Post on 10-Feb-2021
Osteomyelitis and
osteoradionecrosis of jaw DR PRAJESH DUBEY
DEPARTMENT OF ORAL AND MAXILLOFACIAL SURGERY
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
Content
Osteomyelitis
Incidence
Factors predisposing osteomyelitis
Etiology
Pathogenesis
Microbiology
Classifications
Clinical presentations
Imaging
Treatment
Types of osteomyelitis
Osteoradionecrosis
Etiopathogensis
Clinical features
Treatment
Prevention of
osteoradionecrosis
Postirradiation dental care
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
OESTEOMYLITIS
It is defined as an inflammation of the bone marrow with a
tendency to progression.
This is what differentiates it in the jaw from the dentoalveolar
abscess, “dry socket” and “osteitis,” seen in infected fractures.
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
It is described as an inflammatory condition of bone that usually
begins as an infection of medullary cavity rapidly involves the
haversian system and quickly extends to periosteum of that area.
Pus that formed in this area thereby compromise its periosteal
blood supply.
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
Incidence
Much higher in the mandible due to poorly vascularized cortical
plates and the blood supply primarily from the inferior alveolar
vessels.
Diminished host defenses, both local or systemic like diabetes,
autoimmune states, malignancies, malnutrition, and acquired
immunodeficiency syndrome.
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
Factors-
predisposing
osteomyelitis
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
ETIOLOGY
Odontogenic infections
Trauma
Infections derived from periostitis following gingival ulceration
Infections derived by hematogenous route—furuncle on face,
wound on the skin, upper respiratory tract infection, middle ear
infection
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
Pathogenesis
Osteomyelitis primarily occurs as a result of contiguous spread
of odontogenic infections or as a result of trauma.
Primary hematogenous osteomyelitis generally occurs in the
very youngs.
Whereas in adults, process is initiated by inoculation of bacteria
into the jawbones that can occur with the extraction of teeth,
root canal therapy, or fractures of the maxilla or mandible.
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
Inflammation
Hyperemia and increased blood
flow
Additional
leukocytes
Pus is formed
If it is formed in bone marrow it causes decreased blood supply of
the region due to elevated intramedullary pressure
Pus spread via haversian and Volkmann’s canals to medullary
and cortical bones.
Perforation of the cortical
bone
Collection of the pus under the periosteum
Compromised periosteal blood supply
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
Microbiology
Earlier said to be S. aureus and S. epidermidis ranged between 80 to 90%;
remaining bacteria are mainly streptococci, pneumococci, typhoid and
acid fast bacilli.
Now osteomyelitis is recognized as a disease caused primarily by
streptococci and oral anaerobic bacteria present in oral cavity.
Clinician must begin antibiotic treatment, includes penicillin and
metronidazole as dual-drug therapy or clindamycin as a single-drug
treatment.
And definitive therapy should be based on the final culture and
sensitivities.
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
FINDINGS HELPFUL IN PURE AEROBIC/MIXED
AEROBIC ANAEROBIC INFECTION
Foul smelling exudate
Slouging necrotic tissue
Gas & black discharge
Gram stain revealing multiple organism of diff morphological characters
Presence of sequestra
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
Classification
BASED UPON DURATION OF 1 MONTH
-ACUTE
A) Contiguous focus B). Progressive
c). Hematogenous
-SUB ACUTE
-CHRONIC
A) Recurrent multifocal
B) Garré’s
C) Suppurative or nonsuppurative
D) Sclerosing
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
Waldvogel classification system for
osteomyelitis:
Hematogenous osteomyelitis
Osteomyelitis secondary to a contiguous focal infection.
Osteomyelitis with or without associated peripheral vascular
disease.
Chronic osteomyelitis.
