OUTLINE

Introduction
Normal anatomy of bone
Predisposing factors
Etiology
Pathogenesis
Classification
Clinical types
Complications of osteomyelitis
Diagnostic methods
Treatment
2

INTRODUCTION
Osseous in Latin means Bony
Osteon in Greek means Bone
myelos means marrow
itis means inflammation

Definition :
Osteomyelitis is an extensive inflammation of a
bone. It involves the cancellous portion, bone
marrow, cortex, and periosteum.
(Laskin 1989)
Osteomyelitis is defined as an inflammatory
condition of bone primarily involving the soft
tissues
(Archer)

Bone anatomy

COMPACT BONE

Cancellous bone

Predisposing factors
Conditions that alter HOST IMMUNITY
-

Leukemia
Severe anemia
Malnutrition
AIDS
IV- drug abuse
Chronic alcoholism
Febrile illnesses
Malignancy
Autoimmune disease
Diabetes mellitus
Arthritis
Agranulocytosis
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Conditions that alter vascularity of bone

- Osteoporosis
- Pagets disease
- Fibrous dysplasia
- Bone malignancy
- Radiation

Virulence of the organisms

Certain organisms precipitate thrombi formation
by virtue of their destructive lysosomal enzymes.
Organisms proliferate in enriched host medium
while protected from host immunity.
Marx et al (1992) identified Actinomyces,
Eikenella & Arachnia in some refractile forms

10

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

11

RELATIONSHIP OF
EXODONTIA WITH
OSTEOMYELITIS

12

PATHOGENESIS
DEV OF INFECTION
BACTERIAL INVASION
PUS FORMATION
SPREAD OF INFECTION
INCREASED INTRAMEDULLARY PRESSURE ,
BLOOD FLOW , OSTEOCLASTIC ACTIVITY
INFLAMMATORY RESPONSES
INCREASED
PERIOSTEAL PRESSURE
PROCESS BECOMES
CHRONIC
GRANULATION TISSUE FORMATION
LYSIS OF BONE
SEQUESTRUM
FORMATION
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SEQUELAE OF EVENTS
Pulpitis
Acute

Periapical
Abscess

Chronic

Apical Periodontitis
Acute
Chronic
Periapical
Periapical
Granuloma
Cyst

Chronic
Periapical
abscess

Osteomyelitis
Acute

Chronic

Focal

Periostosis
Cellulitis

Abscess

Diffuse

Bacteraemia Toxaemia Septicemia Dissemination

Death

Shock
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In the jaws
Osteomyelitis in maxilla
Osteomyelitis in mandible

15

Sites of osteomyelitis in jaws

16

Definition
Pre disposing factors
Etiology
Site

17

classification
Historically accepted classification [Hudsons
classification]

I.

Acute

a. Contiguous focus trauma, surgery & odontogenic

infections
b. Progressive burns, sinusitis, vascular

insufficiency
c.

Hematogenous metastatic , dev

skeleton(children)
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II Chronic
a. Recurrent multifocal developing skeleton,

escalated osteogenic activity (<25 years)

b. Garres (i)unique proliferative subperiosteal

reaction, (ii) Developing skeleton (children to

young adults)
c. Suppurative or non suppurative (i) inadequately

treated forms , (ii) systemically compromised,

(iii) refractile (CROML)
d. Diffuse sclerosing (i) fastidious organisms, (ii)
compromised host pathogen interface

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 Classification based on clinical picture by

Marx 1991; Mercuri1991;Koorbusch1992.
Classification based on pathogenesis by
Vibhagool 1993.
Classification based on pathological
anatomy and pathophysiology from
Vibhagool 1993 and Cierny 1985.
Zurich classification of osteomyelitis

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Classification based on clinical picture,

radiology, and etiology - Topazian
Suppurative osteomyelitis
1. Acute suppurative osteomyelitis
2. Chronic suppurative osteomyelitis
Primary chronic suppurative
osteomyelitis
Secondary chronic suppurative
osteomyelitis
3. Infantile osteomyelitis
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Nonsuppurative osteomyelitis
1. Chronic sclerosing osteomyelitis
Focal sclerosing osteomyelitis
Diffuse sclerosing osteomyelitis
2. Garre's sclerosing osteomyelitis
3. Actinomycotic osteomyelitis
4. Radiation osteomyelitis and
necrosis
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Acute suppurative osteomyelitis

