Osteomyeltis of

jaw
Instructor – Dr. Jesus George

1
Definition
 It is an inflammatory condition of bone,
that begins as an infection of medullary
spaces and harvesian systems of the
cortex & extends to involve the
periosteum of the affected area.

2
Etiology
 1-Odontogenic infections-
 Infections originating from pulpal or
periodontal tissue
 Pericoronitis
 Infected socket
 Infected cyst
 Tumor
 2.trauma-
 Compound fracture
 Surgery

3
cont.
 3-Infections of orofacial regions
 Periostitis following gingival ulceration
 Lymph nodes infected from furuncles
 Lacerations
 Peritonsillar abscess
 4-Infection from hematogenous route
 Upper respiratory tract infection
 Middle ear infection
 Systemic TB
 Furuncle of face
 Wound on the skin

4
Microbiology
 Strep.Viridans
 Peptostreptococci
 Fusobacteria
 Bacteriodes
 Klebsiella
 Pseudomonas
 Mycobacterium tuberculosis
 Actinomyces

5
Classification
 Suppurative osteomyelitis
 A/c suppurative
 C/c suppurative
 Infantile
 Nonsuppurative osteomyelitis
 C/c sclerosing
○ Focal sclerosing
○ Diffuse sclerosing
 Garre`s Sclerosing Oml

6
CONT.
 Actinomycotic Oml
 Radiation Oml
 Specific Infective Oml
○ Tb
○ Syphilis

7
A/c suppurative Oml
 Microbiology
 Staph.Aureus
 Strep.Pyogenes
 Spirochetes
 E.Coli
 Etiology
 A-Odontogenic Infections
 Periapical Pathology Secondary To Pulpal
Disease
 Periodontal Disease

8
Cont.
 Pericoronitis
 Infected Odontogenic Cyst
 Infection Of Extraction Wound Or fracture
 B-Local traumatic injuries
 injuries to gingiva
 C-Peritonsillar abscess
 D-Furuncles of skin
 E-Infected compound odontome

9
Cont.
 F-Hematogenous infection
 From minor wounds in skin
 Infection of upper respiratory tract
 Infection of middle ear
 G-Compound # of jaws

10
Cont.
 Clinical features
 Fever
 Malaise
 Nausea
 Vomiting
 Anorexia
 Deep seated boring, continuous intense pain
 Paresthesia or anesthesia of lower lip
 Facial cellulitis

11
Cont.
 Indurated swelling
 Trismus
 Involved tooth is loose & tender to
percussion
 Purulent discharge through sinus
 Fetid odour
 Regional lymphadenopathy

12
c/c suppurative oml
 Clinical features
 Pain & tenderness
 Induration of soft tissues
 Intraoral or extraoral draining fistula
 Enlargement of mandible
 Pathologic #
 Teeth in the area becomes loose & sensitive
to percussion

13
Cont.
 Radiographic features
 In early stage there is widening of marrow
spaces giving a mottled appearance
 Granulation tissue b/w dead & living bone
gives irregular lines & zones of radiolucency
resulting in moth -eaten appearance.
 In later stages the devitalized bone appears
sclerosed & called sequestrum.
 Large areas of bone destruction seen as
radiolucent areas.

14
Cont.
 Subperiosteal new bone the involucrum
seen as linear opacity, or onion skin
appearance.
 Sequestra are separated from adjacent
bone by radiolucent areas.

15
Cont.
 Management
 Conservative management
 Complete bed rest
 Supportive therapy
 Nutritional support
 Hydration
 Oral
 I/v

16
Cont.
 Blood transfusion-if RBC & Hb is low
 Analgesics
 Antimicrobial agents-
 Regimen 1-
 Aqueous penicillin 2 million units IV every 4
hrs
 Oxacillin 1gm 4th hrly
 If the patient is asymptomatic for 48 to 72hrs
penicillin v orally 500mg 4th hrly with
cloxacillin 250mg orally 4th hrly for 2-4 weeks

17
Cont.
 Regimen 2
 Oxacillin
 Dicloxacillin
 In case of allergy to penicillin
○ Clindamycin 300-600mg orally 6th hrly
○ Cefazolin 500mg 8th hrly
○ Erythromycin 2gm 6th hrly i/v then 500mg 6th
hrly orally

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Cont.
 Specific treatment for
 Anemia
 Diabetes mellitus
 Malnutrition
 Hyperbaric o2 therapy
 It involves intermittent, inhalation of 100%
humidified o2 under pressure greater than 1
atm
 It decreases hypoxic environment
 Bactericidal action

19
Cont.
 Exotoxins of micro organisms are rendered
inert by exposure to elevated pressure of 02
 It increases vascular supply
 It aids in healing draining sinus
 Improves osteogenesis
 Surgical management
 Incision & drainage
 It relieves pressure & pain caused by pus.

