CHAP 3-INFECTIONS OF THE MAXILLARY BONES Flashcards
ALV E O L A R O S T E I T I S
SYMPTOMS
- PAIN (irradiated to ear)
- Abscence of the blood clot
- Occurs between the first and fourth day
- May last 1 - 2 weeks
- Halitosis, malaise and anorexia
ALV E O L A R O S T E I T I S
Anatomoclinic forms
Dry Socket==>Empty socket + intense pain
Suppurative alveolar osteitis==>Remains of blood clot + pus, less pain.
Marginal alveolitis==>Intermediate situation between the two previous
Phlegmon-like==>Invasion of adjacent sockets
OSTEITIS
Circumscribed lesions with no
tendency to produce bone
sequestrum
OSTEOMYELITIS
Diffuse lesions with sequestrum
formation
OSTEOPERIOSTITIS
CLINICAL FORM
1)ACUTE (AXHAUSEN )
2)CHRONIC
OSTEITIS
1)ACUTE (suppurative)
2)CHRONIC ( sclerosing or condensing )
OSTEOMYELITIS
1)INFANTS
2)ACUTE
3)CHRONIC
4)GARRE’S
localisation
MAX-MAND
Max 1 MAND 10
Rarefaction Stage
Osteolytic (by decreasing Ph) and osteoclastic occurrences
Necrosis Stage
Etiologic agents: Vascular and compressive occurrences
and toxins.
Sequestrate formation
Condensation Stage
Condensing osteitis: reparative action
Periosteum condensing reaction forms “Involucrum”
around sequestrate
(foramina of Troja: small holes into).
ACUTE OSTEOPERIOSTITIS
Axhausen’s osteoperiostitis
1) Children ( mandible )
2) Etiology==>dental infections
3) Exudate that separates the periosteum from the bone
4) Lack of clinical and radiological correlation
5) Swelling , pain , fever ? , fistulae
CHRONIC OSTEOPERIOSTITIS
1) After acute forms (inadequate treatment)
2) Low virulent infections
3) Slight symptoms
4) DIAGNOSIS RADIOLOGY
(Onion layers)
5) Pseudotumoral or pseudosarcomatous
forms (when it’s strictly localized )
ACUTE OSTEITIS (SUPPURATIVE)
1) IN MAXILLA OR MANDIBLE
2) CIRCUMSCRIBED INFECTION
3) ETIOLOGY: GRANULOMAS PERICORONITIS
POST-EXTRACTION ALVEOLAR FRACTURES
4) SIGNS AND SYMPTOMS: LOCALISED SWELLING + INTENSE PAIN
5) Rx: SIMULATE CYSTS (lytic area well defined but no sclerosed in the boundary)
6) CORTICAL BONE OSTEITIS OF DECHAUME
(Secondary to localized mucosal or cutaneous processes that spread by contiguity)
CHRONIC OSTEITIS
▪ Sclerosing or condensing
▪ Stimulation of osteoblasts
▪ Few symptoms
▪ NEURALGIFORM PAIN (few cases)
▪ X rays CONDENSATIONS NEAR THE APEX
independent from radicular cement
ACUTE OSTEOMYELITIS
▪ Etiology odontogenic infection
▪ Pain, trismus, fever, asthenia.
▪ Swelling in the mandibular region
▪ Tooth mobility
▪ Vincent’s sign +
▪ Patients with systemic diseases,
malnutrition
▪ Rx LARGE SEQUESTRUM
Symptoms of Actue osteomyelitis
1-Initial phase
2-infection phase
3-Sequestrum phase
4-Recovery phase
1) INITIAL PHASE
Periodontitis (Enlarged tooth sensation)
Pericoronitis
Pain+Fever+Trismus : 2 or 3 days
2) INFECTION PHASE
Increased pain
Increased Septic Fever
Swelling—> Trismus
Inferior Alveolar Nerve Compression : Vincent’s Sign
Mobility of the causing tooth and the adjacent ones
Mucosal and Cutaneous Fistulae
3)Sequestrum phase
Not in First day , after some weeks
Duration:weeks, Mouths
No general signs
Trismus
Lower lip anesthesia
Edema and jaw deformation
Fistulae
Mobilization of teeth
X ray (3 weeks) Sequestrum
Slow and Irregular Evolution
4) Recovery phase
Bone loss: Gradually Repaired
Deformed bone
Teeth: Stable Outside the Sequestrum
Consequences Retractile Scars
Periosteum is very important for the recovery
CHRONIC OSTEOMIELITIS
▪ PRIMARY (Low virulence microorganism) OR
SECONDARY (poor antibiotic treatment)
▪ FEW SYMPTOMS ,only in exacerbations
▪ LARGE BONE SEQUESTRUM
▪ SUPPURATIVE OCCURRENCES
Rx =RADIOLUCENT AREAS AND SEQUESTRUM
=Around sequestrum: Foramina(Cloacae) of Troja
Involucrum:
Bone cavity of newly formed bone structureless that
contains a sequestrum
Foramina :
Perforations in bone segments, that release pus content from sequestrum or bone cavity around it(Involucrum
GARRÉ’ S OSTEOMYELITIS
- Slight irritation or infection
- No suppuration
- Focal gross thickening of the periosteum
- Peripheral reactive bone formation
- Exclusive process of the mandible
- Young people
TREATMENT OST
