Osteomyelitis

1. OSTEOMYELITIS OF THE
JAWS
Dr. Ghulam Saqulain
Head of Department of ENT,
Capital Hospital

2. Definition:
Osteomyelitis
is an inflammation of the
medullary portion of the bone
However since the process usually also affects the
cortical bone and periosteum, therefore
osteomyelitis may be considered an inflammatory
condition of bone that usually begins as an infection
of the medullary cavity which rapidly involves the
Haversian system and quickly extends to the
periosteum of the area.
Osteomyelitis of the Jaws differs in many important
aspects from the one found in long bones.

3. Stages:
Acute
Sub Acute
Chronic

4. Incidence
The incidence of Jaw Osteomyelitis is very
low and fungal osteomyelitis is rare.
The low incidence of osteomyelitis of jaws is
remarkable considering the high frequency
and severity of odontogenic infections.
The low incidence is a result of fine balance
b/w the host resistance and the virulence of
the microorganisms. The jaw vascularity is
also important

5. Age & Sex Incidence
It can affect any age but most common
in infants, children and older adults
Gender: Males> Females

6. Predisposing Factors
Systemic Conditions that alter the host’s
resistance:
Diabetes mellitus, Autoimmune disorders,
agranulocystosis, anaemia, AIDS, syphilis,
malnutrition, chemotherapy, steroids etc.
Alcohol and tobacco use are frequently
associated with osteomyelitis
Conditions that alter the vascularity of bone:
Radiation, osteoporosis, fibrous dysplasia,
bone malignancy etc.

7. Etiology & Pathogenesis
In infants and children it occurs most commonly in
long bones primarily by Hematogenous Spread
In Adults long bone osteomyelitis and majority of
cases of jaw osteomyelitis are initiated by a
Contiguous focus
In the jaws contiguous spread of odontogenic
infections that originate from pulpal or periapical
tissues is the primary cause of disease.

8. Infection from periostitis after gingival ulcerations,
lymph nodes, infected furuncles or lacerations and
hematogenous origin account for an additional
small number in jaw osteomyelitis.
The extensive blood supply of the maxilla makes it
less prone compared to mandible.
The thin cortical plates and the porosity of the
medullary portion preclude infection from becoming
contained in the bone and facilitate spread of
edema and purulent discharge into adjacent
tissues.
Trauma, esp. non treated compound fractures, is
another leading cause.

9. Microbiology
Staph.Aureus and epidermidis were, until recently,
estimated to be involved in jaw osteomyelitis in 80-
90% of times.
With more sophisticated methods of collection and
appropriate handling of cultures anaerobes eg.,
Peptostreptococcus, Fucobacterium and Provotela
species.
Eikenella corrodens is isolated in high percentage
from cultrues along with Klebsiella, Pseudomonas
and Proteus species.
Mycobacterium TB and Fungi like Candida,
Coccidiodes, Blastomyces, Cryptoccus Sporothrix
Aspergillus species, rarely involve the jaws

10. It is now recognized that if staph is
isolated in cultures probably originates
from skin contamination or through
fistulas

11. Pathophysiology
Infection at the bone locus results in acute
inflammation and creates an increase of
Intramedullary pressure due to inflammatory
exudate that leads to vascular thrombosis followed
by avascular bone necrosis and formation of
sequestra
These sequestra are surrounded by sclerotic
avascular bone.
Haversion canals are blocked with scar tissue.
Periosteal reaction act to circumscribe sequestrum
producing a thick sheet of new bone or involucrum.

12. Classification
Cierny & Mader proposed an anatomic
classification of chronic osteomyelitis
Type 1 Endosteal or medullary
lesion
Type 2 Superfiscial
osteomyelitis limited to
surface
Type 3 Localized, well marked lesion
with sequestration and cavity
formation
Type 4 Diffuse Osteomyelitic lesion

13. Clinical Findings
Four Clinical Types are Observed:
Acute Suppurative (Acute Intramedullary
Osteo)
Deep intense pain
High intermittent fever
Paresthesia or anaesthesia of the lip
Clearly identifiable cause
No loosening of the teeth, no fistulas and
no or minimal swelling

14. If not controlled within 10-14 days after onset Subacute
suppurative osteomyelitis is established. Pus travels
through haversian canals and accumulates under the
periosteum and may spread to soft tissues.
Deep Pain
Malaise
Fever
Anorexia
Teeth are sensitive to percussion and b/c loose
Pus may be seen around sulcus of teeth or through
skin fistulas and has fetid odor
Overlying skin is warm, erythematous, tender. Firm
cellulitis with lymphadenopathy may be present

15. If inadequately treated the progression to
sub acute or chronic form is warranted.
Primary Chronic form is not preceded by an
episode of acute symptoms, is insidious in
onset with:
Mild Pain
Slow increase of jaw size
Gradual development of sequestra, often
without fistula.

