A detailed description of the disease osteomyelitis of jaw, the etiopathogenesis, classification and management

1. We mostly don't get sick. Most often,
bacteria are keeping us well
-bonnie bassler

2. OSTEOMYELITIS

3.  Introduction
 Pathogenesis
 Microbiology
 Classification
 Clinical presentation
 Radiographic features
 Treatment options
 Medical management
 Surgical management
 Recent advances
 Conclusion

4. • Osteomyelitis is defined as an inflammation of the bone marrow with a
tendency to progression, involving the cortical plates and often
periosteal tissues
Dent Clin N Am 61 (2017) 271–282

5. • Occurs after Odontogenic infection, trauma,
• infection derived from periostitis after gingival ulceration,
lymphnodes infected with furuncles, hemtogeneous origin
• Most common in tooth bearing area
• Hematogenous origin is rare and primarily occurs in young
children
• High mortality rate in pre antibiotic era
Topazian – osteomyelitis of jaw p 215

6. • It became a less common disease with the advent of antibiotics
• In recent years, re-emergence of disease due to less effectiveness of
antibiotics – major source of morbidity
• Incidence is higher in mandible – dense cortical bone, end arterial
blood supply
• Infantile osteomyelitis – trauma and infection during birth
Dent Clin N Am 61 (2017) 271–282

7. • Diminished host defense
• Systemic diseases like diabetes, autoimmune states, Acute Leukemia,
malignancies, malnutrition, sickle cell anemia, agranulocytosis and
AIDS
• Medications like steroids, chemotheraputic agents, bisphosphonates.
• Additional factors include noncompliant patients who are refractory to
health care delivery, patient age, nutritional status,
immunosuppression, microvascular disease, and inaccessibility to
health care.
• Local conditions which affects blood supply like radiation therapy,
osteopetrosis
Dent Clin N Am 61 (2017) 271–282

9. Inoculation of bacteria into jaw bone
(extraction of teeth, RCT, Trauma)
Bacteria induced acute inflammation
Pus formation in the bone marrow
Increased intramedullary pressure
Vascular collapse, stasis ischemia of bone
Pus perforated through medullary and cortical bone
& collect under periosteum
Compromised periosteal blood supply
Avascular infected bone,Aggravated local condition
Pus exit through intra oral /extra oral fistula
Oral and maxillofacial infection, Topazian 2nd edition p-216

10. (E)Sequestrum – necrotic
bone
(C) Involucrun – viable new
bone
(D) Cloacae

11. • S aureus is the most common pathogenic organism recovered from
bone earlier
• Recently streptococcus, gram negative and anerobic bacteria
 Mostly mixed infection - streptococci, Eikenella, Staphylococcus,
Actinomyces, Bacteroides, Klebsiella, Fusobacterium, Lactobacillus,
and Haemophilus
 Staphylococcus is found if the exist is out through the skin
• M.tuberculae
• Actinomyces
Baur DA, Altay MA, Flores-Hidalgo A, et al. Chronic osteomyelitis of the mandible: diagnosis and
management - an institution’s experience over 7 years. J Oral Maxillofac Surg 2014;73:655–65.

12.  Hudson classified it into Acute and chronic
i) Acute osteomyelitis (<1 month)
a) Suppurative /non suppurative
b) Progressive
c) hematogeneous
 ii) Chronic Osteomyelitis (> 1month)
a) primary chronic osteomyelitis
b) Garre’s Osteomyelitis
c) Suppurative or non suppurative
d) Sclerosing - Focal /generalized
Peterson’s principle of oral and maxillofacial surgery 2nd ed p 314

13. • Acute osteomyelitis – progression from days to a few weeks
• Pain - deep and boring pain
• Swelling & erythema of overlying tissues
• Lymphadenopathy
• Fever – occurs acute case , rare in chronic condition
• Paresthesia of IAN– classical sign , compression on IAN due to
inflammatory process in the medulla.
• Trismus – due to inflammation of masticatory muscles
• Malaise
• Leukocytosis - common in acute phase. Rare in chronic case

14.  Chronic osteomye litis is a relapsing and persistent
infection spanning months to years with characteristic low-
grade inflammation.
• Complications - pathologic fracture or nerve deficits
Gaetti-Jardim E. Microbiota associated with infections of the jaws. Int J Dent
2012;2012:1–8.

