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Osteomyelitis of jaws dikiohs
1. THE EFFECTS OF PENTOXIFYLLINE
AND TOCOPHEROL IN
OSTEOMYELITIS OF JAWS
Dr Saadia Siddique
Resident OMFS
2. Osteomyelitis is an inflammation of bone marrow
involving the cortical plates, periosteal tissues and
the overlying soft tissues
most cases occurring after trauma to bone or bone
surgery or secondary to vascular insufficiency.
3. PREDISPOSING FACTORS
Patient’s Age
Immunosupression - Diabetes mellitus
- Malignancy
- AIDS
Drugs - Steroids
- Chemotherapeutic Agents
- Immunosuppresive agents
- Bisphosphonates
Local Factors - osteoporosis
- Bone pathology
- radiation
Malnutrition
Auto immune diseases
4. PATHOGENESIS
Osteomyelitis typically occurs as a result of spread of an
odontogenic infection or as a result of trauma.
The presence of teeth provides a direct pathway to the
bone via pulpal or periodontal disease.
The process begins with bacteria spreading to the jaw
bones, either through
i. extraction of teeth,
ii. root canal therapy,
iii. fracture of the jaw bones,
resulting in a bacteria-induced inflammatory process.
5. Inflammation to hyperemia, increased blood flow,
and leukocytes to the affected area
Pus is formed intramedullary pressure is created
decreases blood flow to jaw bones
Pus travels via the haversian system and Volkmann
canals the medullary and cortical bones
vascular collapse
Pus perforates the cortical bone collects under
the periosteum periosteal blood supply
compromised
6.
7. Osteoclastic activity is then responsible for
separating the dead bone from vital bone.
The elevated periosteum involved in the
inflammatory process still contains vital cells
acute phase has passed, form a new bony shell
covering the sequester involucrm
The involucrum tends to hinder sequester from
extruding, which perpetuates the process because
the whole area is bathed in increasing amounts of
pus unless treated promptly and adequately
8. MORE COMMON IN MANDIBLE?
Dense cortical plates
Poorly vascularized cortical plates
Vasculature originating from IANB
affects most commonly the body of the mandible,
followed by the symphysis, angle, ascending
ramus, and condyle
12. ACUTE OSTEOMYELITIS
involves progression from days to a few weeks
Acute symptoms - pain and swelling
- Fever
- Cellulitis
- Trismus
paresthesia or anesthesia of the lower lip is described
(Vincent’s symptom),
Pus may extrude around the gingival sulcus and through
mucosal and cutaneous, fistulas
It may take up to 10 days for bone loss to be
radiographically apparent.
primarily managed medically with IV antibiotics
Marx and Mercuri had set an arbitrary time limit of 4
weeks after onset of disease for acute phase.
13. CHRONIC OSTEOMYELITIS
Chronic osteomyelitis is a persistent infection spanning
months to years with characteristic
low-grade inflammation,
a harder palpable tenderness caused by periosteal
reaction
presence of dead bone,
new bone apposition
fistulas
Nerve deficits, pathological fractures, mobile teeth in the
vicinity
Antibiotics, nsaids and surgical management
A/c to Marx et al, a persisting bone infection for more
than 4 weeks is considered as chronic osteomyelitis.
15. RADIOGRAPHIC FEATURES
Radiographic changes occur only 3 weeks after
initiation of OML
30-60% of mineralized portions of bone must be
destroyed before significant radiographic changes
16. EARLY STAGES
Widening of marrow spaces and volkmann canals
mottled appearance
Granulation tissue b/w dead and living bone
irregular lines of radiolucency moth eaten
appearance
Mottled
appearance
Moth eaten
appearance
17. LATER STAGES
Cortex gets involved ischemia an island of
cortical bone becomes devitalised
Resorption around infarcted area separates it as
a sequestra
Radiolucent area surrounding this sequestra is
Involucrum
Large areas of bone destruction seen as irregular
radiolucencies
19. FOCAL SCLEROSING OSTEOMYELITIS
The focal type, also known as condensing osteitis,
is a rather common condition with a
pathognomonic, well-circumscribed radioopaque
mass of sclerotic bone surrounding the apex of the
root.
Since the infection in these cases is limited to the
apex of the root
Treatment :
i. sufficient endodontic treatment with or without
apex surgery
ii. extraction of the affected tooth
usually leads to regression of these lesions
21. Sclerosis and fibrosis of the intramedullary space
Chronic dull pain is always present
The absence of pus, fistula, and sequestration are
characteristic.
DSO radiographically by presenting sclerosing
opaque and dense masses
Rx: antibiotics, debridement, hbo
DIFFUSE SCLEROSING OSTEOMYELITIS
22. GARRE’S OSTEOMYELITIS
It is merely a periosteal inflammation leading to the
formation of an immature type of new bone outside
the normal cortical layer.
Lifts the periosteum from cortex
Usually effects children due to their increased
vascularity and regenerative capabilities
Clinically painful expansion of bone on lower border
or buccal cortex of the mandible
no pus or fistula
onion skin appearance
23. When new bone is superimposed on the jaw, a
delicate finger print or orange peel appearance is
seen.
