This document discusses osteomyelitis of the jaws, including predisposing factors, pathogenesis, classification, clinical presentation, radiographic features, and management. It notes that osteomyelitis typically occurs due to spread of an odontogenic infection or trauma. Predisposing factors include age, immunosuppression, drugs, local factors like osteoporosis, and malnutrition. Management involves both medical approaches like antibiotics and surgical approaches like incision and drainage, debridement, and sequestrectomy. The document also discusses a recent study finding that pentoxifylline and tocopherol used as an adjunct for more than 3 months can help increase bone density and decrease inflammation in osteomyelitis.

1. THE EFFECTS OF PENTOXIFYLLINE
AND TOCOPHEROL IN
OSTEOMYELITIS OF JAWS
Dr Saadia Siddique
Resident OMFS

2.  Osteomyelitis is an inflammation of bone marrow
involving the cortical plates, periosteal tissues and
the overlying soft tissues
 most cases occurring after trauma to bone or bone
surgery or secondary to vascular insufficiency.

3. PREDISPOSING FACTORS
 Patient’s Age
 Immunosupression - Diabetes mellitus
- Malignancy
- AIDS
 Drugs - Steroids
- Chemotherapeutic Agents
- Immunosuppresive agents
- Bisphosphonates
 Local Factors - osteoporosis
- Bone pathology
- radiation
 Malnutrition
 Auto immune diseases

4. PATHOGENESIS
 Osteomyelitis typically occurs as a result of spread of an
odontogenic infection or as a result of trauma.
 The presence of teeth provides a direct pathway to the
bone via pulpal or periodontal disease.
 The process begins with bacteria spreading to the jaw
bones, either through
i. extraction of teeth,
ii. root canal therapy,
iii. fracture of the jaw bones,
 resulting in a bacteria-induced inflammatory process.

5.  Inflammation  to hyperemia, increased blood flow,
and leukocytes to the affected area
 Pus is formed  intramedullary pressure is created
 decreases blood flow to jaw bones 
 Pus travels via the haversian system and Volkmann
canals  the medullary and cortical bones 
vascular collapse
 Pus perforates the cortical bone  collects under
the periosteum  periosteal blood supply
compromised 

7.  Osteoclastic activity is then responsible for
separating the dead bone from vital bone.
 The elevated periosteum involved in the
inflammatory process still contains vital cells
acute phase has passed, form a new bony shell
covering the sequester  involucrm
 The involucrum tends to hinder sequester from
extruding, which perpetuates the process because
the whole area is bathed in increasing amounts of
pus unless treated promptly and adequately

8. MORE COMMON IN MANDIBLE?
 Dense cortical plates
 Poorly vascularized cortical plates
 Vasculature originating from IANB
 affects most commonly the body of the mandible,
followed by the symphysis, angle, ascending
ramus, and condyle

9. CLASSIFICATION
 Supparative - Acute osteomyelitis
- Chronic osteomyelitis
- Infantile
 Non Supparative - Focal Sclerosing osteomyelitis
- Diffuse sclerosing osteomyelitis
- Garre’s osteomyelitis
- Actinomycotic
- tuberculous
- Syphilitic

10. CLASSIFICATION
 Spread - Haematogenous
- Contigious focus of infection
- peripheral vascular disease

12. ACUTE OSTEOMYELITIS
 involves progression from days to a few weeks
 Acute symptoms - pain and swelling
- Fever
- Cellulitis
- Trismus
 paresthesia or anesthesia of the lower lip is described
(Vincent’s symptom),
 Pus may extrude around the gingival sulcus and through
mucosal and cutaneous, fistulas
 It may take up to 10 days for bone loss to be
radiographically apparent.
 primarily managed medically with IV antibiotics
 Marx and Mercuri had set an arbitrary time limit of 4
weeks after onset of disease for acute phase.

13. CHRONIC OSTEOMYELITIS
 Chronic osteomyelitis is a persistent infection spanning
months to years with characteristic
 low-grade inflammation,
 a harder palpable tenderness caused by periosteal
reaction
 presence of dead bone,
 new bone apposition
 fistulas
 Nerve deficits, pathological fractures, mobile teeth in the
vicinity
 Antibiotics, nsaids and surgical management
 A/c to Marx et al, a persisting bone infection for more
than 4 weeks is considered as chronic osteomyelitis.

