Osteomyelitis of Jaw

Presenter Dr Tegegne, R I
Moderator Dr Tewodros Tefera
(OMFS Consultant )

[Link] G 1
 Outlines
• Introduction
• Predisposing factors
• Etiologies & microbiologies
• Pathogenesis
• Clinical presentation
• Classification
• Investigations
• Complications
• Management
• Osteoradionecrosis
[Link] G 2
 Introduction
• Osteomyelitis is defined as an inflammation
of the bone marrow that later also involves
adjacent cortical plates& periosteal tissues.
– In the preantibiotics era, osteomyelitis of the
mandible was common.
– With the advent of antibiotics, it became a rare
disease.

[Link] G 3
• In recent years antimicrobials have become
less effective(resistant strain) & is major
diagnostic and therapeutic challenges
• Despite modern therapy it can still remain a
major source of morbidity to the patient that
requires multiple surgeries & resulting in
prolonged treatment duration.

[Link] G 4
• The incidence of osteomyelitis is much higher
in the mandible than maxilla due to
• Less vascularized cortical plate of
mandible
• More dense cortical part of mandible
• More prevalent in male than female
• Affects all age groups infant to elderly

[Link] G 5
 Predisposing factors
• Diminished host defenses
• Compromised vascular supply
• Virulent micro organisms are the 3 main risk
factors for osteomyelitis of jaw
• These risk factors can be
• Systemic factors
• Local factors

[Link] G 6
 Systemic factors
• Diabetes , anaemia
• Autoimmune states,agranulocytosis
• Malignancies,leukemia ,multiple myeloma
• Malnutrition and aging
• Acquired immunodeficiency syndrome.
• Steroids therapy
• Chemotherapeutic agents
• Bisphosphonates.
[Link] G 7
 Local factors
Local conditions that adversely affect the blood supply
can also predispose the host to a bony infection.
• Radiation therapy
• Bone pathology
• Paget diseases
• Fibrous dysplasia
• Osteopetrosis
• Osteoporosis

[Link] G 8
• Trauma
• Odontogenic causes
• Soft tissue injuries
• Soft tissue infections
– Furnuncles
– Carbuncle

[Link] G 9
 Etiologies
[Link] causes
Dental caries
Gingival
periodontal diseases
[Link] odontogenic causes
Untreated compound fracture
Gingival or soft tissue lacerations
Bacterial skin infection ( carbuncle ,furnucle)
Hematogenous spread
[Link] G 10
 Pathogenesis
• In the maxillofacial region, osteomyelitis primarily
occurs as a result of
• Contiguous spread of odontogenic infections
• Trauma
• Primary hematogenous osteomyelitis is rare in the
maxillofacial region
• It generally occurs in the very young age

[Link] G 11
• The adult process is initiated by an inoculation
of bacteria into the jawbones
• This can occur with the extraction of
teeth,RCT, or fractures of Jaw bones.
• This initial insult results in a bacteria induced
inflammatory cascade

[Link] G 12
• In the normal healthy host, this process is self-
limiting and Is healed
• Occasionally, however, in the normal host, and
certainly in the compromised host, there is
the potential for this process to progress to
the point where it is considered pathologic.
• With inflammation there is hyperemia&
increased blood flow to the affected area.

[Link] G 13
• Additional leukocytes are recruited to this
area to fight off infection.
• Pus is formed when there is an overwhelming
supply of bacteria and cellular debris
• that cannot be eliminated by the body’s
natural defense mechanisms.

