osteomyelitis presentation for dental medicine

OSTEOMYELITIS
Dr. Demerew D.(MAXILLOFACIAL SURGEON 1

Outline
Definition
Pathogenesis
Classifications
Etiologies and predisposing factors
Managements

Osteomyelitis
 Definition
The words, “osseus” in Latin means bony, and
“osteon” in Greek means ‘‘bone’’, and “myelos”
means marrow; and “itis” in Greek means
inflammation.
 OML may be defined as an inflammatory condition of
bone, that begins as an infection of medullary cavity
and haversian systems of the cortex and extends to
involve the periosteum of the affected area.

Cont.
The inflammation may be acute, subacute or
chronic.
It may be localized; or may involve a larger
portion of bone.
It may be suppurative or nonsuppurative.

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

ETIOLOGIES
i. Odontogenic infections
ii. Local traumatic injuries
iii. Infections from orofacial region
iv. Hematogenous infections

Microbiology
 Most of the cases are caused by aerobic streptococci (α-
hemolytic streptococci, Streptococcus viridans), anaerobic
streptococci; and other anaerobes, such as Peptost
reptococci, Fusobacteria, and Bacteroides.
 Sometimes, anaerobic or microaerophilic cocci, Gram negative
organisms such as Klebsiella, Pseudomonas and Proteus are
also found.
 Other organisms such as M. tuberculosis, T. pallidum, and
Actinomyces species produce their respective specific forms
of OML.

classification
• Due to the long standing existence of OML as
a clinical entity, a variety of classifications of
this disease process have evolved.
Based on clinical course(duration)
Based on clinical features(presence or absence
of suppuration)

1. Based on clinical course
Based on clinical course:
(A) Acute, and (B) Chronic.
• The arbitrary time limit, to identify acute from
chronic forms, is of one month.

Cont.

2. Classification based on presence or absence of suppuration

ACUTE SUPPURATIVE
OSTEOMYELITIS

ACUTE SUPPURATIVE
OSTEOMYELITIS
• Suppurative osteomyelitis is the dominant
form of the disease, which is primarily
characterized by the production of pus and
necrosis of bony tissues.
• 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.

INTRODUCTION
• Microbiology:- Poly microbial in origin
• Most common cause : Dental infection
• Other causes : Infection due to fracture of jaw,
gun shot, or hematogenous spread

PATHOGENESIS
Acute
inflammation
of marrow
tissues
Spread of
exudate
along the
marrow
spaces
Thrombosis
of vessels
due to
compression
Necrosis
of bone
Liquefaction
of necrotic
tissues
Lifting of
periosteum
causing
further
necrosis
Finally ,Osteoclastic activity >>> SEQUESTRUM

Cont.
 As natural host defenses and therapy begin to be effective,
the process may become chronic, inflammation regresses,
granulation tissue is formed; new blood vessels cause lysis of
bone, thus separating fragments of necrotic bone
(sequestrum) from viable bone.
 Small sections of bone may be completely lyzed, whereas
larger ones may be isolated by a bed of granulation tissue
encased in a sheath of new bone (Involucrum).
 Subperiosteal new bone, the involucrum, can be seen as a fine
linear opacity, or as a series of laminated opacities, like an
onion skin, parallel to surface of cortex.

Cont.
Sequestra, may be revascularized, remain
quiescent, or continue to be chronically
infected and require surgical removal.
Occasionally, involucrum gets penetrated by
channels, known as cloacae, through which
pus escapes from sequestrum to an epithelial
surface.

CLINICAL FEATURES
• Almost all occurs in mandible. why?
• Deep seated severe pain
• Trismus
• Parasthesia of lips in case of mandibular involvement
• Elevation of temperature
• Regional lymphadenopathy, chills and malaise
• Loosening of teeth and exudation of pus from gingiva

Cont.
• Facial cellulitis, or indurated swelling
• Purulent discharge through sinuses.
• Fetid odor
• Laboratory?

