osteomyelitis pdf - د.ظفر (كلاسرووم)

Stage/2020

University of Mosul

College of Dentistry

Oral & Maxillofacial Surgery
Department

4

Stage/2020

Osteomyelitis

Osteomyelitis is an inflammatory condition of the bone, which begins as an infection of the

medullary cavity, rapidly involves the haversian systems, and extends to involve the periosteum

of the affected area.

Classification

The general categories of osteomyelitis of the jaws include:

1. Suppurative.

2. Primary.

3. Chronic sclerosing.

4. Osteomyelitis with proliferative periostitis (Garre osteomyelitis).

The vast majority of osteomyelitis cases are caused by bacterial infections and result in an

expanding lytic destruction of the involved bone, with suppuration and sequestra formation.

This condition is more appropriately termed suppurative osteomyelitis, bacterial

osteomyelitis, or secondary osteomyelitis. Traditionally, Staphylococcus species were the

predominant bacteria involved as in the other bones of the body, although it is known now that

several other organisms may contribute to the disease process. The microbiologic profile most

often present in cases of osteomyelitis of the mandible includes Streptococci spp., as well as

anaerobic bacteria, such as Bacteroides or Peptostreptococcus.

Primary chronic osteomyelitis, by contrast, does not respond consistently to antibacterial

medications and typically demonstrate ultimate sclerosis of bone without suppuration or

sequestra formation.

Stage/2020

University of Mosul

College of Dentistry

Oral & Maxillofacial Surgery
Department

4

Stage/2020

Predisposing factors:

Though the marrow of the maxilla and mandible are often exposed to periapical pathogens,

osteomyelitis is rare. This is because host defenses usually localize the infection to a periapical

abscess and limit the progression. However, some conditions increase the incidence of the

occurance such as;

• Chronic systemic diseases.

• Immunocompromised status.
• Disorders associated with hypovascularized bone (e.g., osteopetrosis, dysosteosclerosis,

late Paget disease, end-stage cementoosseous dysplasia).

• Tobacco use, alcohol abuse, IV drug abuse.
• Diabetes mellitus.

• Malaria.
• Sickle cell anemia.

•  Malnutrition.
•  Malignancy.
•  Collagen vascular diseases.

• AIDS.
• Radiation

Note

Osteomyelitis is more common in the mandible than the maxilla; this
is  due  to  the  fact  that  the  blood  supply  to  the  maxilla  is  multifocal
and  robust,  which  is  in  contrast  with  the  mandible  that  primarily
obtains  its  blood  supply  from  the  inferior  alveolar  artery  and
periosteum.  In  contrast,  the  periosteal  blood  supply  to  the  maxilla
penetrates  its  cortex  to  perfuse  the  underlying  porous  bone  much
easier than that of the much thicker cortex of the mandible.

Stage/2020

University of Mosul

College of Dentistry

Oral & Maxillofacial Surgery
Department

4

Stage/2020

1. Suppurative osteomyelitis (Secondary Osteomyelitis)

A. Acute suppurative osteomyelitis exists when an acute inflammatory process spreads

through the medullary spaces of the bone and the patients have signs and symptoms for less

than 1 month in duration.

Clinical features:

Symptoms are pain, tenderness and swelling in the affected area similar to an acute dental

infection . The mandible is affected more frequently than the maxilla. Where the body or lower

ramus of the mandible is affected, an important symptom is a developing numbness over the

chin as a result of inferior alveolar nerve involvement. On occasion, paresthesia of the lower lip,

drainage, or exfoliation of fragments of necrotic bone may be discovered. A fragment of

necrotic bone that has separated from the adjacent vital bone is termed a sequestrum. On

occasion, fragments of necrotic bone may become surrounded by new vital bone, and the dead

bone in this situation is known as an involucrum.

Radiographical findings

Plain dental or panoramic radiographs may demonstrate an ill-defined radiolucency (Fig.1),

occasionally combined with widening of the periodontal ligament, loss of lamina dura, or loss of

circumscription of the inferior alveolar canal or mental foramen. Periosteal new bone formation

also may be seen in response to subperiosteal spread of the infection. Cone-beam CT

represents another excellent alterative with shorter scanning times and lower doses of

radiation when compared to conventional CT.

Stage/2020

University of Mosul

College of Dentistry

Oral & Maxillofacial Surgery
Department

4

Stage/2020

Fig. 1- Acute Osteomyelitis. Ill-defined area of radiolucency of the right body of the mandible

Histopathologic Features

Acute osteomyelitis the biopsy consists predominantly of necrotic bone. The bone shows a loss

of the osteocytes from their lacunae, peripheral resorption, and bacterial colonization (Fig.

