Disease
 Periodontal Disease
8

9. Cont.
 Pericoronitis
 Infected Odontogenic Cyst
 Infection Of Extraction Wound Or fracture
 B-Local traumatic injuries
 injuries to gingiva
 C-Peritonsillar abscess
 D-Furuncles of skin
 E-Infected compound odontome
9

10. Cont.
 F-Hematogenous infection
 From minor wounds in skin
 Infection of upper respiratory tract
 Infection of middle ear
 G-Compound # of jaws
10

11. Cont.
 Clinical features
 Fever
 Malaise
 Nausea
 Vomiting
 Anorexia
 Deep seated boring, continuous intense pain
 Paresthesia or anesthesia of lower lip
 Facial cellulitis
11

12. Cont.
 Indurated swelling
 Trismus
 Involved tooth is loose & tender to
percussion
 Purulent discharge through sinus
 Fetid odour
 Regional lymphadenopathy
12

13. c/c suppurative oml
 Clinical features
 Pain & tenderness
 Induration of soft tissues
 Intraoral or extraoral draining fistula
 Enlargement of mandible
 Pathologic #
 Teeth in the area becomes loose & sensitive
to percussion
13

14. Cont.
 Radiographic features
 In early stage there is widening of marrow
spaces giving a mottled appearance
 Granulation tissue b/w dead & living bone
gives irregular lines & zones of radiolucency
resulting in moth -eaten appearance.
 In later stages the devitalized bone appears
sclerosed & called sequestrum.
 Large areas of bone destruction seen as
radiolucent areas.
14

15. Cont.
 Subperiosteal new bone the involucrum
seen as linear opacity, or onion skin
appearance.
 Sequestra are separated from adjacent
bone by radiolucent areas.
15

16. Cont.
 Management
 Conservative management
 Complete bed rest
 Supportive therapy
 Nutritional support
 Hydration
 Oral
 I/v
16

17. Cont.
 Blood transfusion-if RBC & Hb is low
 Analgesics
 Antimicrobial agents-
 Regimen 1-
 Aqueous penicillin 2 million units IV every 4
hrs
 Oxacillin 1gm 4th hrly
 If the patient is asymptomatic for 48 to 72hrs
penicillin v orally 500mg 4th hrly with
cloxacillin 250mg orally 4th hrly for 2-4 weeks
17

18. Cont.
 Regimen 2
 Oxacillin
 Dicloxacillin
 In case of allergy to penicillin
○ Clindamycin 300-600mg orally 6th hrly
○ Cefazolin 500mg 8th hrly
○ Erythromycin 2gm 6th hrly i/v then 500mg 6th
hrly orally
18

19. Cont.
 Specific treatment for
 Anemia
 Diabetes mellitus
 Malnutrition
 Hyperbaric o2 therapy
 It involves intermittent, inhalation of 100%
humidified o2 under pressure greater than 1
atm
 It decreases hypoxic environment
 Bactericidal action
19

20. Cont.
 Exotoxins of micro organisms are rendered
inert by exposure to elevated pressure of 02
 It increases vascular supply
 It aids in healing draining sinus
 Improves osteogenesis
 Surgical management
 Incision & drainage
 It relieves pressure & pain caused by pus.
20

21. Cont.
 Reduces absorption of toxic products &
prevents further spread of infection
 It can be done by opening the pulp chamber
 It can also be done by making a fenestration
through cortical plate over the apical area
 In an edentulous area, make an incision
over the alveolar crest
 At the angle of mandible a small incision is
made over the point of greatest tenderness.
 Extraction of offending tooth
21

22. Cont.
 Debridement
 Followed by incision & drainage the area is
irrigated with H2O2 & saline.
 Any foreign body ,necrotic tissue or small
sequestrum is removed
 Decortication
 A buccal flap is created by the crestal
incision
 Mucoperiosteal flap is reflected
 Tooth in the involved area is removed
22

23. Cont.
 Chronically infected lateral & inferior cortical
plates of bone 1 to 2 cm beyond the area of
involvement is removed
 Bone is thoroughly debrided
 Flap is closed
 Sequestrectomy
 A preoperative radiograph is taken to decide
the site of incision
 Sequestrum usually lies on the surface of
bone & can be removed easily
23

24. Cont.
 If sequestrum is encased by involucrum ,a
window is made to take it out
 The granulation tissue around the sequestrum
is curetted until healthy bone is exposed.
Antibiotic therapy is continued for 2weeks
 Saucerization
 It is performed when removal of sequestrum
leaves a large cavity
 The buccal cortex is reduced to the level of
unattached mucosa producing a soccer like
defect
24

