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LECTURE 4 Osteomуelitis of the jaws: etiology, pathogenesis, classification, clinical course, diagnostics, treatment, complications, prophylaxis. Specific inflammatory processes of the MFA (actinomycosis, tuberculosis, syfilis): etiology, classification, clinical course, diagnostics, treatment.
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Definition : Osteomyelitis may be defined as “an inflammatory condition of bone, that begins as an infection of medullary cavity and haversian systems of the cortex & extends to involve the periosteum of the affected area”
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etiology Odontogenic infections Trauma Infections of oro facial region
Infections derived from hematogenous route Compound fractures of the jaws.
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pathogenesis
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In the jaws… Osteomyelitis in maxilla : Rare occurrence due to-
Extensive blood supply and significant collaterals Porous nature of membranous bones Thin cortical plates Abundant medullary spaces
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Osteomyelitis in mandible
An important factor in establishment of osteomyelitis in mandible is compromise of blood supply Blood supply – Primary supply – by inferior alveolar artery, except coronoid (temporalis vessels) Secondary supply – periosteal supply Venous drainage – upwards via inferior alveolar vein to pharyngeal plexus Downwards to external jugular veins
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Sites of osteomyelitis in jaws
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classification Acute –
Historically accepted classification –[Hudson’s classification] Acute – Contiguous focus – trauma, surgery & odontogenic infections Progressive – burns, sinusitis, vascular insufficiency Hematogenous – metastatic (children)
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II Chronic Recurrent multifocal – developing skeleton, escalated osteogenic activity (<25 years) Garre’s – (i)unique proliferative subperiosteal reaction, (ii) Developing skeleton (children to young adults) Suppurative or non suppurative – (i) inadequately treated forms , (ii) systemically compromised, (iii) refractile Diffuse sclerosing – (i) fastidiouis organisms, (ii) compromised host pathogen interface
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Based on presence or absence of suppuration
I Suppurative osteomyelitis Acute suppurative (pyogenic) Chronic suppurative (pyogenic) - primary - secondary c) Infantile
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Chronic sclerosing a) focal sclerosing b) diffuse sclerosing
II Non Suppurative Osteomyelitis Chronic sclerosing a) focal sclerosing b) diffuse sclerosing Garre’s sclerosing Actinomycotic Radiation (ORN) Specific infective a) tuberculosis b) syphilis
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Types of osteomyelitis
Acute suppurative Chronic suppurative Focal sclerosing Diffuse sclerosing Infantile Garre’s Specific infective Osteoradionecrosis Malignancy in osteomyelitis
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Clinical Picture
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Radiologic features - Slight decrease in density of involved bone - loss of sharpness of trabeculae
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- Sequestrum & osteolysis with loss of definition of mandibular canal
Radiologic features - Sequestrum & osteolysis with loss of definition of mandibular canal
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Clinical picture Osteomyelitis affecting the maxilla
Bone destruction seen intra orally
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Radiographic picture
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Radiographic picture Characteristic moth eaten appearance
Presence of sequestra
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Radiographic picture Characteristic moth eaten appearance
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Osteomyelitis
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Infective osteomyelitis
Tuberculous osteomyelitis Syphilitic osteomyelitis Actinomycotic osteomyelitis
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Tuberculous osteomyelitis
Results when blood borne bacilli lodge in cancellous bone. Usually commences in metaphyseal area of long bones & causes widespread destruction of osseous tissue. Commonly seen in phalanges and dorsal and lumbar vertebrae. Tuberculous lesions are rare in jaws.
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Lower left buccal vestibule obliterated from 74 to 36
Unilateral diffuse swelling on left side of mandible with draining sinus Lower left buccal vestibule obliterated from 74 to 36
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Occlusal view showing periosteal reaction
Ill defined radiolucent osteolytic lesion Occlusal view showing periosteal reaction
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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. Identity of the organism may be masked due to superimposed bacterial infection.
