OSTEOMYELITIS

Osteomyelitis is defined as an
inflammation of the soft tissue
components of the bone which includes
bone marrow, haversian canals and
periosteum with secondary changes of
the mineralized components of the bone.

Image credit: Google

• AETIOLOGY:

❖ Direct spread of infection from

dental pulp into jawbone.
❖ Spread of infection into bone from
the pre-existing suppurative
infections like periapical abscess,
periodontal abscess, infected
fractured jawbone, acute
necrotizing ulcerative gingivitis,
pericoronitis, etc.

❖ Post-extraction infections.

❖ Jawbone fractures.

❖ Gunshot injuries in the jaw with

soft tissue lacerations and exposure
of bone.

❖ Post-radiation secondary infection.

❖ Secondary infection in a pre-

existing bone disease, e.g., Paget's
disease, osteopetrosis, etc.

❖ Idiopathic factors.
 • PREDISPOSING FACTORS:
❖ Local Factors:
o Pre-existing bone disease: Long
standing bony disease like Paget's
disease of bone, fibrous
dysplasia, cystic lesions,
osteopetrosis, etc. make the jaw
bones more susceptible to
osteomyelitis,

Obliteration of o Radiation injury: Radiotherapy

the arteries
to the head and neck area often
-
produces obliterative
endarteritis, which results in
impaired blood supply to the
jawbones. Therefore, in such
conditions possibility of
osteomyelitis is increased once
the infection in the bone sets in.

❖ Systemic Factors:
o Malnutrition and chronic
alcoholism.
o Drug addiction.
o Immune dysfunction.
 o Anaemia, especially sickle cell
anaemia.
o Diabetes (poorly controlled).
o Acute leukaemia.
o HIV infection and AIDS.

DID YOU KNOW?

Why is the mandible is more commonly affected by

osteomyelitis than the maxilla?

The mandibular bone has poor blood supply in

comparison to that of the maxilla, besides this it
has more compact bony pattern due to which,
osteomyelitis occurs far more commonly in
mandible than maxilla.
• PATHOGENESIS:
Acute inflammation

Tissue necrosis with pus formation

Extensive involvement of marrow and haversian canals

Thrombosis and ischaemia

Sequestrum

Formation of subperiosteal bone and involucrum

 ACUTE SUPPURATIVE OSTEOMYELITIS
Acute suppurative osteomyelitis of the
jaw is a serious sequela of periapical
infection that often results in a diffuse
spread of infection throughout the
medullary spaces, with subsequent
necrosis of a variable amount of bone.

• CLINICAL FEATURES:
❖ Age: Usually occurs after 30 years of
age (due to increased probability of
systemic diseases and reduced bony
resistance to infection).

❖ Gender: Male predilection.

❖ Location: Mandible is involved more
often than the maxilla
❖ The mandibular lesions are usually
diffuse in nature, while the
maxillary lesions are mostly well
localized.
❖ It often causes severe throbbing, deep
seated pain.
❖ It manifests clinically as a diffuse
large swelling of the jaw and
related soft tissues.
❖ Loosening and soreness of the

regional teeth is often seen.

❖ The overlying soft tissue is
erythematous, swollen and tender
on palpation.
❖ Excessive muscle oedema leads to
difficulty in mouth opening and
swallowing.
❖ Multiple intraoral or extraoral
pus discharging sinuses are seen.

❖ Discharge of pus can also be seen

from the gingival crevice or socket
of the affected teeth.
 ↳
pus • • ••

discharge

❖ Regional lymph nodes are enlarged

and tender on palpation.
❖ Paraesthesia or anaesthesia of the
lip (either on affected side or the
entire lip)
❖ Patients are usually febrile with
general symptoms like fever,
malaise, anorexia and vomiting, etc.

• RADIOGRAPHIC FEATURES:
❖ Radiographic changes become more
apparent after 1–2 weeks of the
disease onset.
❖ It is characterized by large area of
radiolucency in the jaw with ill-
It is the dead defined, moth-eaten margins.
bone that is
separated from
❖ Sequestra are frequently seen as
the surrounding radiopaque foci of diminished
normal bone
through the radiodensity within the lesion. They
process of
necrosis.
become more sharply defined as they
 are gradually separated from the
normal bone.

Radiograph of acute osteomyelitis seen

as an ill-defined area of radiolucency
of the right body of the mandible.
Image credits: Oral and maxillofacial
pathology, Neville.

• HISTOPATHOLOGY:
❖ The medullary spaces of bone are
usually occupied by inflammatory
exudates. The inflammatory cell
infiltration predominantly
contain PMN leukocytes with few
lymphocytes and plasma cells.

❖ Some areas of the affected bone

show complete necrosis with
degeneration of both osteoblasts
 (bordering the bony trabeculae)
and osteocytes (inside the lacunae)
along with increased osteoclastic
resorption, which often produces
scalloping of the bony margins and
result in the development of
sequestrum.

❖ Sequestrum gradually undergoes

spontaneous resorption, or it may
exfoliate through mucous
membrane or skin.

DID YOU KNOW?

Sequestrum is a dead or necrosed fragment of
bone, which is separated from the remaining
viable bone.
When the sequestrum becomes surrounded by
new vital bone, the mass of enclosed nonvital
bone is called involucrum.

Image credit: Google

 Histopathological diagram of acute
osteomyelitis.
Image credits: Concise oral pathology,
Manjunath.

CHRONIC SUPPURATIVE OSTEOMYELITIS

Chronic suppurative osteomyelitis may

arise de novo or as a sequela of acute
suppurative osteomyelitis.

• CLINICAL FEATURES:
❖ Age: >30 years.
❖ Gender: Male predilection.
❖ Location: Posterior region of the

mandible.
❖ The pain is usually mild and dull
in nature as it is a chronic
infection.
❖ Jaw swelling is a common feature
but mobility of teeth and sinus
tract
formations, etc are rare.
❖ Rarely, sinus tracts may develop
both intraorally and extraorally
with intermittent discharge of
purulent materials.
❖ Acute exacerbations of the chronic
disease may also occur.
❖ Sequestrum is common, which
protrudes from the ulcerated skin
or mucosal surfaces.
 Chronic suppurative osteomyelitis showing
multiple sinus openings.
Image credits: Textbook of oral pathology,
Shafer.

• RADIOGRAPHIC FEATURES: Four different

patterns are seen:

1. An ill-defined radiolucency in the

bone with ragged borders.

2. Radiolucency with multiple

radiopaque foci within it, which
represent sequestra.
 3.A dense zone of radiopacity with
faint

radiolucency at the margin.

*
4. A 'salt and pepper' radiographic

effect in the bone.

Radiograph of chronic osteomyelitis seen as an

ill-defined area of radiolucency
of the right body of the mandible adjacent to a
recent extraction site.
 Image credits: Oral and maxillofacial
pathology, Neville.

• HISTOPATHOLOGY:
❖ Chronic inflammatory reaction in
the bone with accumulation of
exudates and pus within the
medullary spaces.

❖ The lymphocytes, plasma cells and

macrophages predominate among
the inflammatory cells.

❖ Parallel osteoblastic and

osteoclastic activity with the
formation of irregular bony
trabeculae having reversal lines.

❖ Sequestrum may develop in the later

stages of the disease.
Complete Notes Available on
Dr Teeth App.

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Nerina