15.  It is a chronic non suppurative osteomyelitis
occurs in children and adolesents exclusively
in mandible
 Non odontogenic origin
 Recurrent episodes of pain trismus, swelling,
local induration, lymphadenopathy and
hypoesthesia of IAN.
 Radiographs shows patchy osteosclerosis,
osteolysis and rarely periosteal reaction.
J Oral Maxillofac Surg 66:2073-2085, 2008

16. • Bone Pain and swelling were the most common 2 to 39 months.
• Draining sinus
• Enlarged regional lymph nodes
• Not responding to antibiotics and NSAIDs
• positive tuberculin test/PCR test
• ATT is the mainstay of treatment along with surgical curettage

17.  Fungal osteomyelitis is usually seen in immunocompromised patients
 Aspergillus species has played an important role in the morbidity and
mortality of immunocompromised hosts.
 Amphotericin B is the most commonly used drug to treat Aspergillus
osteomyelitis, followed by itraconazole and voriconazole.
Gabrielli E, Fothergill AW, Sutton DA, et al. Osteomyelitis caused by Aspergillus
Species: a review of 310 cases. Clin Microbiol Infect 2013;20:559–62.

18.  It is a chronic slow progressive infection with both granulomatous and
suppurative features.
 Affects soft tissue and bone
 Clinical features: frim , soft tissue mass, purplish, draiange of serous fluid
with yellowish granular material, dense bone and scaring of soft tissue –
LUMPY JAW.
 Radiolucencies of varying size and periostitis
 Diagnosis based on clinical and culture specimen
 Long term antibiotic therapy- IV 4-6 weeks, oral – 6-12 months
Oral and maxillofacial infection Topazian 2nd ed p234

19. • Radiographic evidence require atleast 4-14days
• 30%-60% of cortical bone loss is required to be evident in
Radiograph
• Moth eaten appearance – classically present in chronic
cases
sequestra
Involucrum

20. • In chronic osteomyelitis with proliferative
periostitis (Garres osteomyelitis ) there is
focal gross thickening of the periosteum , with
peripheral reactive bone formation.
• In focal sclerosing osteomyelitis there is
radioopacity surrounding the root with intact
or widening of PDL space
Intact PDL space

21. CT
• Computed tomography – standard Imaging for
Max fax pathologies
• CT provides excellent multiplanar
reconstructions of the axial images allowing
delineation of even the most subtle osseous
changes
• Sequestra, as on conventional films is shown
as area of dense or high attenuation spicules
of bone lying in areas of osteolysis.

22. MRI
• Highly sensitive for detecting early as 3 to 5 days
after the onset of infection
• , changes in bone and soft tissue oedema may be
identified early, as well as ischemia and
destruction marrow. Prior to the involvement of
cortex

23. Nuclear imaging
• Useful in determining the presence of reactive bone
• Changes are seen as early as 3 days after the onset of symptoms
• Positive Technetium 99 is useful in diagnosis of acute osteomyelitis.
• Gallium 67, Indium 11 as a contrast agent differentiate infection from
trauma as they bind specifically with WBC
• Osteomyelitis appears as hot spot in nuclear imaging.

24.  Diagnosing the condition correctly is the most crucial and first step for the
treatment.
 Malignances can mimic the presentation of osteomyelitis - should be DD
until proven
 Principles of treatment:
• Evaluation and correction of host defence deficiency
• Gram staining , culture and sensitivity, Histopathological examination
• Imaging to rule out tumour
• Administration of stain guided empirical antibiotic , nutritional supplements
• Removal of loose tooth and sequestra
• Administration of culture guided antibiotic – iv followed by oral
• Local wound irrigation and local antibiotic
• Surgical procedures

25. Medical
• Empiric antibiotic
treatment
• Patient specific
antibiotic therapy
• Local drug delivery
• Improvement of
vascularity
Surgical
• Debridement
• saucerisation
• decortication
• Resection and
reconstruction

26. Medical Management
Traditionally, antibiotic treatment of osteomyelitis consists of a 4- to 6-week
course.
Empirical antibiotic therapy
Regimen 1:
Aqueous penicillin G 3-4 million IV 4 hrly, metronidazole 500 mg 6hrly
When improved in 48-72 hrs – penicillin V 500mg 4 hrly, metronidazole 500mg 6hrly
PO 4-6 wks
Or Ampicillin /sulbactum 1.5-3 g IV 6hrly when improved – augmentin 875/125mg PO
BD – 4-6 wks
Regimen 2:
Penicillin V 2g, metronidazole 500mg PO 8hrly 2-4wks
Or clindamycin 600-900 mg IV 6hrly then Clindamycin 300-450 mg 6hrly PO
Or Cefoxitin 1g 8hrly IV then cephalexin 500 mg 6hrly PO 2-4 wks

27. Culture specific antibiotics
Culture-directed antibiotic therapy helps avoid multidrug resistance and ensures
a
more favorable outcome .
Culture and sensitivity at regular interval
• Acute osteomyelitis is primarily managed medically with antibiotics, with the
antibiotic of choice clindamycin, because of its effectiveness against
streptococci. Patients may require hospital admission for intravenous (IV)
antibiotics.
• Clindamycin is given orally after initial intravenous treatment for 1-2 weeks and
has excellent bioavailability.
• It is active against most gram-positive bacteria, including staphylococci.