RADIOGRAPHIC FEATURES
• No radiographic evidence of its presence until the
disease has developed for at least one to two
weeks(at least 30-60% loss of mineralized portion of
bone)
• MOTH EATEN APPEARANCE
• CT SCAN?
• Radio isotope studies
• PET scan

TREATMENT
• Extraction of offending tooth
• Debridement and irrigation
• Rehydration
• Treatment of underlying medical
comorbidities
• Antibiotic of several weeks depending on
severity and host status

CHRONIC SUPPURATIVE
OSTEOMYELITIS
• Chronic suppurative osteomyelitis may be divided
into two subforms, a primary chronic form that
manifests with no acute episode and a secondary
chronic form, which involves a prolonged
inflammatory process
• Inadequately treated acute osteomyelitis
• Osteomyelitis greater than one month duration.
• Clinical features similar to acute forms but milder

clinical features
a. Pain and tenderness: the pain is minimal.
b. Loosening of teeth and tenderness.
c. Induration of overlying soft tissues.
d. Intraoral or extraoral draining fistulae.
e. Thickened or “wooden” character of bone.
f. Enlargement of mandible, because of
deposition of subperiosteal new bone.
g. Pathological fractures may occur.

Radiographic presentation
• The appearance of bony destruction (“moth-eaten”
appearance) and a fragment of necrotic bone,
(sequestrum) can be confirmed using a plain
radiograph.

Treatment
• IV antibiotic for several weeks, then Po
antibiotics and medical treatments
• Extraction of the offending tooth
• Sequestrectomy
• Saucerization
• Decortication
• Trephination
• Resection and Reconstruction

Defn
Saucerization: Excision of margins of necrotic bone
overlying a focus of osteomyelitis.
Trephination or fenestration is the creation of bony holes
or windows in the overlying cortical bone adjacent to the
infectious process for decompression of the medullary
compartment.
 Decortication: Removal of chronically infected lateral and
inferior cortical plates of bone 1 to 2 cm beyond the area of
involvement.
Resection and reconstruction is performed When
extensive portion of bone is involved.

Resection and reconstruction with
recon plate

CFSO OR 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

• well circumscribed
radiopaque mass of
sclerotic bone surrounding
and extending below the
apex of one or both roots
• PDL space widening

• In contrast to focal type , it may occur at any age
group , no gender predominance
• Common in edentulous mandible
• characterized by recurrent pain and swelling
• 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
CHRONIC DIFFUSE
SCLEROSING OSTEOMYELITIS

Etiology
• The etiology and pathogenesis of the disease
remain unclear.
Possible etiologies include
 hyperactive immunological responses
 chronic tendoperiostitis from muscle overuse

• Radiographic appearance of variable amounts of
bone deposition and diffuse sclerosis with ill defined
borders in the jaw
• Cotton wool appearance
• Indistinct borders because of its diffuse nature
• Mimic Paget's disease or fibro osseous
proliferation

• Lesion is too extensive to be removed
surgically.
• Sclerotic bone is hypovascular and resistant to
antibiotics.
• Extraction of associated tooth.
• Antibiotic administration during acute
exacerbation.
TREATMENT

Garre`s chronic nonsuppurative sclerosing
osteitis periostitis ossificans
• 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.

• 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
• Common clinical features include a localized, unilateral and
hard mandibular swelling with little tenderness
CLINICAL 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.
• IOPA often reveals a carious tooth opposite to bony
hard mass.

A .Intense periosteal
reaction in first molar
B. One year after extraction
; Remodeling occurs

DDx
• Ewing’s sarcoma,
• Osteosarcoma
• fibrous dysplasia
• cherubism
• syphilitic osteomyelitis
• healing fracture callus

• 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.
TREATMENT

Infantile osteomyelitis
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

Clinical features
 Pyrexia ,Anorexia ,Dehydration and Vomiting.
 Facial cellulites centered around the orbit .
 Palpebral edema, Conjunctivitis and Proptosis.
 Buccal or palatal swelling in maxillary molar
region.
 Fistulae in the alveolar mucosa .
 Convulsions.

management
• drainage of fluctuant areas
• Irrigation of sinus tracts
• Analgesics and Antipyretics
• Fluids
• Nutritious diet
• Sequestrectomy or removal of necrotic tooth
germs