[Link] G 14
• Pus and subsequent inflammatory response
occur in the bone marrow that leads to
• An elevated intramedullary pressure that
decreases the blood supply to this region

[Link] G 15
• The pus can travel via haversian and
Volkmann’s canals to spread throughout the
medullary and cortical bones.
• Pus has perforated the cortical bone and
collects under the periosteum
• the periosteal blood supply is compromised
• That results in avascular necrosis of bone

[Link] G 16
• Finally the pus exits the soft tissues either by
• Intraoral sinuses or fistulas
• Extraoral sinuses or fistulas

[Link] G 17
• Dental caries /trauma → pulpal
involvelvement→ periapical pathologies →
edema and pus→ increase intramedullary
pressure → compromise blood supply→
edema and pus spread by volkman canal and
haversian canal and accumulates under
cortex

[Link] G 18
→ Involves periosteal layer → compromise
periosteal blood supply→ avascular bone
necrosis → involves soft tissue and skin →
fistulas and sinuses

[Link] G 19
[Link] G 20
 Microbiology

• In the past, staphylococcal species were

[Link] G 21
• The anaerobes responsible are Bacteroides or
Pepto streptococci
• Often, the infections are mixed as of final
culture

[Link] G 22
 Other bacteria that causes OML
• Actinomycotic bacteria
• Mycobateria
• Spirochetes like treponema pallidum

[Link] G 23
 Clinical presentation
 Prevalent in elderly&immuno compromised
and smoker patients.
 Rarely in infant and younger ages
 Presentation differs according to its acute
suppurative ,sub acute ,chronic suppurative
and non suppurative stages

[Link] G 24
 Acute suppurative stage
• It is called intramedulary stage that lasts for 10 to 14
days &characterized by
• Deap intense pain
• Fever
• Paresthesia of lower lip
• Identifiable cause
• Minimal swelling
• No teeth mobility
• No fistula
[Link] G 25
• Leukocytosis
• Increased ESR
• Increased CRP
• Positive radionuclide bone scan

[Link] G 26
 Sub acute stage(Periosteal OML )
• Un treated acute stage changed to sub acute stage after 14
days to 1 month duration and characterized by:
– Mobility of teeth
– Firm cellulitis of cheek
– Expansion of bone
– Mucsal or cutaneous fistula
– Halitosis
– Lymphadenopathy
– Normal temperature and WBC

[Link] G 27
 Secondary chronic stage
• Untreated acute or subacute stage changed to
2ndary chronic after 1month
• Fistula
• Sequestra
• Induration of soft tissues
• Thicken or wooden character of affected area
• Pain and tenderness to palpation

[Link] G 28
 Primary chronic stage
• Is also known as chronic suppurative stage where it
may arises from haematogenous spread or rarely
lymphogenous route
• This has no any acute stage
• Mild pain
• Slow increase in bone size
• Sequestra
• No fistula

[Link] G 29
 Non suppurative stage
• They are chronic OML that is caused by
• low grade infections
• No pus formation
• They are chronic
• Has bone deposition around the periosteum

[Link] G 30
 Classification
• There may ways of classification of OML of jaw
• The two common applicable OML classification are
• Zuric classification &
• literature classification

[Link] G 31
 Literature classification
[Link] OML [Link] suppurative OML
[Link] suppurative [Link] oml
[Link] suppurative • Diffuse &
• Primary • Focal/osteotitis
• Secondary [Link] periostitis
[Link] OML • Garres sclerosing
C. Other OML are : [Link]
– Actinomycotic
– TB, Syphilis
– Chemical&cautery

[Link] G 32
 Zuric classification
• This classification is widely accepted and classify
OML interms of etiology ,pathogenesis ,clinical
features ,radiology and histopathological features
• So OML is classified as
• Acute osteomyelities
• Secondary chronic
• Primary chronic

[Link] G 33
[Link] G 34
[Link] G 35
 Diagnosis &Investigations
• laboratorical and imagings are used to investigate OML .
• Laboratorical investigations are very sensitive & non specific
• Shows acute stages & clinical progression
• These includes :
– WBC……leukocytosis
– Gram stain , culture
– ESR
– CRP &Biopsy

[Link] G 36
• In acute stage 4 to 14 days , history taking clinical
features & bone scan are more important for
investigation of OML
• In established cases ,radiograph are more useful