28.  Oral antibiotics that have been proven to be effective include
rifampin ,trimethoprim-sulfamethoxazole, and fluoroquinolones .
 Linezolid for MRSA, VANCOMYCIN RESISTANT Enterococcus.
 The duration of antibiotic therapy has been reported with varying
recommendations from 4 weeks to 8 weeks or even longer for
chronic osteomyelitis.
 Inadequately treated acute form progress to sub acute or chronic
osteomyelitis

29. • Gentamycin or tobramycin impergnated PMMA beads are available
• Placement are often performed at time of initial debridement
• Aside from the possibility of persistent drainage at the wound site, local
antibiotic therapy with beads
• increased concentrations of antibiotics in the tissues
• decreases the risk of complications of systemic
• antibiotic therapy ,
• obliterate dead space
Local Antibiotic Therapy in Osteomyelitis Semin Plast Surg. 2009 May; 23(2): 100–107

30. 
The irrigation solution is composed of 800 cc normal
saline, 200 cc wetting agent with mcolytic property and any two antibiotics
according to the sensitivity and irrigation to be continued for the
three weeks following the removal of the irrigation tubes.

31. •Sequestrectomy is the unroofing of the bone for thorough debridement
• Saucerization is useful in chronic osteomyelitis
as it permits removal of formed and forming sequestra
The defect is packed open for secondary healing
.
Oral and maxillofacial infection Topazian 2nd ed p 225

32.  Decortication:
• It is the removal of chronically infected cortex.
• The lateral and inferior border cortex is removed 1-2cm beyond the affected
area
• Indicated in case of primary and secondary chronic osteomyelitis

Oral and maxillofacial infection Topazian 2nd ed p 225

33.  indicated in case of low grade, persistent chronic osteomyelitis,
• pathologic fracture
• Persistent infection after decortication
• Involvement of both the cortex
• Using extra oral approach, bone is debrided until bleeding surface are
encountered distally and proximally.
• Reconstruction by block graft.
Oral and maxillofacial infection Topazian 2nd ed p 226

35. • HBOT consists of breathing 100% of oxygen at 2.4 ATM for 90
minutes – one dive
• 5 days per week -30 to 100 dives
• Increased arterial and venous oxygen tension
• Oxygen is carried in physical solution n plasma
• Enhance healing by direct bacteriostatic effect and phagocytosis
• Induce neo-angiogenesis, fibroblastic proliferation and collagen
synthesis
 The widespread use of HBO treatment of osteomyelitis still
remains controversial.

36.  LIMITATIONS:
• Oxygen toxicity
• Seizure
• High pressure nervous syndrome
• Decompression sickness
• Pneumothorax
• Arterial gas embolism
• Tooth and sinus pain
• Optic distress and immunosuppressive disorder – absolute contraindication
• Claustrophobia, COPD – relative contraindication

37. • Systemic antibiotics -10 days to 2 weeks
• Dehydration –I.V. fluids with added vitamins
• High protein diet
• Immobilization of jaw –maxillo-mandibular fixation or a Barton
bandage –for several weeks
• Rubber catheter-normal saline irrigation every 3-4 hrs
• Adjunctive hyperbaric oxygen therapy can promote collagen
production, angiogenesis, and healing in an ischemic or infected wound

38. • Inadequate therapy may lead to relapsing infection and progression to
chronic infection.
• Because of the avascularity of bone, chronic osteomyelitis is curable
only with radical resection or amputation.
• These chronic infections may recur as acute exacerbations, which can
be suppressed by debridement followed by parenteral and oral
antimicrobial therapy.
• Rare complications of bone infection include pathologic fractures,
secondary amyloidosis, and squamous cell carcinoma at the sinus tract
cutaneous orifice, Growth retardation.

39.  Need long term treatment and follow-up

40.  Osteomyelitis, although uncommon, continues to be seen and treated
by dentists and oral and maxillofacial surgeons.
 Complete therapy involves both medical and surgical approaches in
an effort to achieve total care.
 Culture-driven antibiotics are critical in the treatment of
osteomyelitis, and knowledge of microbiological agents is essential.

41. Thank you….