3-46). The periphery of the bone and the haversian canals contain necrotic debris and an acute

inflammatory infiltrate consisting of polymorphonuclear leukocytes.

Treatment and Prognosis

Therapy centers around surgical intervention to 1) resolve the source of infection, 2) establish

drainage, 3) removal of obviously infected bone, and 4) obtain bacteriologic samples for culture

and antibiotic sensitivity testing. While waiting on the bacteriologic evaluation, antibiotics are

administered empirically, usually penicillin with metronidazole or clindamycin. Antibiotics

should be continued for at least 2 weeks after control of the acute infection.

Stage/2020

University of Mosul

College of Dentistry

Oral & Maxillofacial Surgery
Department

4

Stage/2020

Summary of management of acute osteomyelitis

➢ Essential measures

• Bacterial sampling and culture

• Vigorous (empirical) antibiotic treatment

• Drainage

• Analgesics

• Give specific antibiotics once culture and sensitivities

• Debridement

• Remove source of infection, if possible

➢ Adjunctive treatment

• Sequestrectomy

• Decortication if necessary

• Resection and reconstruction for extensive bone destruction

B. Chronic suppurative osteomyelitis

If acute osteomyelitis is not resolved expeditiously, the entrenchment of chronic osteomyelitis

occurs; or the process may arise primarily without a previous acute episode. Chronic

osteomyelitis exists when the defensive response leads to the production of granulation tissue,

which subsequently forms dense scar tissue in an attempt to wall off the infected area. The

encircled dead space acts as a reservoir for bacteria, and antibiotic medications have great

difficulty reaching the site. This pattern begins to evolve about 1 month after the spread of the

initial acute infection and results in a smoldering process that is difficult to manage unless the

problem is approached aggressively.

Stage/2020

University of Mosul

College of Dentistry

Oral & Maxillofacial Surgery
Department

4

Stage/2020

Clinical features

Swelling, pain, sinus formation, purulent discharge, sequestrum formation, tooth loss, or

pathologic fracture may occur. Patients may experience acute exacerbations or periods of

decreased pain associated with chronic smoldering progression.

Radiographical findings

Radiographs reveal a patchy, ragged, and ill-defined radiolucency that may contain central

radiopaque sequestra and be intermixed with zones of radiodensity (Fig.2).

Fig.2- Chronic Osteomyelitis. Ill-defined area of radiolucency of the right body of the mandible adjacent to a

recent extraction site.

Stage/2020

University of Mosul

College of Dentistry

Oral & Maxillofacial Surgery
Department

4

Stage/2020

Histopathologic Features

Biopsy material from patients with chronic osteomyelitis demonstrates a significant soft tissue

component that consists of chronically or subacutely inflamed fibrous connective tissue filling

the intertrabecular areas of the bone (Fig. 3-47). Scattered sequestra and pockets of abscess

formation are common.

Treatment and Prognosis

Chronic osteomyelitis is difficult to manage medically, presumably because pockets of dead

bone and organisms are protected from antibiotic drugs by the surrounding wall of fibrous

connective tissue.

1. The antibiotic medications are similar to those used in the acute form but must be given

intravenously in high doses.

2. Surgical intervention is mandatory. The extent of the surgical intervention depends on

the spread of the process; removal of all infected material down to good bleeding bone

is mandatory in all cases.

➢ For small lesions, curettage, removal of necrotic bone, and saucerization are sufficient.

➢ For extensive osteomyelitis, decortication or saucerization often is combined with

transplantation of cancellous bone chips.

➢ For persisting osteomyelitis, resection of the diseased bone followed by immediate

reconstruction with an autologous graft is required. Weakened jawbones must be

immobilized. Scintigraphic techniques with technetium-99m (99mTc)-labeled

phosphorus compounds can be used to evaluate the therapeutic response and progress

of treatment. Hyperbaric oxygen is recommended primarily for the rare patient who

Stage/2020

University of Mosul

College of Dentistry

Oral & Maxillofacial Surgery
Department

4

Stage/2020

does not respond to standard therapy or for disease arising in hypovascularized bone (e.g.,

osteoradionecrosis, osteopetrosis, Paget disease, and cemento-osseous dysplasia).

2. Primary Chronic Osteomyelitis

Affected patients have recurrent episodes of pain, swelling, local induration, and limited mouth

opening that is not associated with any obvious dental infection. During periods of disease

activity, regional lymphadenopathy and reduced sensation in the distribution of the inferior

alveolar nerve may be present. Absence of fever, purulence, sequestration, and sinus formation

are characteristic. The lack of an obvious association with an odontogenic infection and the

nonsuppurative presentation clearly separate this condition from chronic suppurative

osteomyelitis. one of the proposed causes is an alteration of immune response to an organism

of low virulence. The predominant radiographic alteration of primary chronic osteomyelitis is

medullary sclerosis.