14. CHRONIC OSTEOMYELITIS

15. RADIOGRAPHIC FEATURES
 Radiographic changes occur only 3 weeks after
initiation of OML
 30-60% of mineralized portions of bone must be
destroyed before significant radiographic changes

16. EARLY STAGES
 Widening of marrow spaces and volkmann canals
 mottled appearance
 Granulation tissue b/w dead and living bone 
irregular lines of radiolucency  moth eaten
appearance
Mottled
appearance
Moth eaten
appearance

17. LATER STAGES
 Cortex gets involved  ischemia  an island of
cortical bone becomes devitalised 
 Resorption around infarcted area  separates it as
a sequestra
 Radiolucent area surrounding this sequestra is
Involucrum
 Large areas of bone destruction seen as irregular
radiolucencies

18. SEQUESTRA AND INVOLUCRUM

19. FOCAL SCLEROSING OSTEOMYELITIS
 The focal type, also known as condensing osteitis,
is a rather common condition with a
pathognomonic, well-circumscribed radioopaque
mass of sclerotic bone surrounding the apex of the
root.
 Since the infection in these cases is limited to the
apex of the root
 Treatment :
i. sufficient endodontic treatment with or without
apex surgery
ii. extraction of the affected tooth
 usually leads to regression of these lesions

20. FOCAL SCLEROSING OSTEOMYELITIS

21.  Sclerosis and fibrosis of the intramedullary space
 Chronic dull pain is always present
 The absence of pus, fistula, and sequestration are
characteristic.
 DSO radiographically by presenting sclerosing
opaque and dense masses
 Rx: antibiotics, debridement, hbo
DIFFUSE SCLEROSING OSTEOMYELITIS

22. GARRE’S OSTEOMYELITIS
 It is merely a periosteal inflammation leading to the
formation of an immature type of new bone outside
the normal cortical layer.
 Lifts the periosteum from cortex
 Usually effects children due to their increased
vascularity and regenerative capabilities
 Clinically painful expansion of bone on lower border
or buccal cortex of the mandible
 no pus or fistula
 onion skin appearance

23.  When new bone is superimposed on the jaw, a
delicate finger print or orange peel appearance is
seen.
 Removal of source
 Short course of antibiotic therapy
GARRE’S OSTEOMYELITIS

24. PRIMARY CHRONIC OSTEOMYELITIS
 It is characterized as a strictly nonsuppurative
chronic inflammation of the jawbone with the
absence of pus formation, extra- or intraoral fistula,
or sequestration
 also implies that the patient has never undergone
an appreciable acute phase
 periodic episodes of onset with varying intensity
last from a few days to several weeks and are
Intersected by periods of silence

25. EARLY ONSET
 describes cases with an onset in childhood or
adolescence
 more osteolytic findings and a greater periosteal
reaction in children and adolescents compared to
the cases in adult patients
 In active periods, the swelling and tenderness of
the jaw is more prominent due to a more extensive
periosteal reaction

26. ADULT ONSET
 describes cases with an onset of symptoms in the
adult patient
 chronic inflammation of the jawbone, excluding
signs of suppuration.
 Symptoms less prominent in adult cases

28. SYNDROME ASSOCIATED
 The term SAPHO syndrome describes a chronic
disorder that involves the skin, bones, and joints.
 SAPHO is an acronym that stands for morbid
alteration of the dermatoskeletal system
 synovitis;
 acne
 Pustulosis
 Hyperostosis
 Osteitis

29. MANAGEMENT GOALS
 Eradicate pathological organisms
 Promote healing
 Re establish vascular permeability

30. CONSERVATIVE MANAGEMENT
 Complete bed rest
 Supportive therapy
 Hydration
 Anti biotics
 Control of pain
 Hyperbaric oxygen

31. MEDICAL MANAGEMENT
 Patients should be optimized medically to achieve
the best response to antibiotic therapy.
 Tissues should be sent for Gram stain, culture,
sensitivity, and histopathology.
 Empiric antibiotics should be started based on
Gram stain because cultures and sensitivities may
take several days for a final report
 An infectious disease consultation may be of value
in selecting the most current antimicrobials