20
Cont.
 Reduces absorption of toxic products &
prevents further spread of infection
 It can be done by opening the pulp chamber
 It can also be done by making a fenestration
through cortical plate over the apical area
 In an edentulous area, make an incision
over the alveolar crest
 At the angle of mandible a small incision is
made over the point of greatest tenderness.
 Extraction of offending tooth

21
Cont.
 Debridement
 Followed by incision & drainage the area is
irrigated with H2O2 & saline.
 Any foreign body ,necrotic tissue or small
sequestrum is removed
 Decortication
 A buccal flap is created by the crestal
incision
 Mucoperiosteal flap is reflected
 Tooth in the involved area is removed

22
Cont.
 Chronically infected lateral & inferior cortical
plates of bone 1 to 2 cm beyond the area of
involvement is removed
 Bone is thoroughly debrided
 Flap is closed
 Sequestrectomy
 A preoperative radiograph is taken to decide
the site of incision
 Sequestrum usually lies on the surface of
bone & can be removed easily

23
Cont.
 If sequestrum is encased by involucrum ,a
window is made to take it out
 The granulation tissue around the sequestrum
is curetted until healthy bone is exposed.
Antibiotic therapy is continued for 2weeks
 Saucerization
 It is performed when removal of sequestrum
leaves a large cavity
 The buccal cortex is reduced to the level of
unattached mucosa producing a soccer like
defect

24
Cont.
 Trephination or fenestration
 Creation of bony holes or windows in the
cortical bone adjacent to the infectious
process for decompression of medullary
compartment.
 It allows vascular communication b/w
periosteum & medullary cavity.
 Resection
 When extensive portion of bone is involved
resection is performed

25
Ont.
 Reconstruction
 Iliac crest is the graft is used
 Stabilization is achieved with titanium or
vitallium mesh.
 Complications
 Neoplastic transformation
 Discontinuity defects
 Progressive diffuse sclerosis

26
Infantile oml
 It is seen in infants commonly occuring
in maxilla
 Etiology
 Trauma caused to oral mucosa during
delivery
 Infection of maxillary sinus
 Contaminated human or artificial nipples
 Infections from nose
 Hematogenous spread
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Cont.
 Clinical features
 Pyrexia
 Anorexia
 Dehydration
 Convulsions
 Vomiting
 Facial cellulitis centered around the orbit
 Palpebral edema

28
Cont.
 Conjunctivitis
 Proptosis
 Buccal or palatal swelling in maxillary
molar region
 Presence of fluctuation for the sweeling
 Fistulae in the alveolar mucosa
 Microbiology
 Staph.Aureus
 Streptococci
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Cont.
 Radiographic findings
 In later stages sequestra & necrotic
tooth germs
 Complications
 Permanent Optic Damage
 Neurologic Complications
 Loss Of Tooth Buds

30
Cont.
 Treatment
 Antibiotics-penicillins,flucloxacillin or
broad spectrum antibiotics
 Incision & drainage of fluctuant areas
 Irrigation of sinus tracts
 Analgesics
 Antipyretics
 Fluids

31
Cont.
 Nuritious diet
 Sequestrectomy or removal of necrotic
tooth germs

32
Garre`s sclerosing
osteomyelitis
 First described by carl garre
 There is peripheral subperiosteal bone
deposition caused by mild irritation
Etiology
 Carious tooth
 Overlying soft tissue infection
 Clinical features
 Usually involves mandible

33
Cont.
 Disease occurs in children & young
adults
 localized hard, nontender, bony swelling
of lateral & inferior aspects of mandible
 Radiologic features
 Focal area of well calcified bone & has
an onion skin appearance.

34
Cont.
 Treatment
 Removal of infected tooth & curettage of
the socket
 Surgical recontouring
 Endodontic therapy
 Antibiotics

35
C/c sclerosing oml
 Radiographically there are 2 forms
focal & diffuse
 Focal form
 Occures before the age of 20
 It is more common in mandible
 It is associated with infected pulp of
Lower molars & premolars

36
Cont.
 It appears as a circumscribed radio-
opaque mass of sclerotic bone
associated with the tooth roots
 Treated by extraction or endodontic
therapy
 Diffuse form
 It occures both in maxilla & mandible
 Pain & suppuration may be there

37
Cont.
 Radiologically it shows dense radio-
opaque mass
 Treated by debridement,antibiotic
therapy,alveolectomy & hyperbaric o2
therapy

38
Actinomycotic oml of jaws
 Definition
 It is the c/c infection manifesting both
granulomatous & suppurative
features,usually involves soft tissues &
sometimes bone.
 Types
 Cervicofacial
 Thoracic
 Abdominal

39
Cont.
 Clinical features
 Cervicofacial type usually involves
mandible, overlying soft tissues, parotid
gland, tongue & maxillary sinus
 Appears as soft or firm tissue mass on
skin that have a purple, dark red, oily
areas with small areas of fluctuation
 Spontaneous drainage of serous fluid
containing yellowish