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
ON THE BASIS OF PRESENCE OF PUS
SUPPURATIVE
• ACUTE SUPPURATIVE
• CHRONIC SUPPURATIVE
• (PRIMARY- No acute phase
preceding)
• (SECONDARY- follows acute
phase)
• INFANTILE OSTEOMYELITIS
• NON SUPPURATIVE
• DIFFUSE SCLEROSING
• FOCAL SCLEROSING
(CONDENSING OSTEITIS)
• PROLIFERATIVE PERIOSTITIS
(GARRE’S SCLEROSING OM)
• OSTEORADIONECROSIS
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
Classification based on clinical picture
and radiology
Hjorting-Hansen E, Decortication in treatment of osteomyelitis of the mandible. Oral Surg Oral Med
Oral Pathol 1970 May;29(5):641-55
I. Acute/subacute osteomyelitis
II. Secondary chronic osteomyelitis
III. Primary chronic osteomyelitis
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
Classification based on clinical picture,
radiology, etiology, and pathophysiology
Acute osteomyelitis
1. Associated with Hematogenous spread
2. Associated with intrinsic bone pathology or peripheral vascular disease
3. Associated with odontogenic and nonodontogenic local processes
Marx RE Chronic Osteomyelitis of the Jaws Oral and Maxillofacial Surgery Clinics of North America, Vol 3, No 2,
May 91, 367-81
Mercuri LG Acute Osteomyelitis of the Jaws Oral and Maxillofacial Surgery Clinics of North America, Vol 3, No 2, May 91, 355-65
Chronic osteomyelitis 1. Chronic recurrent multifocal osteomyelitis of children
2. Garrè's osteomyelitis
3. Chronic suppurative osteomyelitis – Foreign body related – Systemic disease related
– Related to persistent or resistant organisms
4. True chronic difuse sclerosing osteomyelitis
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CIERNY-MADER STAGING SYSTEM (1985)
Classification and staging for osteomyelitis
1ANATOMIC TYPE: STAGING SYSTEM:
Stage 1: Medullary osteomyelitis –no cortical
involvement , usually hematogenous
Stage2: Superficial osteomyelitis-less than 2cm
bony defect without cancellous bone.
Stage3: Localized osteomyelitis –less than 2cm
bony defect, without involving both cortices.
Stage4: Diffuse osteomyelitis-Larger than 2 cm
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
2.PHYSIOLOGIC TYPE:
A. Host: Normal host
B. Host
Systemic compromise
Local compromise.
Systemic and local compromise.
C. Host: Treatment worse than disease.
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
Clinical Presentation
4 types can be observed clinically-
1) Acute suppurative osteomyelitis- Deep pain, high fever,
paresthesia and anesthesia of the lower lip, usually deep carious
associated teeth,
Swelling is minimal, tooth are not loose and fistulas are usually
not present.
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
2) Sub acute suppurative- After 10 to 14
days of acute form, pus extends through
haversian canals to accumulate under
the periosteum.
Pain, fever, malaise are present, teeth
begins to loose and tender, pus exudes
around gingival sulcus, fistula formation
and fetid odor.
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
3) Secondary chronic ( begins as acute phase)- clinical findings are fistulas, induration of soft tissue and thickened or ‘wooden’ character to the affected area.
4) Primary chronic- (Not preceded by acute) slight pain, slow increase in jaw size, and gradual development of sequestra, often without fistulas.
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
Maxillofacial imaging for osteomyelitis
Radiographic presentation lag behind the clinical presentation since cortical involvement is
required for any change to be evident. Therefore, it takes several weeks before bony
changes appear.
Orthopanoramic view
CBCT
CT scans
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
• Worth’s Criteria (1969)
• ‘Moth-eaten’ appearance (enlargement of medullary spaces and widening of Volkmann’s
canals)
• Islands that is ‘seqeustrum’ evidence of trabecular pattern and marrow spaces
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
MRI can help in early diagnosis by loss of the marrow appears
before cortical erosion or sequestrum of the bone.
The technetium 99 with the addition of gallium 67 or indium
111 as contrast agents, differentiate areas of infection from
trauma or postsurgical healing as these agents specifically
bind to white blood cells.
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
Conventional radiograph
Positive Negative (suspected)
Technetium bone scan
Positive Negative
Ga 67 or WBC scan
Positive Negative
Drainable abscess- MRI, Sequestrum- CT
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
Treatment
Usually medical and surgical interventions required.
Overall treatment plan includes-
Evaluation and correction of host defense deficiencies
Gram staining, culture and sensitivity
Administration of antibiotics
Removal of loose teeth and sequestra,
Administration of culture guided antibiotics
Sequestrectomy, saucerization, debridement, direct placement of
antibiotic, HBO therapy, resection of infected bone, reconstruction.
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
Inhitial management is administration of high dose intravenous antibiotic
therapy.
Identify and correct host compromise factors, and treat the cause.
For hospitalized pt-
Aqueous penicillin, 2 million U IV 4 hourly, plus metronidazole, 500mg 6 hourly, when improved for 48 to 72 hours- switch to- penicillin V, 500mg PO 6 hourly, plus metronidazole 500mg PO 6 hourly for an additional 4-6 weeks.
For outpatients- Penicillin V 2g, plus metronidazole 400mg 8hourly PO, for 2-4 weeks.
Clindamycin should be prescribed if pt is allergic to penicillin.
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
Whenever possible, specimens should be obtained for gram
staining, aerobic and anaerobic cultures, and antibiotic
sensitivity testing.