Actinomycotic osteomyelitis of jaws
Definition:- It is the c/c infection manifesting
both granulomatous & suppurative features,
usually involves soft tissues & sometimes bone.
Types Cervicofacial ,Thoracic and Abdominal
Dr.Demerew D.(OMFS) 45

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 Granular material called sulphur granules
representing colonies of bacteria.
Enlarged regional lymph nodes
 Trismus and Pyrexia

Cont.
Radiologic features Radiolucent areas of
varying sizes.
investigation
 Management:- Incision & drainage
Parentral antibiotics for 3 to 4 months
Sequestrectomy & saucerization

Tuberculous osteomyelitis of jaw
It is a chronic infectious disease caused by
mycobacterium tuberculosis.
Clinical features
o The sites commonly involved are ramus &
body of mandible
o The age group is b/w 15 to 40 years
o There are 2 types of presentations closed &
open lesions

Cont.
A. 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.
B. Open lesions:- There is multiple sinuses with
mucopurulant discharge.
 Oral focus may or may not be present

Closed lesions

Open lesions

Cont.
 Diagnosis :-Aspiration & culture studies-done
in closed lesions.
-culture or biopsy in open lesions.
 Radiographically:- Closed lesions are seen as
small well defined radiolucency with
destruction of buccal or medial cortical plates.
 Management :-Antikoch’s therapy

Osteoradionecrosis
 Definition:-Osteoradionecrosis 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.

Incidence
• A key factor in ORN, particularly of the mandible
refers to trauma, especially tooth extraction.
• Extraction has been reported as the trigger for
ORN in 60 to 89 percent of cases.
• The time period between the RT and the
development of ORN has been reported as a
mean of 7. 5 years and up to 20 years.

pathophysiology
Marx, (1983) described its causes, as the ‘Three
H’ principle of irradiated tissue.
(i) Hypocellularity,
(ii) Hypovascularity of the irradiated tissues and
(iii) Hypoxia. This comprises of all the elements of
bone; including marrow and periosteum, as well as
the investing soft tissues.
2. Failure of osteoclastic activity.

mechanism
• Therapeutic doses of irradiation cause
endothelial death, thrombosis and
hyalinization of blood vessels.
• It is described as progressive obliterative
endarteritis, periarteritis, hyalinization; and
fibrosis, and thrombosis of vessels that leads
to a decreased microcirculation (ischemia and
reduction in viable osteocyte population)

Cont.
• Periosteum undergoes fibrosis, osteoblasts
and osteocytes are destroyed and marrow
spaces in bone become filled with fibrous
tissue.
• There is a decrease of cellularity of all tissues
and vascularity is markedly decreased.
• These changes lead to a measurable hypoxia
in irradiated tissues.

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
 Foetid odour .
 Pyrexia .
 Pathological fracture
 Radiological fetaures :-Radiolucent area with indefinite
nonsclerotic border or Radio-opacity usually associated with
sequestrum

Treatment
Debridement
Antibiotics and Analgesics
Hydration of the patient
High protien & vitamin diet
 Maintenance Of Good Oral hygiene-oral rinse
 Frequent irrigation of wounds
Sequestrectomy and Bone resection if there is
persistant infection or pathologic #
Hyperbaric o2 therapy

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.
 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

Dental care during radiation therapy
 Mouthwash 0.2% aqueous chlorhexidine
 Supervised cleaning of teeth
 Oral hygiene instructions with flouride tooth
paste, and flouride mouthwash

Post irradiation dental care
 Avoidance of denture for one year
 Maintenance of oral hygiene
 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

Assignment
• Bisphosphonate related osteonecrosis of jaw
• When should extraction have to be undergone?

REFERENCES
• Neelima Anil Malik, Textbook of Oral &
Maxillofacial Surgery- 3th edition :Jaypee
• Lars Andersson, Oral & Maxillofacial Surgery
1st edition:2010 Blackwell Publishing Ltd
• Peterson prinsiples of oral and maxillofacial
surgery 2nd edition

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osteomyelitis presentation for dental medicine

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