16. Clinical Presentation
Chronic osteomyelitis
causes no acute constitutional
symptoms. It can cause:
Fever
Chronic bone pain which
persists despite treatment
Swelling
Warmth
Redness
Tenderness
Long discharging sinus
Irritability
TB Osteomyelitis
Local Symptoms
Pain, Restriction of
joint movement,
redness, warmth,
muscle wasting
General Symptoms
Weight loss, Evening
fever, malaise,
increased sweating
Fungal Osteomyelitis
Swelling
Cold Abscess

17. Investigations
Blood Tests
Blood CP (Leukocytosis)
Raised ESR
Raised C-Reactive Protein
Blood C/S
Pus C/S If there is discharging sinus
Needle Aspiration or bone biopsy

18. Radiologic Assessment
To evaluate extent
To identify soft tissue involvement (Areas of
cellulitis, abscess or sinus tracts)
Findings:
Acute/ Sub Acute: Deep soft tissue swelling,
periosteal reaction, cortical irregularities,
demineralization
Chronic: thick, irregular, sclerotic bone
interspersed with radiolucencies, an elevated
periosteum and chronic draining sinus are seen

19. Complications
General
Septicemia
Pyemia
Metastatic abscess
Local
Secondary involvement of joint
Spontaneous fracture
Deformity
Discharging sinus
Brodie’ s abscess (chronic Abscess within bone)

20. Treatment:
Medical and surgical treatments are
usually required although in some rare
occasions sole antibiotic treatment
may be successful

21. Principles of Treatment:
Evaluation and correction of compromised host
defenses
Gram staining and culture and sensitivity testing
Imaging of the region to determine the extend of the
lesion and to rule out the presence of tumors
Empirical administration of Gram stain-guided
antibiotics
Removal of loose teeth and sequestra
Prescription of culture-guided antibiotic therapy
Possible placement of irrigating drains/
polymethylmethacrylate –antibiotic beads
Sequestrectomy, debridement, decortication,
resection or reconstruction as indicated.

22. Acute Suppurative Osteomyelitis:
The initial management usually is
aided by:
Hospitalization to administer high doses
of antibiotic therapy
Identify and correct host compromise
factors and treat cause

23. Chronic Suppurative Osteomyelitis:
Requires Surgical Procedures in addition to
antibiotic treatment
Antibiotic therapy should be continued for 4-6
weeks after the patient has no symptoms or from
the date of the last debridement.
Closed Wound Irrigation-Suction:
Tubes are placed against the bone to allow for drainage of
pus and serum and for irrigation in order to reduce the
number of accumulated microorganisms
This type of therapy is esp. helpful when determination of
extent of ch. Inf. Of residual bone cannot be determined.
Antibiotic-Impregnated beads:
Hyperbaric oxygen therapy.

24. Surgical Treatment:
In the acute stage it should be limited to removal of severely
loose teeth and bone fragments and incision and drainage of
fluctuant areas.
This may proceed to sequestrectomy with or without
sucerization, decortication resection and then reconstruction
The number and nature of the required surgical procedures
increases with the severity of the infection:
Category 1 – Removal of necrotic tissue by extensive debridement
Category 2 – Dead space obliteration with flaps, antibiotic beads,
and bone grafts
Category 3 – Provision of soft tissue coverage of the bone
Category 4 – Stabilization of bone by external or open reduction
and internal fixation

25. Sequestrectomty:Sequestra are avascular.. Can be cortical or
cortico-cancellous. They can be removed with minimal trauma
Sequestrectomy and Saucerization: Saucerization is the
unroofing of the bone to expose the medullary cavity. It should
be performed as soon as the acute stage has resolved, so to
decompress the bone and allow for extrusion of pus, debris
and avascular bone.
Saucerization is rarely required for the maxilla
Decortication: Involves removal of chronically infected cortex,
usually the buccal and the inferior border are removed 1-2 cm
beyond the affected area.