Osteomyelitis of the jaws

DR. ABHITOSH DEBATA,

DEPT OF OMFS, C.I.D.S
1
1
CONTENTS
• INTRODUCTION – DEFINITION
• NORMAL ANATOMY OF BONE – IN BRIEF
• PREDISPOSING FACTORS
• ETIOLOGY
• PATHOGENESIS
• CLASSIFICATION
• CLINICAL TYPES
• COMPLICATIONS OF OSTEOMYELITIS
• DIAGNOSTIC METHODS
• TREATMENT

2
 INTRODUCTION
• “Osseous” in Latin means – Bony

• “Osteon” in Greek means – Bone

• “myelos” means marrow

• “itis” means inflammation

3
Definition :
• Osteomyelitis is an extensive inflammation of a bone. It
involves the cancellous portion, bone marrow, cortex, and
periosteum.
(Laskin 1989)

• Osteomyelitis is defined as an inflammatory condition of bone

primarily involving the soft tissues
(Archer)

4
Bone – anatomy

5
COMPACT BONE

6
Cancellous bone

7
Predisposing factors
Conditions that alter HOST IMMUNITY

- Leukemia
- Severe anemia
- Malnutrition
- AIDS
- IV- drug abuse
- Chronic alcoholism
- Febrile illnesses
- Malignancy
- Autoimmune disease
- Diabetes mellitus
- Arthritis
- Agranulocytosis
8
Conditions that alter vascularity of bone

- Osteoporosis

- Paget’s disease

- Fibrous dysplasia

- Bone malignancy
- Radiation

9
Virulence of the organisms

• Certain organisms precipitate thrombi formation by virtue of

their destructive lysosomal enzymes.

• Organisms proliferate in enriched host medium while

protected from host immunity.

• Marx et al (1992) identified Actinomyces, Eikenella &

Arachnia in some refractile forms

10
etiology
 Odontogenic infections

 Trauma

 Infections of oro facial region

 Infections derived from hematogenous route

 Compound fractures of the jaws.

11
RELATIONSHIP OF EXODONTIA
WITH OSTEOMYELITIS

12
 PATHOGENESIS
DEV OF INFECTION BACTERIAL INVASION PUS
FORMATION SPREAD OF INFECTION INCREASED
INTRAMEDULLARY PRESSURE , BLOOD FLOW , OSTEOCLASTIC
ACTIVITY INFLAMMATORY RESPONSES INCREASED
PERIOSTEAL PRESSURE PROCESS BECOMES CHRONIC
GRANULATION TISSUE FORMATION LYSIS OF BONE
SEQUESTRUM FORMATION

13
 SEQUELAE OF EVENTS
Pulpitis
Acute Chronic
Apical Periodontitis
Acute Chronic Chronic
Periapical Periapical Periapical Periapical
Abscess Granuloma Cyst
abscess

Osteomyelitis
Acute Chronic Focal
Periostosis
Diffuse
Cellulitis Abscess
Bacteraemia Toxaemia Septicemia Dissemination Shock
Death
14
In the jaws…
 Osteomyelitis in maxilla

 Osteomyelitis in mandible

15
Sites of osteomyelitis in jaws

16
• Definition
• Pre disposing factors
• Etiology
• Site

17
 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 , dev skeleton(children)

18
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
(CROML)

d. Diffuse sclerosing – (i) fastidious organisms, (ii)

compromised host pathogen interface
19
• Classification based on clinical picture by Marx
1991; Mercuri1991;Koorbusch1992.
• Classification based on pathogenesis by Vibhagool
1993.
• Classification based on pathological anatomy and
pathophysiology from Vibhagool 1993 and Cierny
1985.
• Zurich classification of osteomyelitis

20
 Classification based on clinical picture,
radiology, and etiology - Topazian
Suppurative osteomyelitis
• 1. Acute suppurative osteomyelitis
• 2. Chronic suppurative osteomyelitis
• – Primary chronic suppurative osteomyelitis
• – Secondary chronic suppurative
• osteomyelitis
• 3. Infantile osteomyelitis

21
Nonsuppurative osteomyelitis
• 1. Chronic sclerosing osteomyelitis
• – Focal sclerosing osteomyelitis
• – Diffuse sclerosing osteomyelitis
• 2. Garre's sclerosing osteomyelitis
• 3. Actinomycotic osteomyelitis
• 4. Radiation osteomyelitis and necrosis

22
 Acute suppurative osteomyelitis
• Serious sequela of periapical infection.

• Leads to spread of pus through the medullary cavities of bone.

