Osteomyelitis

Oral pathology
4th stage
Dr.Hemn M.Sharif
(B.D.S, MSc, O.Medicine)
2-4-2020
Inflammatory diseases of the jaws:

● Osteitis: a localized inflammation of bone with no

progression through the marrow spaces.
● Osteomyelitis: extensive inflammation of the
interior bone, spreading through the marrow
spaces.
● Periostitis: inflammation of the periosteal surface
of the bone with or without osteomyelitis.
● Osteomyelitis caused by various microorganisms (anaerobic
predominate).
● Osteomyelitis can be classified into :
1. Suppurative :
Acute osteomyelitis
Chronic osteomyelitis .
2. Granulomatous
3. Non suppurative
● Chronic sclerosing Osteomyelitis
a. Focal
b. Diffuse
● Chronic osteomyelitis with proliferative periostitis( Garr’s disease)
● Alveolar ostitis .
● Special types
a .Osteoradionecrosis .
b. Chemical osteomyelitis
Suppurative osteomyelitis of the jaws:

Predisposing factors:
1. Traumatic injuries; penetrating, contaminated open fractures or
gunshot wounds.
2. Radiation, and certain chemical substances.
3. Some bone disease; Paget's disease or osteopetrosis.
4. Impaired immune defence (acute leukaemia, poorly controlled
diabetes mellitus, sickle cell anaemia, chronic alcoholism or
malnutrition).
Clinical features:
• More common in adult with mandibular infection
• Osteomyelitis of Maxilla more common in neonate .
• Sever throbbing pain , deeply sited pain .
• Swelling ,malaise and pyrexia
EARLY :
Gingiva red swollen and tender, involved teeth tender and mobile .
LATE :
Intra and extra-oral pus discharge
FINAL:
• Subperiosteal bone formation cause swelling to become firm
• Regional L.N enlargement
• Paresthesia of lower lips .
• Trismus
● Radiographic:
in the early stages is normal. After 10-14 days bone resorption
produces irregular, moth-eaten radiolucency. Dead bone
appears as dense radio-opaque areas become more sharply
defined as they separated as sequestra.

● Pathology
The mandible is much more frequently involved than the
maxilla ,because the vascular supply is readily compromised.
Thrombosis of the mandibular artery or its branching leads to
extensive necrosis of bone. In contrast, maxilla has rich
collateral circulation.
Histopathology:
❑ The bone marrow undergoes liquefaction, and a purulent
exudate occupies the marrow space. A large number of
neutrophils with the occasional presence of lymphocytes
and plasma cells are seen.
❑ Some areas of affected bone undergo necrosis with
degeneration of both osteoblasts and osteocytes and result
in the development of sequestrum, It is a dead piece of
bone appears with empty lacunae and eroded scalloped
outline which is produced by osteoclastic resorption.
Management:
1. Swab from the depths of the lesion needed for culture and
sensitivity testing, antibiotic for 4-6wks.
2. Debridement and drainage and immobilise of fracture, removal
of loosening tooth and sequestrum.

Complications :
➢Anesthesia of the lower lip usually recovers with the elimination
of the infection.
➢Pathological fracture caused by extensive bone destruction.
➢Cellulitis due to the spread of exceptionally virulent bacteria or
septicemia in an immune deficient patient.
Chronic suppurative osteomyelitis
Persistent low-grade jaw infection, associated with bone
destruction and granulation tissue formation, but little
suppuration.
It results from:
1) inadequately treated acute osteomyelitis.
2) as a complication of irradiation.
3) as a result of infection by weakly virulent bacteria or in
avascular bone.
Clinical features:
▪Long-lasting mild and dull pain in the jaw which has developed
following an acute tooth abscess, tooth fracture or extraction.
▪Sinus tracts may develop intraorally or extra orally with the
discharge of purulent materials.
▪Tooth lose with the development of sequestrum
Radiograph:
Moth-eaten radiolucent area (patchy ill-defined radiolucency) in the
bone with poorly defined margins. Radiopaque foci represent areas of
sequestrum formation.
Histopathology:
Lymphocytes, plasma cells, and macrophages are predominant with
an accumulation of exudates within medullary spaces. Osteoblastic
and osteoclastic activities occur parallel with the formation of
irregular bony trabeculae having reversal lines. Sequestrum also may
be seen.
Chronic non-suppurative osteomyelitis (sclerosing osteomyelitis)
Localised bone reactions to a source of inflammation or infection
with no suppuration or infiltration of marrow spaces by
inflammatory cells and bacteria are not readily cultivable.

1- Chronic Focal is sclerosing (condensing osteitis):

Clinical features:
It is usually asymptomatic, localised area of bone sclerosis associated
with the apices of teeth. The associated tooth usually presents a
large carious lesion. The condition is asymptomatic or associated
with mild pain.
It is most commonly at the apex of the first permanent molar and
remains as a sclerotic area of bone following extraction.
Radiograph:
Localized but uniform increase radio-opacity (not surrounding by
RL) around the apex of the involved tooth.
Histopathology:
localized increase in the number and thickness of the bone
trabeculae with scattered lymphocytes and plasma cells in the
surrounding scanty fibrosed marrow.
Treatment:
Eliminate the source of inflammation.
2- Chronic diffuse sclerosing osteomyelitis:

It is a proliferative reaction in response to low-grade inflammation

or infection in the jaw bone. The infection is widespread in nature
and is derived from the periodontal tissue or pericoronitis, or
multiple periapical tissues.
Clinical:
Usually seen among elderly people. The mandible is mostly
affected, and sometimes all four quadrants of both jaws could be
affected at a time. The disease is asymptomatic, but sometimes
the patient may complain of vague pain in the jaw with a foul taste
in the mouth. Acute exacerbation may occur and produces mild
pain and suppuration.
Radiograph:
multifocal areas of sclerosis (resembles cotton wool radiopacities
seen in Paget’s disease of bone and florid cemento-osseous
dysplasia)
Histopathology:
Bone sclerosis and remodelling with scanty marrow spaces and
little or no inflammatory infiltrate.
Treatment:
Elimination source of inflammation, but sclerotic areas remain
radiographically.
Chronic osteomyelitis with proliferative periostitis :
(Garré osteomyelitis, periostitis ossificans, juvenile mandibular
chronic osteomyelitis).
Characterized by a proliferative subperiosteal reaction (periosteal
osteosclerosis) rather than inflammation of the interior of the
bone. It is essentially a periostitis rather than osteomyelitis.
Clinically:
It appears as bony hard non-tender swelling (expansile) on the
outer surface of the mandible in children and young adults. The
involved jaw often presents a carious non-vital tooth. The
periosteal reaction is thought to result from the spread of a low-
grade, chronic apical inflammation through the cortical bone,
stimulating a proliferative reaction of the periosteum. It associated
with mandibular nerve canal enlargement.
Radiography:
There is a mixed lytic and sclerotic process that evolved over time.
The periapical lesion associated with a carious tooth. The occlusal
radiograph shows smooth, convex, boney overgrowth on the outer
cortex of the jaw, and exhibited many concentric opaque layers
producing a typical onion skin appearance . Few newly formed
boney trabeculae are often oriented perpendicular to the onion
skin layers.
Histopathology:
Supra-cortical and subperiosteal parallel layers of highly cellular
woven bone interspersed with scantily inflamed connective tissue.
Treatment: a root canal or tooth extraction. The bone gradually
remodels after 6 to 12 months.
Thank you