[Link] G 37
 Maxillofacial imagings
• Imagings are used to show destructed parts of bone ,
the location of OML , risk factors like trauma and
predisposing bone pathologies
• However , at least 30 % to 50% of cortical bone has
to be destructed to be seen on radiograph
• They are less important for acute stage than clinical
presentations

[Link] G 38
• OPG,IOPA
• CT
• MRI….. Bone marrow inflammation
• Nuclear Bone scan (Tc 99, Ga 67 ,In 111) contains
labeled methylene diphosphonate
• Show bone turn over
• Non specific and are sensitive
• Used as contrast media
• Bind to WBC that shows infection
[Link] G 39
 Radiologic features
[Link] eaten appearance
• Shows scattered area of bone destructions
[Link] and involucrum
[Link] or granular densification of bon
• Sclerosing OML
[Link] skin appearance
• Garres oml

[Link] G 40
[Link] G 41
[Link] G 42
[Link] G 43
[Link] G 44
[Link] G 45
[Link] G 46
 DDx
• Fibrous dysplasia
• Paget diseases
• Osteoporosis & osteopetrosis
• Leukemia
• Multiple myeloma
• Ewings sarcoma
• Osteosarcoma

[Link] G 47
 Complication
• Osteonecrosis
• Pathologic fracture of bone
• Septicemia &thromboembolism
• Continuity defects
• Septic arthritis
• Impaired growth
• Skin cancer & osteosarcoma

[Link] G 48
 Treatment
• Medical therapy
• Surgical therapy
• Supportive therapy
– Analgesics and bed rest
– High protein diet
– Vitamin diet
– High fluid intake
– Treat the underlying causes

[Link] G 49
 Medical therapy
Systemic antibiotics
[Link] G 2million units IV 6x/ day plus
metronidazole #2 to 3 day& then continues :
– Pencillin V 6x/day po plus metronidazole 500mg
tid po for 2 to 6 weeks

[Link] G 50
[Link] allergic pt
[Link] 600mg iv QID for 2 to 3 days &then
– Clindamycin 300mg po QID for 2 to 6 weeks or
[Link] 1g iv tid for 2 to 3 days and then
– Cephalexin 500mg po tid or
D. Vancomycine 1G iv bid

[Link] G 51
• Resistant and recurrent OML that is caused by
methiline resistant staphylococus and vancomycine
resistant enterococci are treated by
• Tigecycline
• Linezolid

[Link] G 52
 Surgical therapy
• There 6 options of surgical management of OML
depending on its extent of involvement
• Exodontia
• I&D
• Sequestrectomy
• Saucerization
• Decortication
• Resection & reconstruction

[Link] G 53
• Sequestreomy ,saucerization and decortication are
basically the same procedure that differs by
invasiveness of the procedure.
• Sequestrectomy is removal of sequestrum that is
localized only at the center of the bone

[Link] G 54
• Saucerization is removal of sequetrum along with
lateral portion of cortical part of the bone
• Decortication is more extensive procedure that
involves removal of sequestrum ,lateral and inferior
part of the cortex

[Link] G 55
[Link] G
56
 ORN
• Osteoradionecrosis is a chronic nonhealing wound
that is hypoxic,hypocellular& hypovascular
• In years past, the radiation therapist used ortho
voltage therapy &there was a high incidence of ORN.
• However, the modern radiation therapists use
megavoltage which is felt to be kinder to the bone
&soft tissues..

