Osteomyelitis

1. OSTEOMYELITIS

2. DEFINITION The word “osteomyelitis” originates from the ancient Greek words osteon (bone) and muelinos (marrow ) Inflammation process of the entire bone including the cortex and the periosteum, recognizing that the pathological process is rarely confined to the endosteum.

3. PREDISPOSING FACTORS Fractures due to trauma and road traffic accidents Gun shot wounds Radiation damage Paget`s disease Osteoporosis Systemic disease : Malnutrition, Acute Leukemia, Uncontrolled diabetes, sickle cell anemia, Chronic alcoholism

4. CLASSIFICATION OF OSTEOMYELITIS

5. Classification based on clinical picture, pathology, etiology and radiology: The two major groups: Acute C hronic

6. Acute suppurative osteomyelitis Chronic suppurative osteomyelitis Chronic focal sclerosing osteomyelitis (pseudo- paget , condensing osteomyelitis ) Chronic diffuse sclerosing osteomyelitis Chronic osteomyelitis with proliferative periostitis (Garre's chronic nonsuppurative sclerosing osteitis, ossifying periostitis ) Specific osteomyelitis: 1. Tuberculosis osteomyelitis 2. Syphilitic osteomyelitis 3. Actinomycotic osteomyelitis

7. • Neonatal, tooth germ associated • Trauma/fracture related • Odontogenic • Foreign body, transplant/implant induced • Associated with bone pathology and/ or systemic disease Secondary Chronic Osteomyelitis Primary Chronic Osteomyelitis Acute Osteomyelitis • Early onset (juvenile chronic osteomyelitis) • Adult onset • Syndrome associated The Zurich classification of osteomyelitis of the jaws

8. I. Suppurative osteomyelitis: 1. Acute suppurative osteomyelitis 2. Chronic suppurative osteomyelitis II. Nonsuppurative osteomyelitis 1. Chronic focal sclerosing osteomyelitis 2. Chronic diffuse sclerosing osteomyelitis 3. Garre's chronic sclerosing osteomyelitis (proliferative osteomyelitis ) III. Osteoradionecrosis /Radio osteomyelitis

9. ACUTE SUPPURATIVE OSTEOMYELITIS

10. (I) INTRODUCTION Serious sequela of periapical infection that often results in diffuse spread of infection throughout the medullary spaces , with subsequent necrosis of variable amount of bone. Poly microbial Most common cause : Dental infection Other causes : Infection due to fracture of jaw, g un shot, or hematogenous spread

11. (II) CLINICAL FEATURES Maxilla : localized ; Mandible : Diffuse and widespread Sever pain Trismus Parasthesia of lips in case of mandibular involvement Elevation of temperature Regional lymphadenopathy Loosening of teeth and exudation of pus from gingiva No swelling and redness till periostitis develops

12. (III) ROENTGENOGRAPHIC FEATURES Roentgenographic evidence of its presence until the disease has developed for atleast one to two weeks Trabeculae becomes fuzzy and indistinct Ill defined margins MOTH EATEN APPEARANCE

13. Raggedness of inferior border

14. (IV) PATHOLOGY Finally ,Osteoclastic activity >>> SEQUESTRUM

15. The inflammatory cells are chiefly neutrophilic polymorphonuclear leukocytes but may show occasional lymphocytes and plasma cells Osteoblasts bordering the bony trabeculae are destroyed Trabeculae may lose their viability and begin to undergo slow resorption (V) HISTOLOGIC FEATURES

16. 3D >> D ebridement , D rainage and D rugs [Anti-microbial] Sequestrum >> If small, exfoliates through mucosa >> If large, surgical removal Involucrum : When Sequestrum is surrounded by new living bone Untreated cases may proceed to development of periostitis , soft tissue abscess or cellulitis (VI) TREATMENT AND PROGNOSIS

17. CHRONIC OSTEOMYELITIS

18. CHRONIC OSTEOMYELITIS CHRONIC SUPPURATIVE OSTEOMYELITIS SCLEROTIC CEMENTAL MASSES CHRONIC FOCAL SCLEROSING OSTEOMYELITIS CHRONIC DIFFUSE SCLEROING OSTEOMYELITIS

19. CHRONIC SUPPURATIVE OSTEOMYELITIS Inadequately treated acute osteomyelitis Clinical features similar to acute forms but milder Acute exacerbations of chronic stage may occur Fistulous tract may form which open to surface

20. Chronic osteomyelitis of the left mandible ( a) Extraoral fistula and scar formation ( b) large exposure of infected bone and sequestra (c) Large sequester collected from surgery