• Depending upon the main site of involvement of bone, can be

of two types-

i. Acute intramedullary

ii. Acute subperiosteal

23
 Acute Intramedullary Osteomyelitis
CLINICAL FEATURES:
• Patient experiences dull , continuous pain , indurated swelling
forms over the affected region of jaw involving the cheek ,
febrile.

• When mandible involved, loss of sensation occurs on lower lip

on affected side due to involvement of inferior alveolar nerve.

• Teeth become loose later along with tender on percussion

• Pus discharge , trismus , foul smell , regional
lymphadenopathy , weakness

24
RADIOGRAPHIC FEATURES

• Earliest radiographic change is that trabeculae in involved area

are thin, of poor density & slightly blurred.

• Subsequently multiple radiolucencies appear which become

apparent on radiograph.

• In some cases there is saucer shaped area of destruction with

irregular margins.

• Loss of continuity of lamina dura, seen in more than one tooth.

25
HISTOLOGIC FEATURES:

• Dense infiltration of marrow by polymorphonuclear

leukocytes.

• Bone trabeculae in involved site (sequestrum) are devoid of

cells in the lacunae.
• separation of considerable portions of devitalized bone.

26
Acute Subperiosteal Osteomyelitis
CLINICAL FEATURES
• Pain , febrile condition , i/o and e/o swelling , parasthesia
• Bone involvement limited to localized areas of cortex.
• Pus ruptures rapidly through the overlying cortex, tracks along
the surface of mandible under the periosteal sheath.
• Elevation of periosteum from cortex is followed eventually by
minute cortical sequestration.

27
Radiologic features

28
 Radiologic features

29
 Histologic picture

• Devitalized scalloped edges

• Absence of osteoblasts and

osteocytes

30
 Chronic Osteomyelitis
• As soon as pus drains intra or extraorally, condition ceases to
spread and chronic phase commences.
• Infection is localized but persistent as bacteria are able to
grow in dead bone inaccessible to body’s defenses.

31
Clinical features
• Primary – insidious in onset , slight pain , gradual increase in
jaw size.
• Secondary - Pain is deep pain and intermittent, temperature
fluctuations , pyrexia , cellulitis eventually leading to abscess
• New bone formation leads to thickening causing facial
asymmetry.
• Thickened or “wooden” character of bone in cr sec
osteomyelitis.

• Eventually cures itself as the last sequestra is discharged.

32
 Radiographic
Features
• Trabeculae in the involved area become thin or appear fuzzy & then
lose their continuity.

• After some time “moth eaten” appearance is seen

• Sequestra appear denser on radiographs.

• Where the subperiosteal new bone formation , the new bone is
superimposed upon that of jaw, “fingerprint” or “orange peel”
appearance is seen
33
• Cloacae seen as dark shadows passing through opacity.
Histologic features
• Areas of acute and subacute inflammation in the cancellous
spaces of the necrotic bone.

• Foci of acute inflammation

• Active osteoclastic resorption of bone noted in peripheral

portions

34
 Chronic Subperiosteal
Osteomyelitis
• Cortical plate deprived of its blood supply undergoes necrosis,
underlying medullary bone is slightly affected.

• Multiple small sequestra form, eventually discharged through

sinuses with pus.

• Following extrusion of sequestra, healing occurs.

• Spontaneous drainage poor in submassetric area.

• Much of body of mandible is lost due to poor central blood

supply of the region.
35
 D/D
• Paget’s disease – particularly wen periosteal
bone is involved
• Fibrous dysplasia
• Osteosarcoma

36
Chronic sclerosing osteomyelitis – focal
- diffuse

37
Focal Sclerosing Osteomyelitis

38
Clinical features
• Most commonly in children and young adults, rarely in older
individuals.

• Tooth most commonly involved is the mandibular third molar

presenting with a large carious lesion.

• No signs or symptoms other than mild pain associated with

infected pulp.

39
 Radiographic
features

• Entire root outline always visible with intact lamina dura.

• Periodontal ligament space widened.

• Border smooth & distinct appearing to blend into surrounding

bone

40
D/D for focal sclerosing osteomyelitis
• Local bone sclerosis

• Sclerosing cementoma

• Gigantiform cementoma

41
Treatment & prognosis
• Affected tooth may be treated endodontically or extracted.

• Sclerotic bone not attached to tooth and remains behind after

tooth is removed.