[Link] G 57
• Collimation&shielding of tissues in conjunction with
careful dental evaluation preoperatively have greatly
decreased the incidence of ORN.
• The effects of radiation last a lifetime and do not
decrease over time.
• ORN is generally caused by trauma to the radiated
area usually by dental extraction
• But it can also occur spontaneously

[Link] G 58
• Radiation above 5,000 to 6,000 rads is generally felt
to make the mandible susceptible ORN

[Link] G 59
 Clinical features
• Severe ,deep boring pain in irradiated area
• Trismus
• Swelling
• Soft tissue abscess
• Draining sinuses and fistulas
• Halitosis
• Induration&ulceration of surrounding tissues

[Link] G 60
• Evidence of exposed bone
• Pathological fracture
• Other radiation effects
• Radiation caries
• Mucositis
• Xerostomia
• Food lodgment

[Link] G 61
 Investigation &Diagnosis
• History of radiation
• Clinical features
• Radiographs
• Early stage … no bone changes
• Late stage …sequestrum and pathological #
– OPG
– CT
– MRI

[Link] G 62
 Management
• The main aim of treatment of radionecrosis is to
restore vascular supply and removal of affected by
there by restore revascularization that promote the
body to heal itself
• They can be
• Medical and surgical therapy

[Link] G 63
• Tissue removed in a prior cancer patient should be
sent to pathology
• To rule out occult or recurrent malignant diseases
that masquerade as a bony infection

[Link] G 64
 Medical therapy
• Pain alleviation by narcotics and nerve blocks
• Local wound debridement and packing every 7days
by neomycine and ZOE
• Antiobiotis therapy
• HBO
• U/S Therapy
• Adequate nutrition

[Link] G 65
 Hyperbaric oxygen therapy
• HBO is one dive therapy that consists of 100 %
oxygen at 2.4 Atmospheric pressure in 90 minutes
• Frequency of therapy is 5 times per week
• Duration of therapy 30 dives and or 10 dives

[Link] G 66
 Beneficial effects
• Enhances WBC lysosomal activity
• Neutralize bacterial toxins
• Bactericidal and anti oxidant to anaerobes
• Promote wound healing and collagen synthesis
• Neoangiogenesis effect
• Increased oxygen perfusion to hypoxic areas

[Link] G
67
 Clinical applications
• ORN
• OML
• Air embolism
• CO poisoning
• Mucormycosis
• Promote bone graft healing and flap uptake

[Link] G 68
 Contraindication
• Optic neuritis
• Immunosuppressive disorder
• COPD
• Claustrophobia

[Link] G 69
 Complication
• Oxygen toxicity
• Seizures
• Tooth and sinus pain
• Visual changes
• High pressure nervous syndromes
• Decompression sickness
• pneumothorax

[Link] G 70
 Marx protocol of HBO
Stage I
30 dives
examine exposed bone

Response no response cutaneous fistula

10 dives stage II pathologic #

response no response

stop stage III

[Link] G 71
 Surgical therapy
• Sequestrectomy
• Bone resection
• Intraoral and extraoral approaches

[Link] G 72
 Prevention
• Extraction before radiation therapy
• All teeth in line of radiation
• Carious and periodontally involved teeth
• Good oral hygiene maintenance
• Fluoride therapy

[Link] G 73
• Atraumatic extraction after radiation therapy can be
treated by :
• Pentoxifylline 400mg bid that ( ↑Blood supply )

• Tocopherol1ooIU daily – anti oxidant

[Link] G 74
 Top tips
• Osteomyelitis &ORN present an ongoing%potentially
difficulty clinical scenario to manage.
• Many patients will receive a combination of surgery
and medical management
• Some patients will ben required to undergo extensive
and potentially disfiguring surgery

[Link] G 75
• The medical management includes antibiotic therapy
and HBO treatment
• Medical therapy may expensive, longer duration &
disruptive to the patient’s life.
• Both of these conditions can be started with simple
dental extraction treatment .

[Link] G 76
• Clinicians must always be vigilant for post-treatment
complications -osteomyelitis and osteoradionecrosis.
• Despite advances in both medical management and
surgical therapy, the absolute answer to the
prevention is the simplest and most effective

[Link] G 77
 References
• Baltensperger –Eyrich jaw osteomyelitis 2009
• Peterson principle of maxillofacial surgery ,2nd
edition

[Link] G 78
Thank you

[Link] G 79