32. MEDICAL MANAGEMENT
 Penicillin remains the empiric antibiotic of choice.
 6-8 weeks for acute osteomyelitis - Amoxicillin
 6 months for chronic osteomyelitis - Clindamycin

33. HYPERBARIC OXYGEN
 30 or 60 dives at 2.4 atm for 90 minutes while
breathing 100% oxygen twice daily
 Increases oxygen in plasma and inturn delievered
to the tissues
 Reduces hypoxia
 Neo angiogenesis
 Free radicals are toxic to many pathogenic
anaerobics

34. HYPERBARIC OXYGEN

35. SURGICAL MANAGEMENT
 Extraction of offending tooth
 Incision and drainage
 Sequestrectomy
 Saucerization
 Decortication
 Resection of jaw

36. EXTRACTION OF OFFENDING TEETH
 Drainage is sometimes achieved by the extraction
of the offending tooth

37. INCISION AND DRAINAGE
Various methods employed for I & D are :
 Opening up the pulp chamber
 By making fenestration through cortical plate over
the apical area with a drill
 In posterior maxilla, by making an incision over the
alveolar crest
 OML at the angle of the mandible or ramus area,
drainage can be done by a small incision

38. DEBRIDEMENT
 Thorough debridement of the affected area should
be done
 The area maybe irrigated with hydrogen peroxide
and saline
 Any necrotic tissue or sequestra should be
removed

39. DECORTICATION
 Removal of chronically infected lateral and inferior
cortical plates of bone 1-2cm beyond the area of
involvement
 It is based on the principle that the involved cortical
bone is avascular and harbors microrganisms
where anti biotics cannot penetrate
 Thus an access is produced to medullary cavity
which improves the blood supply to the bone

40. DECORTICATION

41. SEQUESTRECTOMY
It helps in establishment of local microvascular
proliferation
Sequestra are usually cortical
Are not seen until 2 weeks after onset of infection
These are avascular and poorly penetrated by
antibiotics
Pathological fracture can also occur in this area due
to bone loss
Generally, the sequestra lies on the surface of the
bone can be removed easily with reflection of
mucoperiosteal flaps
If the sequestra is encased by the involucrm, a
window must be made to allow it to taken out

42. SEQUESTRECTOMY

43. SAUCERIZATION
 Excision of margins of necrotic bone overlying a
focus of OML
 It permits removal of already formed or forming
sequestra with better visualization
 It is performed when removal of sequestra leaves a
large defect
 Buccal cortex is reduced to the level of unattached
mucosa producing a saucer like defect

44. SAUCERIZATION

45. TREPHINATION/FENESTRATION
Creation of bony holes or windows in the overlying
cortical bone adjacent to the infectious process for
decompression of medullary spaces
This inturn allows vascular communication between
the periosteum and medullary cavity

46. RESECTION
 When extensive portion of the bone is involved in
the disease process, then resection of the jaw is
advocated

47. RECONSTRUCTION
After resection, reconstruction is advocated
 To maintain continuity of fragments
 To prevent pathological fracture
 To prevent facial deformity

48.  According to the recent article which was published
in Korea 2020, PTX and TC can be used as an
adjunctive treatment in osteomyelitis.
 Mi Hun Seo et al emphasized on using the
combination of PTX and tocopherol for more than 3
months
 He observed that the
i. bone density got increased
ii. Inflammation decreased (TNF-a and TGF-b)
iii. Bone exposure reduced
PENTOXIFYLLINE AND TOCOPHEROL AS AN
ADJUNCTIVE TREATMENT

49. CONCLUSION
 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.
 Many authors stress that early and aggressive
intervention is associated with more predictable
outcome.
 It will limit the need for surgical intervention and that
appropriate antibiotic alone might be sufficient

50. REFERENCES
 Mi Hyun Seo, Mi Young Eo, Hoon Myoung, Soung
Min Kim, Jong Ho Lee Department of Oral and
Maxillofacial Surgery, School of Dentistry and
Dental Research Institute, Seoul National
University, Seoul, Korea
 Marc Baltensperger and Gerold Eyrich,
Osteomyelitis of the Jaws Definition and
Classification
 Textbook of oral and maxillofacial surgery Neelima
malik 4th edition

51. THANK YOU