Removal of source
Short course of antibiotic therapy
GARRE’S OSTEOMYELITIS
24. PRIMARY CHRONIC OSTEOMYELITIS
It is characterized as a strictly nonsuppurative
chronic inflammation of the jawbone with the
absence of pus formation, extra- or intraoral fistula,
or sequestration
also implies that the patient has never undergone
an appreciable acute phase
periodic episodes of onset with varying intensity
last from a few days to several weeks and are
Intersected by periods of silence
25. EARLY ONSET
describes cases with an onset in childhood or
adolescence
more osteolytic findings and a greater periosteal
reaction in children and adolescents compared to
the cases in adult patients
In active periods, the swelling and tenderness of
the jaw is more prominent due to a more extensive
periosteal reaction
26. ADULT ONSET
describes cases with an onset of symptoms in the
adult patient
chronic inflammation of the jawbone, excluding
signs of suppuration.
Symptoms less prominent in adult cases
27.
28. SYNDROME ASSOCIATED
The term SAPHO syndrome describes a chronic
disorder that involves the skin, bones, and joints.
SAPHO is an acronym that stands for morbid
alteration of the dermatoskeletal system
synovitis;
acne
Pustulosis
Hyperostosis
Osteitis
31. MEDICAL MANAGEMENT
Patients should be optimized medically to achieve
the best response to antibiotic therapy.
Tissues should be sent for Gram stain, culture,
sensitivity, and histopathology.
Empiric antibiotics should be started based on
Gram stain because cultures and sensitivities may
take several days for a final report
An infectious disease consultation may be of value
in selecting the most current antimicrobials
32. MEDICAL MANAGEMENT
Penicillin remains the empiric antibiotic of choice.
6-8 weeks for acute osteomyelitis - Amoxicillin
6 months for chronic osteomyelitis - Clindamycin
33. HYPERBARIC OXYGEN
30 or 60 dives at 2.4 atm for 90 minutes while
breathing 100% oxygen twice daily
Increases oxygen in plasma and inturn delievered
to the tissues
Reduces hypoxia
Neo angiogenesis
Free radicals are toxic to many pathogenic
anaerobics
35. SURGICAL MANAGEMENT
Extraction of offending tooth
Incision and drainage
Sequestrectomy
Saucerization
Decortication
Resection of jaw
36. EXTRACTION OF OFFENDING TEETH
Drainage is sometimes achieved by the extraction
of the offending tooth
37. INCISION AND DRAINAGE
Various methods employed for I & D are :
Opening up the pulp chamber
By making fenestration through cortical plate over
the apical area with a drill
In posterior maxilla, by making an incision over the
alveolar crest
OML at the angle of the mandible or ramus area,
drainage can be done by a small incision
38. DEBRIDEMENT
Thorough debridement of the affected area should
be done
The area maybe irrigated with hydrogen peroxide
and saline
Any necrotic tissue or sequestra should be
removed
39. DECORTICATION
Removal of chronically infected lateral and inferior
cortical plates of bone 1-2cm beyond the area of
involvement
It is based on the principle that the involved cortical
bone is avascular and harbors microrganisms
where anti biotics cannot penetrate
Thus an access is produced to medullary cavity
which improves the blood supply to the bone
41. SEQUESTRECTOMY
It helps in establishment of local microvascular
proliferation
Sequestra are usually cortical
Are not seen until 2 weeks after onset of infection
These are avascular and poorly penetrated by
antibiotics
Pathological fracture can also occur in this area due
to bone loss
Generally, the sequestra lies on the surface of the
bone can be removed easily with reflection of
mucoperiosteal flaps
If the sequestra is encased by the involucrm, a
window must be made to allow it to taken out
43. SAUCERIZATION
Excision of margins of necrotic bone overlying a
focus of OML
It permits removal of already formed or forming
sequestra with better visualization
It is performed when removal of sequestra leaves a
large defect
Buccal cortex is reduced to the level of unattached
mucosa producing a saucer like defect
45. TREPHINATION/FENESTRATION
Creation of bony holes or windows in the overlying
cortical bone adjacent to the infectious process for
decompression of medullary spaces
This inturn allows vascular communication between
the periosteum and medullary cavity
46. RESECTION
When extensive portion of the bone is involved in
the disease process, then resection of the jaw is
advocated
48. According to the recent article which was published
in Korea 2020, PTX and TC can be used as an
adjunctive treatment in osteomyelitis.
Mi Hun Seo et al emphasized on using the
combination of PTX and tocopherol for more than 3
months
He observed that the
i. bone density got increased
ii. Inflammation decreased (TNF-a and TGF-b)
iii. Bone exposure reduced
PENTOXIFYLLINE AND TOCOPHEROL AS AN
ADJUNCTIVE TREATMENT
49. CONCLUSION
Osteomyelitis, although uncommon, continues to be
seen and treated by dentists and oral and
maxillofacial surgeons.
Complete therapy involves both medical and
surgical approaches in an effort to achieve total
care.
Many authors stress that early and aggressive
intervention is associated with more predictable
outcome.
It will limit the need for surgical intervention and that
appropriate antibiotic alone might be sufficient
50. REFERENCES
Mi Hyun Seo, Mi Young Eo, Hoon Myoung, Soung
Min Kim, Jong Ho Lee Department of Oral and
Maxillofacial Surgery, School of Dentistry and
Dental Research Institute, Seoul National
University, Seoul, Korea
Marc Baltensperger and Gerold Eyrich,
Osteomyelitis of the Jaws Definition and
Classification
Textbook of oral and maxillofacial surgery Neelima
malik 4th edition