• This dense area may not get remodeled.

• Recognizable on bone years later and is referred as bone scar.

42
 Diffuse Sclerosing Osteomyelitis
• May occur at any age, most common in older persons, esp in
edentulous mandibles
• vague pain, unpleasant taste.

• Many times spontaneous formation of fistula seen opening

onto mucosal surface to establish drainage
• Slowly progressive, not particularly dangerous since it is non
destructive & seldom produces complications

43
Radiographic features
• Diffuse patchy, sclerosis of bone – “cotton wool” appearance
• Radiopacity may be extensive and bilateral.
• Due to diffuse nature, border between sclerosis & normal bone
is often indistinct.

44
D/D for DIFFUSE sclerosing osteomyelitis
FLORID OSSEOUS DYSPLASIA

SCLEROTIC CEMENTAL MASSES

TRUE CHR DIFFUSE SCLEROSING OSTEOMYELITIS

FIBROUS DYSPLASIA

45
Treatment & Prognosis
• Resolution of adjacent foci of chronic infection often leads to
improvement.

• Usually too extensive to be removed surgically,

• Acute episodes treated with antibiotics.

46
Initial results of the treatment of diffuse sclerosing osteomyelitis of the mandible
with bisphosphonates Sophie C.C. Kuijpers Journal of Cranio-Maxillo-Facial Surgery 39
(2011) 65e68

• Study design: Seven patients suffering from

treatment resistant DSO were treated with
intravenous bisphosphonates. Diagnosis was
based on clinical, radiological and
histopathological examination.
• Follow-up varied from 18 to 46 months (mean
30).
47
• Results: In all patients, symptoms and the
need for analgesic drugs diminished
considerably. One patient remained free of
symptoms after one treatment. In two
patients a switch in bisphosphonate was made
based on a decreased response.
• Conclusion: In therapy-resistant DSO
bisphosphonate treatment may be a good
option
48
 Infantile Osteomyelitis
• Osteomyelitis Maxillaries Neonatarum,
Maxillitis of infancy

• Osteomyelitis in the jaws of new born infants occurs almost

exclusively in maxilla.

49
Etiology
• Trauma – through break in mucosa cause during delivery.

• Infection of maxillary sinus

• Paunz & Ramon et al believe that disease caused through

infection from the nose.

• Hematogenous spread through streptococci & pneumococci

50
 Clinical features
• Fever, anorexia & intestinal disturbances.
• swelling or redness below the inner canthus of the eye in lacrimal
region.
• Followed by marked edema of the eyelids on the affected side.
• Next, alveolus & palate in region of first deciduous molar become
swollen.
• Pus discharge from affected sites

51
 D/D for Infantile Osteomyelitis
• Dacrocystitis neonatarum

• Orbital cellulitis

• Ophthalmia neonatarum

• Infantile cortical hyperostosis

52
 TREATMENT
• Intravenous antibiotics, preferably penicillin.

• Culture & sensitivity testing

• Incision & drainage of fluctuant areas

• Sequestrectomy

• Supportive therapy

53
Garre’s Osteomyelitis (Chronic
Osteomyelitis with Proliferative Perosteitis)
• Chronic Non Suppurative Sclerosing Osteitis/ Periostitis
Ossificans.

• Non suppurative productive disease characterized by a hard

swelling.
• Occurs due to low grade infection and irritation
• The infectious agent localizes in or beneath the periosteal
covering of the cortex & spreads only slightly into the interior of
the bone.

• Occurs primarily in young persons who possess great osteogenic

activity of the periosteum.
54
Clinical Features
• Uncommonly encountered, described in tibia and in the head and
neck region, in the mandible.

• Typically involves the posterior mandible & is usually unilateral.

• Patients present with an asymptomatic bony, hard swelling with

normal appearing overlying skin and mucosa.

• On occasion slight tenderness may be noted

• pain is most constant feature

• The increase in the mass of bone may be due to mild toxic
stimulation of periosteal osteoblasts by attenuated infection.
55
Radiographic features

• Laminations vary from 1 – 12 in number, radiolucent

separations often are present between new bone and original
cortex. (“onion skin appearance”)
• Trabeculae parallel to laminations may also be present.

56
Histologic Features
• Reactive new bone.

• Parallel rows of highly cellular & reactive woven bone in which

the individual trabeculae are oriented perpendicular to surface.