A foul- smelling, dark exudate- suggest anaerobic osteomyelitis.
A thick creamy pus from a localized abscess indicates a
staphylococcal infection.
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
Local antibiotic therapy
Closed wound irrigation- suction-
Irrigation without surgical debridement to the point of bleeding bone is unlikely to be effective, prolongs the process, and delays definitive treatment.
Various agents containing antibiotics, proteolytic enzymes, wetting agents may be used.
Antibiotics may be placed in direct contact with the bone manually or with an implantable pump.
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
Antibiotic-impregnated Beads- They can be used to
deliver high concentrations of antibiotics into the
wound bed.
Antibiotic leaches from the beads, and produce high
local concentrations and low systemic
concentrations.
Tobramycin or gentamycin is generally used as AIB.
Beads and drain are left in place for 10 to 14 days.
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
Surgical management
Necessary with medical therapy.
Surgical management is removal of loose teeth, bone fragments, I&D
of fluctuant areas and if necessary sequestrectomy, saucerization,
decortication, or resection and then reconstruction.
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
Sequestrectomy
Sequestra are generally seen after 2 weeks of onset of infection.
Once fully formed, sequestra persists for several months before they
are resorbed.
Once the sequestra has formed completely, it can be removed with
the minimum of the surgical trauma.
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
Saucerization
Saucerization is “Unroofing” of the bone to expose
medullary cavities for thorough debridement.
The margins of necrotic bone overlying the focus of
osteomylities are excised allowing visualization of sequestra
and exision of affected bone.
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
Steps- 1) Buccomucoperioseteal flap is reflected.
2) loose teeth and bone segment are removed.
3) lateral cortex of the mandible is reduced using
burs.
4) All granulation tissue and loose bone fragments
are removed from the bone bed using curettes.
5) buccal flap is trimmed and a medicated ¼ or ½
inch pack is inserted for hemostasis and to
maintain the flap in a retracted position until initial
healing occurs.
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
Decortication
First described for jaw osteomyelitis in 1917 by Mowlem.
It refers to the removal of chronically infected cortical bone.
Lateral and inferior cortex is removed 1 to 2 cm beyond the
affected area thus providing access to the medullary cavity.
Usually granulation tissue and pus exists within the medullary cavity
that antibiotics cannot penetrates.
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
Steps- 1) Creation of a buccal flap by
a crestal incision extending along the
neck of teeth.
2) Reflection of the mucoperiosteal
flap to inferior border.
3) Removal of the teeth of the
involved area.
4) Removal of the lateral cortical
plate and the inferior border with
chisels.
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
Resection and reconstruction-
Used in cases of-
Pathological fracture
Persistent infection after decortications
Marked closure of both cortical plates.
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
Types of osteomyelities
1) Osteomyelitis associated with fractures-
Develops when failure to use effective methods of reduction,
fixation and immobilization, as debris and microorganisms gain
access to the fracture site.
Overzealous use of intraosseous wiring, bone plates, screws that
devascularize bone segment.
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
2)- Infantile Osteomyelitis
Occurs most often a few weeks after birth and usually affects
maxilla.
It believed to occur by hematogenous route or from perinatal
trauma of the oral mucosa.
Have risk of involvement of eye, extension to dural sinuses, and
the potential for facial deformities and loss of teeth.
Clinically patient has cellulitis centered around the orbit.
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
3)- Proliferative periostitis (garre’s
sclerosing osteomyelitis)
Resembles infectious osteomyelitis and affects mainly children.
First described by Carl Garre in 1893.
Characterized clinically by-
Localized, hard, non tender, unilateral bony swelling of the lateral
and inferior aspects of the mandible.
Skin appears normal,
Associated with carious first molar with a history of past toothache.
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
Radiographically- laminated or Onion skin appearance.
It is considered a response to a low grade infection or
irritation that influence the potentially active periosteum of
young individual to lay down new bone.
D/D- Ewing’s Sarcoma, Osteosarcoma, cortical hyperostosis.
T/t- removal of identifiable source of inflammation.
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
CHRONIC SCLEROSING OSTEOMYELITIS
1)- Chronic diffuse sclerosis osteomyelitis-
Inflammatory, non-suppurative, painful disease with a protracted
course.
It occurs only in the mandible and affects the both the basal
bone and the alveolar process, involve the entire height of the
mandible.
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
Bone is often mildly expanded and tender.
Episodes of recurrent swelling and pain occur.
Mainly seen in adult in their 3rd decade.
2/3rd times in females.
