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LECTURE 4Osteomуelitis of the jaws: etiology, pathogenesis, classification, clinical

course, diagnostics, treatment, complications, prophylaxis.

Specific inflammatory processes of the MFA (actinomycosis,

tuberculosis, syfilis): etiology, classification, clinical course,

diagnostics, treatment.

Definition :

Osteomyelitis may be defined as “an inflammatory condition of bone, that begins as an infection of medullary cavity and haversian systems of the cortex & extends to involve the periosteum of the affected area”

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etiology

Odontogenic infections

Trauma

Infections of oro facial region

Infections derived from hematogenous route

Compound fractures of the jaws.

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pathogenesis

Pulpitis

Acute Chronic

Apical Periodontitis

Acute ChronicPeriapical Abscess

Periapical Granuloma

Periapical Cyst

Osteomyelitis

Acute Chronic Focal

DiffusePeriostosis

Cellulitis Abscess

Bacteraemia Toxaemia Septicemia Dissemination Shock

Death

Chronic Periapical abscess

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In the jaws…

Osteomyelitis in maxilla :

• Rare occurrence due to-- Extensive blood supply and significant

collaterals- Porous nature of membranous bones- Thin cortical plates- Abundant medullary spaces

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Osteomyelitis in mandible

• An important factor in establishment of osteomyelitis in mandible is compromise of blood supply

• Blood supply – - Primary supply – by inferior alveolar artery,

except coronoid (temporalis vessels)- Secondary supply – periosteal supply

• Venous drainage – upwards via inferior alveolar vein to pharyngeal plexus

• Downwards to external jugular veins6

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Sites of osteomyelitis in jaws

classification• Historically accepted classification –[Hudson’s

classification]

I. Acute –

a. Contiguous focus – trauma, surgery & odontogenic infections

b. Progressive – burns, sinusitis, vascular insufficiency

c. Hematogenous – metastatic (children)8

II Chronic

a. Recurrent multifocal – developing skeleton, escalated osteogenic activity (<25 years)

b. Garre’s – (i)unique proliferative subperiosteal reaction, (ii) Developing skeleton (children to young adults)

c. Suppurative or non suppurative – (i) inadequately treated forms , (ii) systemically compromised, (iii) refractile

d. Diffuse sclerosing – (i) fastidiouis organisms, (ii) compromised host pathogen interface

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Based on presence or absence of suppuration

I Suppurative osteomyelitis

a)Acute suppurative (pyogenic)

b)Chronic suppurative (pyogenic) - primary - secondary

c) Infantile

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II Non Suppurative Osteomyelitis

i) Chronic sclerosing a) focal sclerosing b) diffuse sclerosing

ii)Garre’s sclerosing

iii)Actinomycotic

iv)Radiation (ORN)

v)Specific infective a) tuberculosis b) syphilis

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Types of osteomyelitis

• Acute suppurative

• Chronic suppurative

• Focal sclerosing

• Diffuse sclerosing

• Infantile

• Garre’s

• Specific infective

• Osteoradionecrosis

• Malignancy in osteomyelitis

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Clinical Picture

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- Slight decrease in density of involved bone

- loss of sharpness of trabeculae

Radiologic features

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- Sequestrum & osteolysis with loss of definition of mandibular canal

Radiologic features

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Clinical picture

• Osteomyelitis affecting the maxilla

• Bone destruction seen intra orally

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Radiographic picture

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Radiographic picture

• Characteristic moth eaten appearance

• Presence of sequestra

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Radiographic picture

• Characteristic moth eaten appearance

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Osteomyelitis

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Infective osteomyelitis

• Tuberculous osteomyelitis

• Syphilitic osteomyelitis

• Actinomycotic osteomyelitis

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Tuberculous osteomyelitis

• Results when blood borne bacilli lodge in cancellous bone.

• Usually commences in metaphyseal area of long bones & causes widespread destruction of osseous tissue.

• Commonly seen in phalanges and dorsal and lumbar vertebrae.

• Tuberculous lesions are rare in jaws.

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Lower left buccal vestibule obliterated from 74 to 36

• Unilateral diffuse swelling on left side of mandible with draining sinus

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Occlusal view showing periosteal reaction

• Ill defined radiolucent osteolytic lesion

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Syphilitic Osteomyelitis• Difficult to distinguish syphilitic osteomyelitis of the jaws from

pyogenic osteomyelitis on clinical & radiographic examination.

• Main features are progressive course & failure to improve with usual treatment for pyogenic osteomyelitis.

• Massive sequestration may occur resulting in pathologic fracture.

• If unchecked, eventually causes perforation of the cortex.

• Identity of the organism may be masked due to superimposed bacterial infection.

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Actinomycotic Osteomyelitis

• Actinomyces – generic term applied to group of non acid fast organisms that are microaerophilic.