25. Cont.
 Trephination or fenestration
 Creation of bony holes or windows in the
cortical bone adjacent to the infectious
process for decompression of medullary
compartment.
 It allows vascular communication b/w
periosteum & medullary cavity.
 Resection
 When extensive portion of bone is involved
resection is performed
25

26. Ont.
 Reconstruction
 Iliac crest is the graft is used
 Stabilization is achieved with titanium or
vitallium mesh.
 Complications
 Neoplastic transformation
 Discontinuity defects
 Progressive diffuse sclerosis
26

27. Infantile oml
 It is seen in infants commonly occuring
in maxilla
 Etiology
 Trauma caused to oral mucosa during
delivery
 Infection of maxillary sinus
 Contaminated human or artificial nipples
 Infections from nose
 Hematogenous spread
27

28. Cont.
 Clinical features
 Pyrexia
 Anorexia
 Dehydration
 Convulsions
 Vomiting
 Facial cellulitis centered around the orbit
 Palpebral edema
28

29. Cont.
 Conjunctivitis
 Proptosis
 Buccal or palatal swelling in maxillary
molar region
 Presence of fluctuation for the sweeling
 Fistulae in the alveolar mucosa
 Microbiology
 Staph.Aureus
 Streptococci
29

30. Cont.
 Radiographic findings
 In later stages sequestra & necrotic
tooth germs
 Complications
 Permanent Optic Damage
 Neurologic Complications
 Loss Of Tooth Buds
30

31. Cont.
 Treatment
 Antibiotics-penicillins,flucloxacillin or
broad spectrum antibiotics
 Incision & drainage of fluctuant areas
 Irrigation of sinus tracts
 Analgesics
 Antipyretics
 Fluids
31

32. Cont.
 Nuritious diet
 Sequestrectomy or removal of necrotic
tooth germs
32

33. Garre`s sclerosing
osteomyelitis
 First described by carl garre
 There is peripheral subperiosteal bone
deposition caused by mild irritation
Etiology
 Carious tooth
 Overlying soft tissue infection
 Clinical features
 Usually involves mandible
33

34. Cont.
 Disease occurs in children & young
adults
 localized hard, nontender, bony swelling
of lateral & inferior aspects of mandible
 Radiologic features
 Focal area of well calcified bone & has
an onion skin appearance.
34

35. Cont.
 Treatment
 Removal of infected tooth & curettage of
the socket
 Surgical recontouring
 Endodontic therapy
 Antibiotics
35

36. C/c sclerosing oml
 Radiographically there are 2 forms
focal & diffuse
 Focal form
 Occures before the age of 20
 It is more common in mandible
 It is associated with infected pulp of
Lower molars & premolars
36

37. Cont.
 It appears as a circumscribed radio-
opaque mass of sclerotic bone
associated with the tooth roots
 Treated by extraction or endodontic
therapy
 Diffuse form
 It occures both in maxilla & mandible
 Pain & suppuration may be there
37

38. Cont.
 Radiologically it shows dense radio-
opaque mass
 Treated by debridement,antibiotic
therapy,alveolectomy & hyperbaric o2
therapy
38

39. Actinomycotic oml of jaws
 Definition
 It is the c/c infection manifesting both
granulomatous & suppurative
features,usually involves soft tissues &
sometimes bone.
 Types
 Cervicofacial
 Thoracic
 Abdominal
39

40. Cont.
 Clinical features
 Cervicofacial type usually involves
mandible, overlying soft tissues, parotid
gland, tongue & maxillary sinus
 Appears as soft or firm tissue mass on
skin that have a purple, dark red, oily
areas with small areas of fluctuation
 Spontaneous drainage of serous fluid
containing yellowish
40

41. Cont.
 Granular material called sulphur
granules representing colonies of
bacteria
 Enlarged regional lymph nodes
 Trismus
 Pyrexia
 Radiologic features
 Radiolucent areas of varying sizes
41

42. Cont.
 Management
 Incision & drainage
 Parentral antibiotics
 Penicillin 10 to 20 million units daily for 3 to
4 months
 If allergic to penicillin tetracycline 250mg 4
times daily for 8 to 16 weeks or
erythromycin 500mg 4 times daily for 6
months
 Sequestrectomy & saucerization
42