Treatment

Even with significant surgical and medical intervention, the disease course is characterized by

flares separated by partial remissions. Most treatments directed toward elimination of

infection have been proven ineffective. Long-term antibiotic treatment with or without

hyperbaric oxygen therapy has not produced consistent long-term success. Surgical

decortication has decreased the intensity and frequency of symptoms but has failed to resolve

the process totally. Because of inconsistent results from surgical intervention, extensive surgery

is contraindicated, especially in young, growing patients. Corticosteroid medications, NSAIDs,

calcitonin, and tumor necrosis factor-α antagonists have been reported to relieve symptoms

but usually are associated with incomplete resolution. In a number of publications, IV

Stage/2020

University of Mosul

College of Dentistry

Oral & Maxillofacial Surgery
Department

4

Stage/2020

administration of bisphosphonates has shown significant therapeutic benefits with reduction of

symptoms and radiographic resolution of bony abnormalities

3. Chronic Sclerosing Osteomyelitis

This rare form of osteomyelitis is an intramedullary bone infection with one of the Actinomyces

species as well as Eikenella corrodens as the offending organisms. The combination of these

two organisms produces a sclerosis and fibrosis of the medullary space. The pathognomonic

clinical sign is intense pain. This pain may fluctuate along with acute exacerbations of

mandibular expansion and soft tissue edema. Usually a chronic dull pain is always present. In

general, there is no purulence of drainage present. Symptoms may persist for up to 5 years

before recognition and establishment of a diagnosis. Radiographically, there is an increased

trabecular bone density is present in the alveolar and basal bone of the mandible.

Treatment

Although antibiotic therapy, combined with or without hyperbaric oxygen therapy, may

mitigate the progression of the disease, surgical resection of the diseased bone is often

required.

4. Osteomyelitis with Proliferative Periostitis (Garre Osteomyelitis)

It is a chronic disease that usually affects children due to their increased vascularity and

regenerative capabilities. The most notable radiographic finding is paracortical bone formation

(“onion-skinning”) due to repetitive irritation of the periosteum usually associated with a

periapical infection of the mandibular tooth (Fig. 17.25). Clinically there is expansion of the

mandible with pain, but no purulence, drainage, or erythema. Removal of the infectious source

is of paramount importance, and biopsy is considered when a source of infection is not

Stage/2020

University of Mosul

College of Dentistry

Oral & Maxillofacial Surgery
Department

4

Stage/2020

identified because malignancy may have similar radiographic findings.

Radiographical findings

Extracortical bone formation in the form of woven bone in layers parallel to the cortex

connected by bridges of bone perpendicular to the cortex is seen.

Treatment

Removal of the offending infectious source a short course of antibiotic therapy (penicillin,

tetracycline, or clindamycin) until the bone inflammation resolves spontaneously.

Alveolar osteitis (dry socket ; fibrinolytic alveolitis)

Alveolar osteitis (dry socket) is the most frequent painful complication of extractions. It is not

really an infection but leads to superficial bacterial contamination of exposed bone and can

progress to osteomyelitis. Osteitis simply means inflamed bone, not infection. The prevalence is

between 1% and 3% of all extractions, but it increases to 25% to 30% for impacted mandibular

third molars.

The cause is early loss of clot from the extraction socket due to excessive local fibrinolytic

activity. The alveolar bone and gingiva have a high content of fibrinolysin activators (plasmin),

that are released when the bone is traumatised, degrading the clot and leaving the socket

empty. Once the clot has been destroyed, bacterial colonisation from the mouth is inevitable,

and bacterial enzymes contribute to clot lysis.

Stage/2020

University of Mosul

College of Dentistry

Oral & Maxillofacial Surgery
Department

4

Stage/2020

➢ Predisposing factors for alveolar osteitis

• Difficult disimpactions of third molars or traumatic extractions.

• Lower molar region, where the bone is denser and less vascular than elsewhere.

• Limited local blood supply.

• Gingival infection such as acute ulcerative gingivitis, pericoronitis or abscess.

• Local anaesthesia with vasoconstrictor.

• Smoking.

• Oral contraceptives. The oestrogen component of oral contraceptives enhances serum

fibrinolytic activity and interferes with clotting, and its use is associated with a higher incidence

of alveolar osteitis.

• Osteosclerotic disease: Paget’s disease, cementoosseous dysplasia.

• Radiotherapy.

• History of previous dry socket.

➢ Clinical features

Patients aged 20–40 years are most at risk, and women are more frequently affected if oral

contraceptive use is taken into account.