Serious sequela of periapical infection.
Leads to spread of pus through the medullary
cavities of bone.
Depending upon the main site of involvement of
bone, can be of two typesi. Acute intramedullary
ii. Acute subperiosteal
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Acute Intramedullary Osteomyelitis

CLINICAL FEATURES:
Patient experiences dull , continuous pain , indurated
swelling forms over the affected region of jaw involving
the cheek , febrile.
When mandible involved, loss of sensation occurs on
lower lip on affected side due to involvement of inferior
alveolar nerve.
Teeth become loose later along with tender on
percussion
Pus discharge , trismus , foul smell , regional
lymphadenopathy , weakness
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RADIOGRAPHIC FEATURES
Earliest radiographic change is that trabeculae in
involved area are thin, of poor density & slightly
blurred.
Subsequently multiple radiolucencies appear
which become apparent on radiograph.
In some cases there is saucer shaped area of
destruction with irregular margins.
Loss of continuity of lamina dura, seen in more
than one tooth.
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HISTOLOGIC FEATURES:
Dense infiltration of marrow by
polymorphonuclear leukocytes.
Bone trabeculae in involved site (sequestrum) are
devoid of cells in the lacunae.
separation of considerable portions of devitalized
bone.

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Acute Subperiosteal Osteomyelitis

CLINICAL FEATURES
Pain , febrile condition , i/o and e/o swelling ,
parasthesia
Bone involvement limited to localized areas of
cortex.
Pus ruptures rapidly through the overlying cortex,
tracks along the surface of mandible under the
periosteal sheath.
Elevation of periosteum from cortex is followed
eventually by minute cortical sequestration.

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Radiologic features

28

Radiologic features

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Histologic picture

Devitalized scalloped
edges
Absence of
osteoblasts and
osteocytes

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Chronic Osteomyelitis
As soon as pus drains intra or extraorally,
condition ceases to spread and chronic phase
commences.
Infection is localized but persistent as bacteria
are able to grow in dead bone inaccessible to
bodys defenses.

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Clinical features
Primary insidious in onset , slight pain , gradual
increase in jaw size.
Secondary - Pain is deep pain and intermittent,
temperature fluctuations , pyrexia , cellulitis
eventually leading to abscess
New bone formation leads to thickening causing
facial asymmetry.
Thickened or wooden character of bone in cr
sec osteomyelitis.
Eventually cures itself as the last sequestra is
discharged.
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Radiograph
ic Features
Trabeculae in the involved area become thin or appear
fuzzy & then lose their continuity.
After some time moth eaten appearance is seen
Sequestra appear denser on radiographs.
Where the subperiosteal new bone formation , the new
bone is superimposed upon that of jaw, fingerprint or
orange peel appearance is seen
Cloacae seen as dark shadows passing through opacity.

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Histologic features
Areas of acute and subacute inflammation in the
cancellous spaces of the necrotic bone.

Foci of acute inflammation

Active osteoclastic resorption of bone noted in

peripheral portions

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Chronic Subperiosteal Osteomyelitis

Cortical plate deprived of its blood supply
undergoes necrosis, underlying medullary bone
is slightly affected.
Multiple small sequestra form, eventually
discharged through sinuses with pus.
Following extrusion of sequestra, healing occurs.
Spontaneous drainage poor in submassetric area.
Much of body of mandible is lost due to poor
central blood supply of the region.

35

D/D
Pagets disease particularly wen
periosteal bone is involved
Fibrous dysplasia
Osteosarcoma

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Chronic sclerosing osteomyelitis focal

diffuse

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Focal Sclerosing Osteomyelitis

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Clinical features
Most commonly in children and young adults,
rarely in older individuals.
Tooth most commonly involved is the mandibular
third molar presenting with a large carious lesion.
No signs or symptoms other than mild pain
associated with infected pulp.