43. Tuberculous osteomyelitis
of jaw bones
 It is a c/c infection caused by
mycobacterium tuberculosis
Clinical features
 The sites commonly involved are ramus
& body of mandible
 The age group is b/w 15 to 40 years
 There are 2 types of presentations
closed & open lesions
43

44. Cont.
 Closed lesions
 Located centrally in bone.
 It presents as swelling & no draining
sinuses.
 There is absence of oral septic focus.
 Usually ramus of mandible is involved.
 Open lesions
 There is multiple sinuses with mucopurulant
discharge.
 Oral focus may or may not be present
44

45. Cont.
 Diagnosis
 Aspiration & culture studies-done in
closed lesions
 Radiographs
 OPG
 PA mandible
 Lateral oblique view of mandible.
 Closed lesions are seen as small well
defined radiolucency with destruction of
buccal or medial cortical plates
 45

46. Cont.
 Chest radiograph
 Mantaux testing-intradermal injection of
5 tuberculous units in 0.1ml solution of
purified protien derivativeis given using
a 27 guage needle.A positive reaction is
seen after 48hrs as erythema &
induration >5 to 10 mm.
 Sputum for AFB-early morning sputum
samples are collected on 3 consecutive
days
46

47. Cont.
 Biopsy-
 Incisional biopsy is done for open cases.
 Aspiration is done for closed cases
 Treatment
 Antikoch`s treatment-isoniazide,
rifampicin, ethambutol,pyrizinamide for
first 4 months
 Isoniazide, rifampicin for next 4 months
47

48. Osteoradionecrosis of
facial bones
 Definition
 Osteradionecrosis is an exposure of
non - viable , non - healing , non -
septic lesion in the irradiated bone ,
which fails to heal without intervention .
 It is a sequelae of irradiation induced
tissue injury , in which hypocellularity ,
hypovascularity & hypoxia are the
underlying causes .
48

49. Cont.
 Mechanism
Therapeutic doses of irradiation

Endothelial death, thrombosis &
hyalinsation of blood vessels .

Progressive obliterative endarteteritis
hyalinisation & fibrosis &
thrombosis of vessels
 49

50. Cont.
Decreased microcirculation

Osteoblasts & osteocytes are destroyed
& marrow spaces in bone become filled
with fibrous tissue .

Decrease of cellularity & vascularity

Hypoxia in irradiated tissue
50

51. Cont.
 Clinical features .
 Severe , deep , boring pain which may
continue for weeks or months .
 Swelling of face when infection develops
 Soft tissue abscesses & persistently
draining sinuses .
 Exposed bone ; in association with
intraoral or extraoral fistulae .
 Trismus .
51

52. Cont.
 Foetid odour .
 Pyrexia .
 Pathological fracture
 Radiological fratures .
 Radilucent area with indefinite
nonsclerotic border
 Radioopacity usually associated with
sequestrum
52

53. Cont.
 Treatment
 Debridement
 Antibiotics
 Hydration of the patient
 High protien & vitamin diet
 Analgesics
 Maintenance Of Good Oral hygiene-oral
rinse
53

54. Cont.
 Frequent irrigation of wounds
 Loose exposed dead bone is removed
 Sequestrectomy
 Bone resection if there is persistant
infection or pathologic #
 Hyperbaric o2 therapy
54

55. Cont.
 Prevention
 Preirradiation dental care
 Teeth in direct beam of radiation ,
nonrestorable teeth, teeth with
periodontal disease are extracted.
 Radiation therapy is delayed for 10 to 14
days after extraction.
 Prominent interdental septa,sharp
socket margins are trimmed
55

56. Cont.
 Unerupted, deeply buried teeth are left
in situ
 Restorable teeth are restored
 Periodontal therapy is done
 Oral Hygiene Instructions Are Given
 Topical Flouride 0.4% Stannous Flouride
Gel, or 1% acidulated flourophosphate
gel is applied for 15 min. twice a day for
2 weeks
56

57. Cont.
 Dental care during radiation therapy
 Mouthwash 0.2% aqueous chlorhexidine
 Supervised cleaning of teeth
 Oral hygiene instructions with flouride
tooth paste, flouride mouthwash
 Post irradiation dental care
 Avoidance of denture for one year
 Maintenance of oral hygiene
57

58. Cont.
 Saliva substitutes to reduce xerostomia
induced disorders
 Restoration of teeth with post -irradiation
Pulpitis
 Extraction should be the last resort.
 Teeth should be removed atraumatically.
 Sharp bony margins should be trimmed.
 Risk of ORN is is highest in 4to 12
months.
58