• Osteoblasts predominate in this area.

57
D/D for Garre’s Osteomyelitis
• Ewing's sarcoma

• Caffey’s disease

• Fibrous dysplasia

• Osteosarcoma

58
Treatment

• Removal of the offending cause.

• Once inflammation resolves, layers of the bone consolidate in

6 – 12 months, as the overlying muscle helps to remodel.

• If no focus of infection evident, biopsy recommended.

59
 Infective osteomyelitis
• Tuberculous osteomyelitis

• Syphilitic osteomyelitis

• Actinomycotic osteomyelitis

60
 Tuberculous osteomyelitis
• Non healing sinus tract formation
• Age group affected is around 15 – 40 years.

• Commonly seen in phalanges and dorsal and lumbar vertebrae.

• Usually occurs secondary to tuberculosis of lungs.

• Cases have been reported where mandibular lesions were not

associated with pulmonary disease.
• Another common entrance is through a carious tooth via open
pulp.
61
 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.

62
 Actinomycotic Osteomyelitis
• The organisms thrive in the oral cavity, especially tissues adjacent
to mandible.
• May enter the bone through a fresh wound, carious tooth or a
periodontal pocket at the gingival margin of erupting tooth.
• Soft or firm tissue masses on skin, which have purplish, dark red,
oily areas with occasional zones of fluctuation.

• Spontaneous drainage of serous fluid containing granular

material.

• Regional lymph nodes occasionally enlarged.

• Mimics parotitis / parotid tumors
63
 investigations

• CULTURE & SENSITIVITY TESTS

• STAINING and microscopy
• Biopsy
• BLOOD INVESTIGATIONS
• BONE MARROW ASPIRATION
• IMAGING

64
 Imaging
CONVENTIONAL
• IOPA
• OCCLUSAL
• OPG
• LATERAL OBLIQUE
• BONE SCAN
• CT SCAN
• MRI
• POSITRON EMISSION TOMOGRAPHY
65
 Follow-up of acute osteomyelitis in children: the
possible role of PET/CT in selected cases Steven W.
Warmann Journal of Pediatric Surgery (2011)
• Magnetic resonance imaging (MRI) and/or scintigraphy
are commonly used for follow-up in children after
treatment of acute osteomyelitis.
• The PET/CT was superior to MRI in distinguishing
between infection and reparative activity within the
musculoskeletal system in selected children after acute
osteomyelitis. The termination of antibiotic treatment
for children after acute osteomyelitis seems justified
when laboratory parameters as well as clinical
presentation are normal, and PET/CT scan is 66
 treatment
• Goal of management

• Management includes –
 Conservative management
 Surgical management

67
Conservative Management
• bed rest

• Rehydration

• Pain control

• Antimicrobial therapy

68
69
• Erythromycin
• Neoporin irrigants
• Antibiotics impregnated beads

70
 Duration of post-surgical antibiotics in chronic
osteomyelitis : empiric or evidence-based by Rachid
Haidar et al.(International Journal of Infectious
Diseases , 2010)
Despite all of the advances in antibiotic and operative treatment,
osteomyelitis remains difficult to treat. This is because bacteria can
elude host defense mechanisms by hiding intracellularly and by
developing a protective slimy coat. By acquiring a very slow
metabolic rate, bacteria become less sensitive to antibiotics. For all
the above reasons, operative treatment is considered whenever
possible. Osteomyelitis has traditionally been treated with 4–6
weeks of parenteral antibiotics after definitive debridement surgery.
However, this time frame has no documented superiority over other
time intervals, and there is no evidence that prolonged parenteral
antibiotics will penetrate the necrotic bone.
Hence this review article questions the continuous and traditional
use of long-term antibiotic treatment for chronic osteomyelitis in
spite of the advances in surgical treatment using flaps. 71
 Surgical Therapy
• Incision & drainage
• Extraction of loose teeth
• Debridement
• Decortication
• Sequestrectomy
• Saucerization
• Trephination or fenestration
• Resection
• Immediate/ delayed reconstruction
• Postoperative care

72
• SEQUESTRECTOMY
• SAUCERIZATION
• DECORTICATION
• TREPHINATION

73
74
75
 Osteoradionecrosis

• Defined as “exposure of non viable, non healing, non septic lesion

in the irradiated bone, which fails to heal without intervention”.

• One of the most serious complications of radiation to the head

and neck.

• Acute form of osteomyelitis caused by damage to intraosseous

blood vessels.