21. Unusual reaction of bone to infection High degree of tissue reaction and tissue reactivity CHRONIC FOCAL SCLEROSING OSTEOMYELITIS ( CONDENSING OSTEITIS)

22. (I) FEATURES OF CONDENSING OSTEITIS Commonly affects young adults and children Mandibular molar is affected commonly Symptoms : mild pain due to infected pulp Tissues reacts to the infection by proliferation rather than destruction , since the infection acts as a stimulus rather than a irritant Treatment : Extraction or endodontic treatment

23. Pathognomic ,well circumscribed radiopaque mass of sclerotic bone surrounding and extending below the apex of one or both roots PDL space widening {violet arrow mark} (distinguishes from cementoblastoma) (II) ROENTGENOGRAPHIC FEATURES

24. Dense bony trabeculae with little interstitial marrow tissue Many reversal and resting lines giving pagetoid appearance If interstitial soft tissue is present , it is generally fibrotic and infiltrated with small amount of lymphocytes Osteocystic lacunae appears empty (III) HISTOLOGIC FEATURES

25. Residual chronic focal sclerosing osteomyelitis ( BONE SCAR)

26. In contrast to focal type , it may occur at any age group , no gender predominance Common in edentulous mandible Insidious in nature , no clinical indications of its presence Acute exacerbation can result in : vague pain , unpleasant taste , mild suppuration , many times drainage through fistulous tract CHRONIC DIFFUSE SCLEROSING OSTEOMYELITIS

27. Cotton wool appearance Indistinct borders because of its diffuse nature Mimic Paget's disease or fibro osseous proliferation (I) ROENTGENOGRAPHIC FEATURES

28. Dense , irregular trabeculae of bone bordered by active layer of Osteoblasts ; focal Osteoclastic area may be present Mosaic pattern appearance Interstitial soft tissue is fibrotic Proliferating fibroblasts and occasional small capillaries as well as small focal collection of lymphocytes and plasma cells Burned – out appearance leaving only sclerotic bone and fibrosis (II) HISTOLOGIC FEATURES

29. Lesion is too extensive to be removed surgically Sclerotic bone is hypovascular and resistant to antibiotics Bell has recommended extraction of tooth as a last option utilizing a surgical approach with removal of liberal amounts of bone to facilitate extraction and increase bleeding . Antibiotic administration during acute exacerbation may help (III) TREATMENT AND PROGNOSIS

30. Multiple symmetric lesions producing pain, drainage or localized expansion Common in black females Roentgenographic features similar to chronic diffuse type SCLEROTIC CEMENTAL MASSES

31. Cemental masses have tissues interrupted by the cementum unlike diffuse type which mostly have sclerotic bone In some instances ,the cementum is in the form of large solid masses with smooth, lobulated margins often with a globular accretion pattern Only significant difference was in microscopic appearance which is radiopaque lesional tissue in cemental masses HISTOLOGIC FEATURES

32. CHRONIC OSTEOMYELITIS WITH PROLIFERATIVE PERIOSTITIS [Garre`s chronic nonsuppurative sclerosing osteitis \periostitis ossificans]

33. (I) INTRODUCTION Distinctive type of chronic osteomyelitis in which there is focal gross thickening of the periosteum , with peripheral reactive bone formation resulting from mild reaction or infection Periostel osteosclerosis analogous to endosteal osteosclerosis in chronic focal and diffuse sclerosing types

34. Common : Children and young adults; Mandible ; especially in bicuspids and molars Toothache or pain in the jaws Bony hard swelling on the outer surface of jaw , which may last for several weeks May develop only due to dental infection but also from soft tissue infection or cellulitis (II) CLINICAL FEATURES

35. (III) ROENTGENOGRAPHIC FEATURES ONION PEEL APPEARANCE : Focal overgrowth of bone on the outer surface of cortex ,which may be described as duplication of the cortical layer of bone (Image B) IOPA often reveals a carious tooth opposite to bony hard mass This mass of bone is smooth rather well calcified which itself shows a thin but definite cortical layer

36. A .Intense periosteal reaction in first molar B . One year after extraction ; Remodeling occurs

37. Supracortical but subperiosteal mass is composed of much reactive new bone and osteoid tissue , with Osteoblasts bordering many of trabeculae Trabeculae is perpendicular to cortex and parallel to each other Connective tissue is fibrous and shows sprinkling of lymphocytes and plasma cells (III) HISTOLOGIC FEATURES

38. Extraction or endodontic treatment of the teeth No surgical intervention except biopsy to confirm diagnosis After extraction the jaws undergo remodeling and facial symmetry is restored Neoperiostitis or new periosteum formation may occur in certain conditions. (III) TREATMENT AND PROGNOSIS