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Actinomycotic Osteomyelitis
Actinomyces – generic term applied to group of non acid fast organisms that are microaerophilic. Three species – Actinomyces israeli – primarily saprophytic, occasionally pathogenic. Actinomyces bovis – in cattle Actinimyces baudetti – cats and dogs
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Complications in osteomyelitis
Neoplastic transformation Discontinuity defects Progressive diffuse sclerosis Cavernous sinus thrombosis
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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 at 2.4 ATA for 90 minutes while breathing 100% oxygen twice daily
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Surgical Therapy Incision & drainage Extraction of loose teeth
Debridement Decortication Sequestrectomy Saucerization Trephination or fenestration Resection Immediate/ delayed reconstruction Postoperative care
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Osteomyelitis treatment plan
FOR ACUTE ASTEOMYELITIS Healthy host Conservative decompression & debridement with extraction Drainage & irrigation if pus present Culture & sensitivity of infected foci Antibiotic treatment for 3 – 4 weeks Regional bony stabilization if necessary
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Compromised Host Stabilize condition – especially nutrition Aggressive debridement & decompression with disruption of involved periosteal layer Culture & sensitivity of infected foci Sustained antibiotic treatment for 6 – 12 weeks Regional bony stabilization if necessary
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FOR CHRONIC OSTEOMYELITIS
Host almost always compromised. CT, nuclear medicine scan, bone perfusion Stabilize condition of host especially nutrition status Wide bony sequestrectomy & decortication to normal bleeding bone
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If purulent, consider drainage & irrigation
Sustained antibiotic therapy for 3 – 6 months Regional bony stabilization Postoperative HBO – dives for 90 min at 2.5 ATA Reconstruction as necessary
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Specific inflammatory processes of the MFA (actinomycosis, tuberculosis, syfilis): etiology, classification, clinical course, diagnostics, treatment.
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Cervicofacial Actinomycosis
This is the most common and recognized presentation of the disease. Actinomyces species are commonly present in high concentrations in tonsillar crypts and gingivodental crevices. Many patients have a history of poor dentition, oral surgery or dental procedures, or trauma to the oral cavity. Chronic tonsillitis, mastoiditis, and otitis are also important risk factors for actinomycosis. Dr.T.V.Rao MD
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Infection Cervicofacial region
Periostitis or osteomyelitis can develop if the infection extends to facial and maxillary bones. The mandible appears to be one of the most common osteomyelitis sites. Dr.T.V.Rao MD
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Actinomycosis (cont.)
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Cervicofacial Actinomycosis
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Actinomycosis
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Actinomycosis, nodules and sinus of the buccal mucosa. FIG. 1
Dr.T.V.Rao MD
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Actinomycosis, abscess and draining sinus of the maxilla. FIG. 2
Dr.T.V.Rao MD
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Actinomycosis, multiple nodules and sinus of the skin. FIG. 3
Dr.T.V.Rao MD
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Tuberculosis (cont.)
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Tuberculosis
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Syphilis (cont.)
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Primary Syphilis Chancre develops at site of inoculation after 2-3 weeks – if untreated, initial lesion heals in 3-8 weeks Spreads through lymphatic channels Oral lesions may be found on lip, tongue, palate, gingiva, tonsils Oral lesions may be painless, clean-based ulcerations or vascular proliferations
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Primary Oral Syphilis
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Oral chancres in primary syphilis
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Secondary Syphilis Sore throat, malaise, headache, weight loss, fever, musculoskeletal pain Diffuse, painless maculopapular cutaneous widespread rash which may involve the oral cavity Mucous patches – superficial areas of irregular grayish mucosal necrosis most commonly found on tongue, lip, buccal mucosa, palate
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Secondary Syphilis Occasional papillary lesions (condylomata lata)
Lues maligna – found in person with compromised immune system: fever, headache, myalgia, necrotic ulcerations of the face and scalp, oral lesions
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Secondary Syphilis
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Tertiary Syphilis Develops in 30% of patients
Most severe complications are congestive heart failure, dementia, death Gumma – zone of granulomatous inflammation affecting skin, mucosa, soft tissue, bones, and internal organs; intraoral involvement of palate and tongue; may perforate through palate to nasal cavity Luetic glossitis - Tongue appears large and irregularly shaped due to diffuse atrophy and loss of dorsal tongue papillae
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Tertiary Oral Syphilis
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Congenital Syphilis Maternal transmission during primary and secondary stages usually results in miscarriage, stillbirth, or congenital malformations Hutchinson’s triad – Hutchinson’s teeth, interstitial keratitis, eighth nerve deafness
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Dr.T.V.Rao MD
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Congenital Syphilis - Mucous Patches
Clinical Manifestations Congenital Syphilis - Mucous Patches
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Congenital Syphilis - Hutchinson’s Teeth
Clinical Manifestations Congenital Syphilis - Hutchinson’s Teeth
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Congenital Syphilis - Perforation of Palate
Clinical Manifestations Congenital Syphilis - Perforation of Palate
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THANK YOU FOR ATTENTION
Dr.T.V.Rao MD
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