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Radiogra
phic
features
Entire root outline always visible with intact lamina
dura.
Periodontal ligament space widened.
Border smooth & distinct appearing to blend into
surrounding bone
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D/D for focal sclerosing

osteomyelitis
Local bone sclerosis
Sclerosing cementoma
Gigantiform cementoma

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Treatment & prognosis

Affected tooth may be treated endodontically or
extracted.
Sclerotic bone not attached to tooth and remains
behind after tooth is removed.
This dense area may not get remodeled.
Recognizable on bone years later and is referred
as bone scar.

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Diffuse Sclerosing
Osteomyelitis
May occur at any age, most common in older
persons, esp in edentulous mandibles
vague pain, unpleasant taste.
Many times spontaneous formation of fistula seen
opening onto mucosal surface to establish
drainage
Slowly progressive, not particularly dangerous
since it is non destructive & seldom produces
complications

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Radiographic features
Diffuse patchy, sclerosis of bone cotton wool
appearance
Radiopacity may be extensive and bilateral.
Due to diffuse nature, border between sclerosis &
normal bone is often indistinct.

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D/D for DIFFUSE sclerosing

osteomyelitis
FLORID OSSEOUS DYSPLASIA
SCLEROTIC CEMENTAL MASSES
TRUE CHR DIFFUSE SCLEROSING OSTEOMYELITIS
FIBROUS DYSPLASIA

45

Treatment & Prognosis

Resolution of adjacent foci of chronic infection
often leads to improvement.
Usually too extensive to be removed surgically,
Acute episodes treated with antibiotics.

46

Initial results of the treatment of diffuse sclerosing

osteomyelitis of the mandible
with bisphosphonates Sophie C.C. Kuijpers Journal of CranioMaxillo-Facial Surgery 39 (2011) 65e68

Study design: Seven patients suffering

from treatment resistant DSO were
treated with intravenous
bisphosphonates. Diagnosis was based
on clinical, radiological and
histopathological examination.
Follow-up varied from 18 to 46 months
(mean 30).
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 Results: In all patients, symptoms and

the need for analgesic drugs diminished
considerably. One patient remained free
of symptoms after one treatment. In two
patients a switch in bisphosphonate was
made based on a decreased response.
Conclusion: In therapy-resistant DSO
bisphosphonate treatment may be a
good option
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Infantile Osteomyelitis
Osteomyelitis Maxillaries Neonatarum, Maxillitis
of infancy
Osteomyelitis in the jaws of new born infants
occurs almost exclusively in maxilla.

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Etiology
Trauma through break in mucosa cause during
delivery.
Infection of maxillary sinus
Paunz & Ramon et al believe that disease caused
through infection from the nose.
Hematogenous spread through streptococci &
pneumococci

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Clinical features
Fever, anorexia & intestinal disturbances.
swelling or redness below the inner canthus of the
eye in lacrimal region.
Followed by marked edema of the eyelids on the
affected side.
Next, alveolus & palate in region of first deciduous
molar become swollen.
Pus discharge from affected sites

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D/D for Infantile

Osteomyelitis
Dacrocystitis neonatarum
Orbital cellulitis
Ophthalmia neonatarum
Infantile cortical hyperostosis

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TREATMENT
Intravenous antibiotics, preferably penicillin.
Culture & sensitivity testing
Incision & drainage of fluctuant areas
Sequestrectomy
Supportive therapy

53

Garres Osteomyelitis (Chronic

Osteomyelitis with Proliferative
Perosteitis)
Chronic Non Suppurative Sclerosing Osteitis/
Periostitis Ossificans.
Non suppurative productive disease characterized
by a hard swelling.
Occurs due to low grade infection and irritation
The infectious agent localizes in or beneath the
periosteal covering of the cortex & spreads only
slightly into the interior of the bone.
Occurs primarily in young persons who possess
great osteogenic activity of the periosteum.

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Clinical Features

Uncommonly encountered, described in tibia and in the

head and neck region, in the mandible.
Typically involves the posterior mandible & is usually
unilateral.
Patients present with an asymptomatic bony, hard swelling
with normal appearing overlying skin and mucosa.
On occasion slight tenderness may be noted
pain is most constant feature
The increase in the mass of bone may be due to mild toxic
stimulation of periosteal osteoblasts by attenuated
infection.
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Radiographic features
Laminations vary from 1 12 in number,
radiolucent separations often are present
between new bone and original cortex. (onion
skin appearance)
Trabeculae parallel to laminations may also be
present.