• Three species –

i. Actinomyces israeli – primarily saprophytic, occasionally pathogenic.

ii. Actinomyces bovis – in cattle

iii.Actinimyces baudetti – cats and dogs

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Complications in osteomyelitis

• Neoplastic transformation

• Discontinuity defects

• Progressive diffuse sclerosis

• Cavernous sinus thrombosis

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Hyperbaric Oxygen Therapy

• Involves intermittent, usually daily, inhalation of 100% humidified oxygen under pressure greater than 1 absolute atmospheric pressure

• Patient is placed in a chamber, oxygen is given by mask or hood

• Each session, or dive, is 90 minutes in length.

• Treatment given 5 days per week for 30, 60 or more dives at 2.4 ATA for 90 minutes while breathing 100% oxygen twice daily

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Surgical Therapy

• Incision & drainage

• Extraction of loose teeth

• Debridement

• Decortication

• Sequestrectomy

• Saucerization

• Trephination or fenestration

• Resection

• Immediate/ delayed reconstruction

• Postoperative care

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Osteomyelitis treatment plan

• FOR ACUTE ASTEOMYELITIS

Healthy host Conservative decompression & debridement with extraction Drainage & irrigation if pus present Culture & sensitivity of infected foci Antibiotic treatment for 3 – 4 weeks Regional bony stabilization if necessary

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Compromised Host

Stabilize condition – especially nutrition Aggressive debridement & decompression with disruption of

involved periosteal layer Culture & sensitivity of infected foci Sustained antibiotic treatment for 6 – 12 weeks Regional bony stabilization if necessary

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FOR CHRONIC OSTEOMYELITIS

• Host almost always compromised.

• CT, nuclear medicine scan, bone perfusion

• Stabilize condition of host especially nutrition status

• Wide bony sequestrectomy & decortication to normal bleeding bone

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• If purulent, consider drainage & irrigation

• Sustained antibiotic therapy for 3 – 6 months

• Regional bony stabilization

• Postoperative HBO – 20- 40 dives for 90 min at 2.5 ATA

• Reconstruction as necessary

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• Specific inflammatory processes of the MFA

(actinomycosis, tuberculosis, syfilis): etiology,

classification, clinical course, diagnostics, treatment.

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• This is the most common and recognized presentation of the disease.

• Actinomyces species are commonly present in high concentrations in tonsillar crypts and gingivodental crevices. Many patients have a history of poor dentition, oral surgery or dental procedures, or trauma to the oral cavity.

• Chronic tonsillitis, mastoiditis, and otitis are also important risk factors for actinomycosis.

Cervicofacial Actinomycosis

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• Periostitis or osteomyelitis can develop if the infection extends to facial and maxillary bones. The mandible appears to be one of the most common osteomyelitis sites.

Infection Cervicofacial region

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Actinomycosis (cont.)

Cervicofacial Actinomycosis

Actinomycosis

Actinomycosis, nodules and sinus of the buccal mucosa. FIG. 1

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Actinomycosis, abscess and draining sinus of the maxilla. FIG. 2

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Actinomycosis, multiple nodules and sinus of the skin. FIG. 3

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Tuberculosis (cont.)

Tuberculosis

Syphilis (cont.)

Primary Syphilis

Chancre develops at site of inoculation after 2-3 weeks – if untreated, initial lesion heals in 3-8 weeks

Spreads through lymphatic channels

Oral lesions may be found on lip, tongue, palate, gingiva, tonsils

Oral lesions may be painless, clean-based ulcerations or vascular proliferations

Primary Oral Syphilis

Oral chancres in primary syphilis

Secondary Syphilis Sore throat, malaise, headache, weight loss,

fever, musculoskeletal pain

Diffuse, painless maculopapular cutaneous widespread rash which may involve the oral cavity

Mucous patches – superficial areas of irregular grayish mucosal necrosis most commonly found on tongue, lip, buccal mucosa, palate

Secondary Syphilis

Occasional papillary lesions (condylomata lata)

Lues maligna – found in person with compromised immune system: fever, headache, myalgia, necrotic ulcerations of the face and scalp, oral lesions

Secondary Syphilis

Tertiary Syphilis

• Develops in 30% of patients• Most severe complications are congestive heart failure,

dementia, death• Gumma – zone of granulomatous inflammation affecting

skin, mucosa, soft tissue, bones, and internal organs; intraoral involvement of palate and tongue; may perforate through palate to nasal cavity

• Luetic glossitis - Tongue appears large and irregularly shaped due to diffuse atrophy and loss of dorsal tongue papillae

Tertiary Oral Syphilis

Congenital Syphilis

Maternal transmission during primary and secondary stages usually results in miscarriage, stillbirth, or congenital malformations

Hutchinson’s triad – Hutchinson’s teeth, interstitial keratitis, eighth nerve deafness

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Congenital Syphilis - Mucous Patches

Clinical Manifestations

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Congenital Syphilis - Hutchinson’s Teeth

Clinical Manifestations

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Congenital Syphilis - Perforation of Palate

Clinical Manifestations

THANK YOU FOR

ATTENTIONDr.T.V.Rao MD 66