40
Cont.
 Granular material called sulphur
granules representing colonies of
bacteria
 Enlarged regional lymph nodes
 Trismus
 Pyrexia
 Radiologic features
 Radiolucent areas of varying sizes

41
Cont.
 Management
 Incision & drainage
 Parentral antibiotics
 Penicillin 10 to 20 million units daily for 3 to
4 months
 If allergic to penicillin tetracycline 250mg 4
times daily for 8 to 16 weeks or
erythromycin 500mg 4 times daily for 6
months
 Sequestrectomy & saucerization
42
Tuberculous osteomyelitis
of jaw bones
 It is a c/c infection caused by
mycobacterium tuberculosis
Clinical features
 The sites commonly involved are ramus
& body of mandible
 The age group is b/w 15 to 40 years
 There are 2 types of presentations
closed & open lesions

43
Cont.
 Closed lesions
 Located centrally in bone.
 It presents as swelling & no draining
sinuses.
 There is absence of oral septic focus.
 Usually ramus of mandible is involved.
 Open lesions
 There is multiple sinuses with mucopurulant
discharge.
 Oral focus may or may not be present
44
Cont.
 Diagnosis
 Aspiration & culture studies-done in
closed lesions
 Radiographs
 OPG
 PA mandible
 Lateral oblique view of mandible.
 Closed lesions are seen as small well
defined radiolucency with destruction of
buccal or medial cortical plates
 45
Cont.
 Chest radiograph
 Mantaux testing-intradermal injection of
5 tuberculous units in 0.1ml solution of
purified protien derivativeis given using
a 27 guage needle.A positive reaction is
seen after 48hrs as erythema &
induration >5 to 10 mm.
 Sputum for AFB-early morning sputum
samples are collected on 3 consecutive
days
46
Cont.
 Biopsy-
 Incisional biopsy is done for open cases.
 Aspiration is done for closed cases
 Treatment
 Antikoch`s treatment-isoniazide,
rifampicin, ethambutol,pyrizinamide for
first 4 months
 Isoniazide, rifampicin for next 4 months

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Osteoradionecrosis of
facial bones
 Definition
 Osteradionecrosis is an exposure of
non - viable , non - healing , non -
septic lesion in the irradiated bone ,
which fails to heal without intervention .
 It is a sequelae of irradiation induced
tissue injury , in which hypocellularity ,
hypovascularity & hypoxia are the
underlying causes .

48
Cont.
 Mechanism
Therapeutic doses of irradiation

Endothelial death, thrombosis &
hyalinsation of blood vessels .

Progressive obliterative endarteteritis
hyalinisation & fibrosis &
thrombosis of vessels
 49
Cont.
Decreased microcirculation

Osteoblasts & osteocytes are destroyed
& marrow spaces in bone become filled
with fibrous tissue .

Decrease of cellularity & vascularity

Hypoxia in irradiated tissue
50
Cont.
 Clinical features .
 Severe , deep , boring pain which may
continue for weeks or months .
 Swelling of face when infection develops
 Soft tissue abscesses & persistently
draining sinuses .
 Exposed bone ; in association with
intraoral or extraoral fistulae .
 Trismus .

51
Cont.
 Foetid odour .
 Pyrexia .
 Pathological fracture

 Radiological fratures .
 Radilucent area with indefinite
nonsclerotic border
 Radioopacity usually associated with
sequestrum

52
Cont.
 Treatment
 Debridement
 Antibiotics
 Hydration of the patient
 High protien & vitamin diet
 Analgesics
 Maintenance Of Good Oral hygiene-oral
rinse

53
Cont.
 Frequent irrigation of wounds
 Loose exposed dead bone is removed
 Sequestrectomy
 Bone resection if there is persistant
infection or pathologic #
 Hyperbaric o2 therapy

54
Cont.
 Prevention
 Preirradiation dental care
 Teeth in direct beam of radiation ,
nonrestorable teeth, teeth with
periodontal disease are extracted.
 Radiation therapy is delayed for 10 to 14
days after extraction.
 Prominent interdental septa,sharp
socket margins are trimmed
55
Cont.
 Unerupted, deeply buried teeth are left
in situ
 Restorable teeth are restored
 Periodontal therapy is done
 Oral Hygiene Instructions Are Given
 Topical Flouride 0.4% Stannous Flouride
Gel, or 1% acidulated flourophosphate
gel is applied for 15 min. twice a day for
2 weeks
56
Cont.
 Dental care during radiation therapy
 Mouthwash 0.2% aqueous chlorhexidine
 Supervised cleaning of teeth
 Oral hygiene instructions with flouride
tooth paste, flouride mouthwash
 Post irradiation dental care
 Avoidance of denture for one year
 Maintenance of oral hygiene

57
Cont.
 Saliva substitutes to reduce xerostomia
induced disorders
 Restoration of teeth with post -irradiation
Pulpitis
 Extraction should be the last resort.
 Teeth should be removed atraumatically.
 Sharp bony margins should be trimmed.
 Risk of ORN is is highest in 4to 12
months.
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