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Histologic Features
Reactive new bone.
Parallel rows of highly cellular & reactive woven
bone in which the individual trabeculae are oriented
perpendicular to surface.
Osteoblasts predominate in this area.

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D/D for Garres Osteomyelitis

Ewing's sarcoma
Caffeys disease
Fibrous dysplasia
Osteosarcoma

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Treatment
Removal of the offending cause.
Once inflammation resolves, layers of the bone
consolidate in 6 12 months, as the overlying
muscle helps to remodel.
If no focus of infection evident, biopsy
recommended.

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Infective osteomyelitis
Tuberculous osteomyelitis

Syphilitic osteomyelitis

Actinomycotic osteomyelitis

60

Tuberculous
osteomyelitis
Non healing sinus tract formation
Age group affected is around 15 40 years.
Commonly seen in phalanges and dorsal and
lumbar vertebrae.
Usually occurs secondary to tuberculosis of lungs.
Cases have been reported where mandibular
lesions were not associated with pulmonary
disease.
Another common entrance is through a carious
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tooth via open pulp.

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.
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Actinomycotic Osteomyelitis
The organisms thrive in the oral cavity, especially tissues
adjacent to mandible.
May enter the bone through a fresh wound, carious tooth
or a periodontal pocket at the gingival margin of erupting
tooth.
Soft or firm tissue masses on skin, which have purplish,
dark red, oily areas with occasional zones of fluctuation.
Spontaneous drainage of serous fluid containing granular
material.
Regional lymph nodes occasionally enlarged.
Mimics parotitis / parotid tumors
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investigations
CULTURE & SENSITIVITY TESTS
STAINING and microscopy
Biopsy
BLOOD INVESTIGATIONS
BONE MARROW ASPIRATION
IMAGING
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Imaging
CONVENTIONAL
IOPA
OCCLUSAL
OPG
LATERAL OBLIQUE
BONE SCAN
CT SCAN
MRI
POSITRON EMISSION TOMOGRAPHY
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Follow-up of acute osteomyelitis in children:

the possible role of PET/CT in selected cases
Steven W. Warmann Journal of Pediatric
Surgery (2011)
Magnetic resonance imaging (MRI) and/or
scintigraphy are commonly used for follow-up in
children after treatment of acute osteomyelitis.
The PET/CT was superior to MRI in distinguishing
between infection and reparative activity within
the musculoskeletal system in selected children
after acute osteomyelitis. The termination of
antibiotic treatment for children after acute
osteomyelitis seems justified when laboratory
parameters as well as clinical presentation are
66
normal, and PET/CT scan is unsuspicious.

treatment
Goal of management

Management includes
Conservative management
Surgical management

67

Conservative Management
bed rest
Rehydration
Pain control
Antimicrobial therapy

68

69

 Erythromycin
Neoporin irrigants
Antibiotics impregnated beads

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chronic osteomyelitis : empiric or

evidence-based by Rachid Haidar et al.
(International Journal of Infectious
2010)and operative
Despite all of theDiseases
advances in ,antibiotic
treatment, osteomyelitis remains difficult to treat. This is
because bacteria can elude host defense mechanisms by hiding
intracellularly and by developing a protective slimy coat. By
acquiring a very slow metabolic rate, bacteria become less
sensitive to antibiotics. For all the above reasons, operative
treatment is considered whenever possible. Osteomyelitis has
traditionally been treated with 46 weeks of parenteral
antibiotics after definitive debridement surgery. However, this
time frame has no documented superiority over other time
intervals, and there is no evidence that prolonged parenteral
antibiotics will penetrate the necrotic bone.
Hence this review article questions the continuous and
traditional use of long-term antibiotic treatment for chronic
osteomyelitis in spite of the advances in surgical treatment
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using flaps.

