1. This document outlines a 10 point protocol for managing tuberculous osteomyelitis of the jaws. It includes procedures like aspiration/biopsy for smear and culture, various imaging tests, Mantoux testing, examining sputum and other samples, confirming the diagnosis, surgical treatment if needed, prescribing a standard 6 month antibiotic regimen, monitoring for side effects, and long term follow up to check for recurrence. 2. Key tests and procedures include aspiration or biopsy of the infected site for smear and culture, taking chest and jaw radiographs, scintigraphy, and computed tomography. Positive sputum, biopsy or other tests would confirm tuberculosis infection. 3. Treatment involves a 6 month course of

1. Management protocol for tuberculous osteomyelitis of jaws
10 point protocol for the management of tuberculous osteomyelitis of jaws
1) Aspiration for smear and culture studies
Smear tested For acid fast bacilli
Culture done on Lowenstein Jensen medium
2) RADIOGRAPHS
OPG
PA MANDIBLE
LATERAL OBLIQUE VIEW MANDIBLE; small well defined radiolucency in ascending ramus with
destruction of medial cortical plate or buccal cortical plate.
PA WATERS VIEW
CHEST RADIOGRAPH TO RULE OUT LUNG INVOLVEMENT
3) SCINTIGRAPHY
Metabolic changes within the bone
Hot spots on scan; increased activity
4) Computed tomography bone +soft tissue changes
5) Mantoux testing positive reaction:erythema & induration measuring 5-10 mm
Not confirmatory
6) Sputum for AFB early morning sputum, collected 3 consecutive days sent to lab for sputum & culture
Positive report :involvement of lungs or nasopharynx
Nasopharyngeal swab and scraping :positive :involved
7) BIOPSY
Incisional biopsy :for open cases
Aspiration: for closed cases
Smear and culture: tissue curreted from sinus tract& deeper tissues sent in normal saline
H/P EVALUATION: tissue send in 5% formaline to identify tuberculoma , early casseation, langhans giant
cells & lymphoid activity
Positive biopsy : tuberculous infection
8) Surgical treatment:
a)Closed lesions: usually no oral septic focus present
Aspirate positive for acid fast bacillus: antikoch regimen started .review after 6-8 months clinically
&radiographically to evaluate the need for surgical debridement.
Aspirate negative for acid fast bacillus: incisional biopsy not indicated.
Complete excisional biopsy and debridement of tissue done.tissue sent for H/P .Positive for tuberculosis:
start on antikoch therapy.
b) open lesions:
a biopsy of tissue from sinus tract & deeper tissues sent for H/P studies.
Positive study: antiokoch treatment started, no surgery performed immediately to prevent spread of
military T.B.
Reassess after 6-8 weeks clinically and radiographically to decide upon need for surgery
9) Antikoch treatment:
Six months regimen with four drugs advised.
Intensive tx: First four months:isoniazid, rifampicin, ethambutol, pyrazinamide.
Continuation phase: isoniazid and rifampicin given for next 4 months.
Ciprofloxacin added to the above regimen because known to be extremely effective in bone TB.
High protein ,high carb diet.
Anti tb drugs hepatotoxic:LFT done every six weeks.

2. 10) Long term follow up :
Ensure patient compliance in taking drugs
Monitor patient both clinically and R/G
FOLLOW UP for recurrence.