Radiographically, a diffuse intramedullary sclerosing with poorly
defined margins defect can be seen.
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
2)- Florid osseous dysplasia-
Multiple, exuberant, lobulated densely opaque masses, restricted to the
alveolar process in either or both jaw.
Most often in black women.
Focal sclerosing osteomyelitis- Localized area of bone sclerosing
associated with the apex of a carious tooth and peripheral periodontitis.
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
Actinomycotic osteomyelitis-
Chronic, slowly progressive infection with both granulomatous and
suppurative features,
Affects soft tissue only and occasionally, bone.
It forms external sinuses that discharge distinctive sulfur granules
and spreads unimpeded by anatomical structures.
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
Actinomyecitis are not fungi but rather gram positive,
microaerophilic, non spore forming, non acid-fast bacteria.
Firm, soft tissue masses are present on the skin, they have
purplish, dark red, oily areas with occasional small zone of
fluctuance.
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
Fungal Osteomyelitis
Very rare and generally presents in an indolent fashion.
Fungal infections are opportunistic infections and devastating to
patients if it is invasive in nature.
These frequently enter the body due to a decrease in host defense
or through an invasive gateway, such as a dental extraction.
Candidal infection is more often encountered when compared to
other fungal infection, i.e. mucormycosis, aspergillosis etc.
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
The clinical presentations of fungal osteomyelitis are similar to the
bacterial osteomyelitis (e.g. Exposed bone with varying pain).
Involvement of maxillary sinus with a complaint of sinusitis in maxillary
fungal osteomyelitis has been seen more.
The fungus invades the arteries leading to thrombosis that
subsequently causes necrosis of hard and soft tissues. Mucormycosis
is frequent in diabetic patients because a favorable environment is
created due to an excess of ketone bodies in diabetic patients.
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
It is extremely rare to find candidal osteomyelitis in the
maxilla and because of nonspecific symptoms,
diagnosis is very challenging.
Aspergillosis is the second most common fungal
infection after candida. It is usually invasive in nature
when involving maxillary sinus though noninvasive forms
have also been reported and does not cause bone
destruction when compared to mucormycosis.
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
OSTEORADIONECROSIS
Osteoradionecrosis is a radiation
induced non –healing, hypoxic
wound rather than true
osteomyelitis of irradiated bone.
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
Infection is usually initiated by injury to irradiaated tissue
According to Marx it is a chronic, nonhealing wound caused
by hypocellularity , hypovascularity and hypoxia of the
irradiated tissue.
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
Etiopathogenesis of osteoradionecrsis
Radiation
Trauma
Infection
Effect of irradiation depends upon:
Quality and quality of radiation
Size of the portals used
Location and extent of the lesion
Condition of teeth and peridontium
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
Mandible is more commonly affected than maxilla.
Radiation often has serious effects: -Mucositis
-Atrophic mucosa
-Xerostomia
-Radiation caries etc.
Breakdown occur because the tissue cannot maintain normal cellular
turnover and collagen synthesis such tissue is susceptible to spontaneous
breakdown, breakdown from other trauma especially tooth extraction.
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
Clinical features of osteoradionecrosis
Pain and evidence of exposed bone (grey to yellow color)
Trismus
Elevated temperature
Pathological fractures
Tissue surrounding the exposed bone may be indurated and ulcerated.
Nutritional deficiencies
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
Treatment:
1) Hospitalized to allow parental antibiotic and fluids.
2) Penicillin plus metronidazole or clindamycin alone is recommended.
3) Gentle, pulsating irrigation of the soft tissue margin is useful in
removing debris and reducing inflammation. But high pressure
irrigation should be avoided because debris might be pushed
deeply into the tissue.
4) Supportive treatment with fluids and a liquid or semiliquid diet, high
in protein and vitamin is desirable.
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
6)- Exposed bone then is mechanically debrided and smoothened
with large round or barrel shaped burs and covered with a pack
saturated with zinc peroxide and neomycin.
7) Irrigation and packing repeated weekly until sequestration
occurs or the bone is penetrated by granulation tissue.
Pentoxyfylline and tocopherol (Vit E) are the usually used medical
treatment for ORN.
Pentoxyfylline- 400mg TDS, Improves blood flow by decreasing its
viscosity.
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
Ultrasound therapy:
Promotes neo-vascularity and neo-cellularity of ischemic tissue.
Bone resection:
Patient who are not candidates for extensive treatment because
of their medical condition may achieve pain relief by resection
of the segment of the involved bone.
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
HYPERBARIC OXYGEN THERAPY:
The therapeutic principle of HBOT lies in its ability to drastically increase in
the oxygen transport capacity of the blood.