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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SEQUESTRECTOMY
SAUCERIZATION
DECORTICATION
TREPHINATION

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74

75

Osteoradionecrosis
Defined as exposure of non viable, non healing, non
septic lesion in the irradiated bone, which fails to heal
without intervention.
One of the most serious complications of radiation to the
head and neck.
Acute form of osteomyelitis caused by damage to
intraosseous blood vessels.
Seen in patients receiving more than 60Gy during
radiation therapy
76

Factors leading to
osteoradionecrosis
Irradiation of area of previous surgery before
healing occurs
Irradiation of lesions in close proximity to bone
High dose of radiation
Combination of external radiation and intraoral
implants
Poor oral hygiene and continue use of irritants
77

Pathogenesis
Not an infection itself, it is the bones reduced
ability to heal resulting in lesions, pain and
fragility

78

PATHOGENESIS

RADIATION - NORMAL CELLS

DESTRUCTION ALONG WITH CANCER
CELLS ENDARTERITIS OBLITERANS
DECREASED MICROCICULATION
HYPOVASCULARITY HYPOXIA HYPOCELLULARITY

79

Clinical features
Mandible affected far more frequently than
maxilla.
Trismus , Foetid odour , Pyrexia , Pathologic
fracture , Sequestration , Dull pain which may
continue for weeks or months , Swelling of face
when infection develops
Soft tissue abscess & persistently draining sinuses
Exposed bone, associated with intra or extraoral
fistulae
80

Radiologic features
May appear radiolucent, with indefinite
nonsclerotic borders & occasional areas of
radiopacity.
Sequestra & involucra occur late or not at all; due
to severely compromised blood supply.

81

Steps to avoid Osteoradionecrosis

PRE THERAPY:
All teeth with questionable prognosis should be
extracted
All restorable teeth should be restored.
Thorough prophylaxis & topical fluoride application.
Oral hygiene measures & instructions should be
demonstrated & reinforced.
Any sharp cusps should be rounded to prevent
mechanical irritation.
Impressions for fabrication of custom fluoride trays
to be used during treatment.
Stop habits like tobacco use & alcohol consumption.
82

DURING THERAPY:
Pt should rinse mouth with saline.
Chlorhexidine mouth rinses twice daily to
minimize bacterial/ fungal levels within mouth.
Weekly oral hygiene evaluation by dentist.
If overgrowth of candida albicans nystatin or
clotrimazole topical application.
Monitor mouth opening.
Monitor nutritional status.

83

POST THERAPY
Dental evaluation every 3 4 months.
Oral prophylaxis.
Topical fluoride application should be done using
custom trays.
Pt to be instructed in daily self administration of
topical fluoride administration.
Salivary substitutes should be prescribed.
84

 Restore teeth developing post-radiotherapy caries

using amalgam or composites.
Extraction of teeth can be carried out with the
use of
- Hyperbaric oxygen before & after extraction
- Prophylactic antibiotic
Evaluate artificial dentures.

85

Treatment
CONSERVATIVE METHOD:

Systemic antibiotics
Selective rinsing with topical antiseptics
Selective removal of small sequestra
Curetting & local debridement
Burring of bone until normal bleeding bone
appears.

86

RADICAL TREATMENT

Debridement
Control of infection
Hydration & nutritional supplements
Analgesics
Maintaining good oral hygiene
Frequent irrigation of wounds
Sequestrectomy
Bone resection
Hyperbaric Oxygen therapy

87

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 for
90 minutes while breathing 100% oxygen twice daily
Free radicals of oxygen bactericidal to many pathogens.
Many exotoxins liberated by microorganisma rendered inert by
88
exposure to elevated partial pressure of oxygen.

Contraindications
As considered by the HBO Committee of the
Undersea Medical Society, Fisher et al(1988) &
Marx et al (1985)
Pneumothorax
Severe COPD
Acute viral infection
Upper respiratory tract infection
Uncontrolled acute seizures
Malignant disease

89

CONCLUSION
Evidence for osteomyelitis found in
the fossil record is studied by
paleopathologists, specialists in
ancient disease and injury. It has
been reported in fossils of the large
carnivorous dinosaurAllosaurus
fragilus
90

References
Textbook of Oral Surgery Topazian
A textbook of oral pathology 5th edition;
Shafer, Hine & Levy
Textbook of Oral & Maxillofacial Surgery
Neelima Anil Malik
Textbook of Oral Medicine Anil Govindrao
Ghom
Oral & Maxillofacial Pathology Marx &
Stern
Osteomyelitis of the Jaws: Definition and
Classification - Marc Baltensperger and
Gerold Eyrich
91