• Seen in patients receiving more than 60Gy during radiation

therapy

76
 Factors leading to osteoradionecrosis
• Irradiation of area of previous surgery before healing occurs

• Irradiation of lesions in close proximity to bone

• High dose of radiation

• Combination of external radiation and intraoral implants

• Poor oral hygiene and continue use of irritants

77
 Pathogenesis

• Not an infection itself, it is the bone’s reduced ability to heal

resulting in lesions, pain and fragility

78
PATHOGENESIS

RADIATION - NORMAL CELLS DESTRUCTION

ALONG WITH CANCER CELLS –
ENDARTERITIS OBLITERANS – DECREASED
MICROCICULATION – HYPOVASCULARITY –
HYPOXIA - HYPOCELLULARITY

79
Clinical features
• Mandible affected far more frequently than maxilla.

• Trismus , Foetid odour , Pyrexia , Pathologic fracture ,

Sequestration , Dull pain which may continue for weeks or
months , Swelling of face when infection develops

• Soft tissue abscess & persistently draining sinuses

• Exposed bone, associated with intra or extraoral fistulae

80
Radiologic features
• May appear radiolucent, with indefinite nonsclerotic borders
& occasional areas of radiopacity.

• Sequestra & involucra occur late or not at all; due to severely

compromised blood supply.

81
 Steps to avoid Osteoradionecrosis
PRE THERAPY:

• All teeth with questionable prognosis should be extracted

• All restorable teeth should be restored.
• Thorough prophylaxis & topical fluoride application.
• Oral hygiene measures & instructions should be demonstrated
& reinforced.
• Any sharp cusps should be rounded to prevent mechanical
irritation.
• Impressions for fabrication of custom fluoride trays to be used
during treatment.
• Stop habits like tobacco use & alcohol consumption.

82
DURING THERAPY:

• Pt should rinse mouth with saline.

• Chlorhexidine mouth rinses twice daily to minimize bacterial/
fungal levels within mouth.
• Weekly oral hygiene evaluation by dentist.
• If overgrowth of candida albicans – nystatin or clotrimazole
topical application.
• Monitor mouth opening.
• Monitor nutritional status.

83
POST THERAPY

• Dental evaluation every 3 – 4 months.

• Oral prophylaxis.

• Topical fluoride application should be done using custom trays.

• Pt to be instructed in daily self administration of topical

fluoride administration.

• Salivary substitutes should be prescribed.

84
• Restore teeth developing post-radiotherapy caries using
amalgam or composites.

• Extraction of teeth can be carried out with the use of

- Hyperbaric oxygen before & after extraction
- Prophylactic antibiotic

• Evaluate artificial dentures.

85
 Treatment
CONSERVATIVE METHOD:

• Systemic antibiotics
• Selective rinsing with topical antiseptics
• Selective removal of small sequestra
• Curetting & local debridement
• Burring of bone until normal bleeding bone appears.

86
RADICAL TREATMENT

• Debridement
• Control of infection
• Hydration & nutritional supplements
• Analgesics
• Maintaining good oral hygiene
• Frequent irrigation of wounds
• Sequestrectomy
• Bone resection
• Hyperbaric Oxygen therapy

87
 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 for 90
minutes while breathing 100% oxygen twice daily
• Free radicals of oxygen bactericidal to many pathogens.

• Many exotoxins liberated by microorganisma rendered inert by

88
exposure to elevated partial pressure of oxygen.
 Contraindications
• As considered by the HBO Committee of the Undersea Medical
Society, Fisher et al(1988) & Marx et al (1985)

 Pneumothorax
 Severe COPD
 Acute viral infection
 Upper respiratory tract infection
 Uncontrolled acute seizures
 Malignant disease

89
• Evidence for osteomyelitis found in the fossil
record is studied by paleopathologists,
specialists in ancient disease and injury. It has
been reported in fossils of the large
carnivorous dinosaur Allosaurus fragilus

90
 References
• Textbook of Oral Surgery – Topazian
• A textbook of oral pathology – 5th edition; Shafer, Hine &
Levy
• Textbook of Oral & Maxillofacial Surgery – Neelima Anil
Malik
• Textbook of Oral Medicine – Anil Govindrao Ghom
• Oral & Maxillofacial Pathology – Marx & Stern
• Osteomyelitis of the Jaws: Definition and Classification - Marc
Baltensperger and Gerold Eyrich

91