At normal atmospheric pressure, oxygen transport is limited by the oxygen
binding capacity of hemoglobin and very little oxygen is transported
by blood plasma.
Oxygen transport by plasma, however, is significantly increased using
HBOT because of the higher solubility of oxygen as pressure increases.
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
HBO therapy causes an increase in the
arterial and venous oxygen tension; the
additional oxygen is carried in physical
solution in the plasma.
HBO therapy consists of breathing 100%
oxygen through a face mask or a large
chamber at 2.4 absolut atmospheres
pressure for 90 minute sessions for as many
as 5 days a week, totaling 30 or more
sessions often fallowed by another 10 more
sessions.
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
Oxygen under increased tension enhances healing by a direct
bacteriostatic effect on micro-organisms and by enhancing
phagocytic activity.
Neoangiogenesis, fibroblastic changes and collagen synthesis
also occurs.
Osteomyelitis and osteoradionecrosis patients may be
candidates for HBO treatment in conjunction with antibiotic and
surgical care.
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
Marx-University of Miami Protocol Stage-I
- 30 X (100% O2for 90 mins at 2.4 ATA)
- Examine exposed bone
Responder (Formation of healthy granulation tissue)
- 10 X (100% O2for 90 mins at 2.4 ATA)
Nonresponders
Stage- II
Decortication sequestretomy, saucirization etc till bleeding margins
- 10 X (100% O2for 90 mins at 2.4 ATA)
Responder
Healing without exposed bone
Nonresponders
Stage III
Excision of the nonvital bone,
Fixation of the mandibular segments,
10 X (100% O2for 90 mins at 2.4 ATA)
Reconstruction after 3 months
No further HBO required
Cutaneous fistula,
Pathological fracture
Resorption of inferior border of mandible
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
PREVENTION OF OSTEORADIONECROSIS:
Preirradiation dental care:
Preventive dental measures are effective in reducing the risk of
osteoradionecrosis.
The radiotherapist should seek dental consultation sufficiently
early before initiation of radiation therapy to allow achievement
of optimal oral health.
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
1. All non-restorable teeth in the direct beam of radiation and
teeth with significant periodontal disease should be extracted
10 to 14 days before radiation therapy begins.
2. Judicious alveoplasty should performed to permit a liener
closure of the mucoperiosteum.
3. All remaining teeth should be restored and periodontal
therapy be completed within 2 weeks interval.
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
Postirradiation dental care:
Dentures should not be used in the irradiated arch for 1 year after
radiotherapy .
A saliva substitute may be used to lubricate the mouth.
(Pilocarpine).
If postirradiated pulpitis develops endodontic treatment should be
provided.
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
Necessary extraction should be limited to one or two teeth per
appointment. Removal of teeth should be performed as atraumatic
as possible. No attempt should be made to raise mucoperiosteal flap
or linear closure.
A plain local anesthecis should be used.
A suggested regimen is 2 grm penicillin V plus 500mg metronidazole
orally 1 hour before surgery and 500mg of both drugs given four
times a day for 1 week after extraction.
Alternatively 600mg of clindamycin 1 hour before surgery and 300mg
three times a day for a week is recommended.
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
Thankyou
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
Classification of osteomyelitis:
1. Acute form of osteomyelitis ( suppurative or nonsuppurative)
A. Contignuous focus
I. 1.Trauma
II. 2.Surgery
III. 3.Odontogenic infection
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
B) Progressive
I. 1.Burns
II. 2.Sinusitis
III. 3.Vascular insufficiency
C) Hematogenous (metastatic)
i. Developing skeleton (children)
ii. Developing dentition (children)
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
2) Chronic forms of osteomyelitis
A) Recurrent multifocal
i. Developing skeleton (children)
ii. Escalated osteogenic activity (
C). Suppurative nonsuppurative
i. Inadequately treated forms
ii. Systemically compromised forms.
iii. Reractory forms (chronc refractory osteomyelitis (CROM))
D). Sclerosing:
i. Diffuse-
a) Fastidious microorganisms
b) Compromised host and pathogen interface.
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
ii) Focal
a predominantly odontogenic
B. Chronic localized injury.
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Dr. Prajesh Dubey, Subharti Dental College, SVSU
APPLIED SURGICAL ANATOMY
The bone has essentially three structures, a cortical bone, a cancellous
bone and the periosteum. The cortical bone is present outside and is
covered by the periosteum, while the cancellous bone lies within the
cortical bone
Figs 18.1A to D: Haversian system of the bone
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Dr. Prajesh Dubey, Subharti Dental College, SVSU