1. 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.

2. 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”

3. etiology Odontogenic infections Trauma Infections of oro facial region
Infections derived from hematogenous route
Compound fractures of the jaws.

4. pathogenesis

5. 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

6. 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

7. Sites of osteomyelitis in jaws

8. classification Acute –
Historically accepted classification –[Hudson’s classification]
Acute –
Contiguous focus – trauma, surgery & odontogenic infections
Progressive – burns, sinusitis, vascular insufficiency
Hematogenous – metastatic (children)

9. 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

10. Based on presence or absence of suppuration
I Suppurative osteomyelitis
Acute suppurative (pyogenic)
Chronic suppurative (pyogenic)
- primary
- secondary
c) Infantile

11. 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

12. Types of osteomyelitis
Acute suppurative
Chronic suppurative
Focal sclerosing
Diffuse sclerosing
Infantile
Garre’s
Specific infective
Osteoradionecrosis
Malignancy in osteomyelitis

13. Clinical Picture

14. Radiologic features
- Slight decrease in density of involved bone - loss of sharpness of trabeculae

15. - Sequestrum & osteolysis with loss of definition of mandibular canal
Radiologic features
- Sequestrum & osteolysis with loss of definition of mandibular canal

16. Clinical picture Osteomyelitis affecting the maxilla
Bone destruction seen intra orally

17. Radiographic picture

18. Radiographic picture Characteristic moth eaten appearance
Presence of sequestra

19. Radiographic picture
Characteristic moth eaten appearance

20. Osteomyelitis

21. Infective osteomyelitis
Tuberculous osteomyelitis
Syphilitic osteomyelitis
Actinomycotic osteomyelitis

22. 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.

23. 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

24. Occlusal view showing periosteal reaction
Ill defined radiolucent osteolytic lesion
Occlusal view showing periosteal reaction

25. 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.

26. 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

28. Complications in osteomyelitis
Neoplastic transformation
Discontinuity defects
Progressive diffuse sclerosis
Cavernous sinus thrombosis

29. 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

30. Surgical Therapy Incision & drainage Extraction of loose teeth
Debridement
Decortication
Sequestrectomy
Saucerization
Trephination or fenestration
Resection
Immediate/ delayed reconstruction
Postoperative care

31. 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

32. 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

33. 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

34. 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

35. Specific inflammatory processes of the MFA (actinomycosis, tuberculosis, syfilis): etiology, classification, clinical course, diagnostics, treatment.

36. 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

37. 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

38. Actinomycosis (cont.)

39. Cervicofacial Actinomycosis

40. Actinomycosis

41. Actinomycosis, nodules and sinus of the buccal mucosa. FIG. 1
Dr.T.V.Rao MD

42. Actinomycosis, abscess and draining sinus of the maxilla. FIG. 2
Dr.T.V.Rao MD

43. Actinomycosis, multiple nodules and sinus of the skin. FIG. 3
Dr.T.V.Rao MD

44. Tuberculosis (cont.)

45. Tuberculosis

46. Syphilis (cont.)

47. 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

48. Primary Oral Syphilis

49. Oral chancres in primary syphilis

50. 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

51. 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

52. Secondary Syphilis

53. 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

54. Tertiary Oral Syphilis

55. 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

56. Dr.T.V.Rao MD

63. Congenital Syphilis - Mucous Patches
Clinical Manifestations
Congenital Syphilis - Mucous Patches

64. Congenital Syphilis - Hutchinson’s Teeth
Clinical Manifestations
Congenital Syphilis - Hutchinson’s Teeth

65. Congenital Syphilis - Perforation of Palate
Clinical Manifestations
Congenital Syphilis - Perforation of Palate

66. THANK YOU FOR ATTENTION
Dr.T.V.Rao MD