Typically, pain usually starts a few days after the extraction, but sometimes may be delayed for

a week or more. It is deep-seated, severe and aching or throbbing. On occasion, the pain

radiates from the socket to the ipsilateral ear, temporal region, or eye.

other symptoms include foul odour, and (less frequently) swelling and lymphadenopathy

develop 3 to 4 days after extraction of the tooth. Rarely, trismus also may be noted. The signs

and symptoms may last from 10 to 40 days.

The mucosa around the socket is red and tender. There is no clot in the socket, which contains,

Stage/2020

University of Mosul

College of Dentistry

Oral & Maxillofacial Surgery
Department

4

Stage/2020

instead, saliva and often decomposing food debris. When debris is washed away, whitish, dead

bone may be seen or may be felt as a rough area with a probe and probing is painful. The

appearance of an empty socket and exposed bone is diagnostic. Sometimes the socket becomes

concealed by granulations growing in from the gingival margins, narrowing the opening and

trapping food debris. Pain often continues for a week or two, or occasionally longer.

Sequestration of the socket wall may sometimes be seen radiographically (Fig. 8.3), but a

radiograph performs no useful purpose except to exclude retention of a root fragment.

➢ Prevention of dry socket

• Preoperative infection control

• Scaling teeth before extraction

• Chlorhexidine rinsing preoperatively and for 3 days postoperatively

• Atraumatic extraction

•Immediately after the extraction the socket edges should be squeezed firmly together and

held for a few minutes until the clot has formed.

• For norma patients, the value of prophylactic antibiotics is unproven, and there is no

indication for using antibiotics for routine dental extractions.

• Patients who have had irradiation for oral cancer or have sclerotic bone disease,

postoperative antibiotic cover should be given and the tooth removed surgically to cause as

little damage as possible to surrounding bone. Antibiotics are given primarily to prevent

osteomyelitis rather than dry socket.

• Adherence to postoperative instructions

• No rinsing or forceful spitting

• No hot fluids

• No smoking

Stage/2020

University of Mosul

College of Dentistry

Oral & Maxillofacial Surgery
Department

4

Stage/2020

• Postoperative antibiotics only for those at particular risk.

• It is important to explain to patients that they may have a week or more of discomfort. It is

also important to explain that the pain is not due, as patients usually think, to a broken root.

➢ Treatment

The aim of treatment is to control symptoms, keep the open socket clean and to protect

exposed bone from excessive bacterial contamination until healing is complete, usually after

approximately 10 days.

➢ Cleaning: The socket should be irrigated with mild warm antiseptic or saline to remove

all food debris. Curettage of the socket is not recommended, because this typically

increases the associated pain.

➢ Dressing: It is then traditional to place a dressing into the socket to deliver analgesia and

close the opening so that further food debris cannot enter the socket. Many socket

dressings have been formulated and should be antiseptic, obtundent, adhere to the

socket wall, and be absorbable. Whatever is used, the minimum dressing to close the

socket opening is used because dressing packed hard into the socket will delay healing.

Non-absorbable dressings must be removed as soon as possible to allow the socket to

heal. A dressing may only last 1–2 days, and the whole process needs repeating until

pain subsides, normally after one or two dressings. Frequent hot saline mouthwashes

also help keep the socket free from debris.

➢ Analgesic prescription.

Stage/2020

University of Mosul

College of Dentistry

Oral & Maxillofacial Surgery
Department

4

Stage/2020

Case scenario

Please, read the following senario then explain your management (diagnosis & treatment) of

this case based on the clinical and radiographical presentation

A 48-year-old man reported to the Department of Oral and Maxillofacial Surgery, with an

extraorally draining sinus in the left anteroinferior border of mandible and a foul odor from the

oral cavity for 4.5 months. The patient also complained of paresthesia of the left lower lip for

the previous 1.5 months. The patient reported having pain in the lower left back of the jaw 4.5

months previously.The patient visited a local dentist who extracted the left mandibular second

premolar and first and second molars; following the extractions, pain decreased but the

draining sinus and dull continuous pain persisted. As the condition did not improve, the patient

presented to Oral and Maxillofacial Surgery department for definitive treatment. A panoramic

radiograph was taken, which revealed bifocal radiolucent areas extending between left

mandibular first premolar and third molar.

Note

The  colonisation  of  the  socket  and  sequestra  by  oral  bacteria
probably  contributes  to  pain  and  slow  healing.  Anaerobes  are
thought  to  be  significant  and  can  produce  fibrinolytic  enzymes.
However,  antibiotics  including  metronidazole  have  not  been
shown to either prevent dry socket or speed healing reliably. Only
chlorhexidine  rinsing  preoperatively  has  been  shown  to  reduce
incidence.

Stage/2020

University of Mosul

College of Dentistry

Oral & Maxillofacial Surgery
Department

4

Stage/2020