- Ant biotherapy (same as Odontogenic Inf. but LONG TERM:
==>3 to 6 months in OM;8-12 days in PO and O)<==
2.Hyperbaric O2-therapy
3.He-Ne Laser - Surgical treatment
* Remove risk factors
* Eradicate the primary infection
* Fight the etiological infectious agent
* Facilitate drainage of the osteomyelitis focus
* Repair the destructive effects of the process
SURGICAL TREATMENT
- Drainage
- Debridement
- Sequestrectomy
- Decortication
- Saucerization ( marsupialization)
- Intralesional antibiotic
- Resection
- Bone remodulation ( insclerosing forms )
ETIOLOGICAL FACTORS
1.- Radiation: > 60 Gy
2.- Localization: 30 - 40% in carcinomas of the floor of the mouth
3.- Anatomical region: Mandible > Maxilla
People with teeth 4 > 1 Edentulous
4.- Systemic alterations: Hyperthyroidism Diabetes,
Syphilis, Tbc, Arteriosclerosis …
5.- Trauma: mucosa-bone continuity
OSTEORRADIONECROSIS
PROPHYLAXIS
- Pre-radiotherapy extractions
Anterior teeth > 7 days
Premolars > 10 days
Molars > 12 days
Impacted > 20 days
OSTEORRADIONECROSIS
AFTER RADIOTHERAPY
- Avoid extractions
- Treatment of xerostomia/hyposalivation:
sialagogues, lysozyme, or substitutes - Discontinuous antibiotic and antifungal
administration - Radiological controls (OPG) every six months
- Hyperbaric oxygen therapy or laser
BISPHOSPHONATES-RELATED OSTEONECROSIS
(BRONJ) or Medication-Related ONJ
-Osteoporosis treatment (orally)
-To decrease bone fracture
-Paget disease
-Malign Hipercalcemias due to bone metastasis of lung, breast and prostate
cancers (IV)
-Multiple Mieloma
ONJ TREATMENT
Depending on the patient’s clinical stage:
Stage 1:
CHX mouthwash 0,12% and analgesic treatment in case of pain. Surgical treatment is not recommended
Stage 2:
CHX, analgesic treatment and Atb (15 days – 2/ 3 months)
Stage 3:
CHX, analgesic treatment, Atb + Surgical treatment:
sequestrectomy or block resection
ODONTOGENIC SINUSITIS
ETIOLOGY
1- Nasal causes (ENT)
2- Odontogenic Causes
3- Other causes
ODONTOGENIC SINUSITIS
➢ Chronic periodontitis (granuloma)
Contiguity mechanism / continuity of sinus mucosa and antral teeth
Caries –> Necrosis –> Granuloma
➢ Acute suppurative apical periodontitis
Acute suppurative apical periodontitis–> Pus breaks into the maxillary
sinus–> EMPYEMA
➢ Odontogenic suppurative cellulitis – } drains into the maxillary
sinus
➢ Osteitis and osteomyelitis after extraction
➢ No antral teeth through a subperiosteal abscess
➢ Radicular and dentigerous cysts
— } They usually reject the sinus mucosa:
- Sinus mucosa adhesions to the capsule of the cyst
- Acute infections- Pus in sinus cavity–> EMPYEMA
➢ Periodontal diseases
➢ Iatrogenic causes (Currently 2º cause)
ACUTE MAXILLARY SINUSITIS:
CLINICAL SYMPTOMS
- Etiology: allergic, viral and bacterial. Uncommon odontogenic cause.
Last 1 month - Pain, irradiation to the orbit, frontal, zygomatic and alveolar region.
Headaches - Swelling of the infraorbital soft tissue
- Catarrhal purulent secretion: 1º fluid —- 2º purulent
- Rhinoscopy: edema and redness of the nasal turbinates
mucopurulent secretions in the middle
meatus - Cacosmia
- Systemic involvement
- If oroantral communication: mucosal prolapse
CHRONIC SINUSITIS
- More usual: odontogenic cause. Lasts 3 weeks
to 3 months - Slight symptoms
- Characteristic nasal syndrome: vasomotor rhinitis:
- nasal itching and nasal obstruction of the affected side
-paroxysmal sneezing producing watery rhinorrhea - If fistula:
- Liquid reflux from the oral cavity
- Oral polyps
- If the immune status of the patients is good and there is not a
rhinogenic component: the evolution is usually asymptomatic (casual
diagnosis) - Irregular hyperplastic mucosa: sinus cavity occupation
SINUS EMPYEMA
- Purulent accumulation in the maxillary sinus
- Obliterated ostium
- Cessation of ciliary activity
- Sinus pressure increases: ACUTE PAIN
- Infraorbital and cheek edema
- RX: fluid levels. They change with head movements
ODONTOGENIC SINUSITIS
TREATMENT
Intranasal antrostomy with endoscopic surgery
- Surgical creation of a drainage opening in the sinus
- Removal of hyperplastic mucosa, foreign bodies…
- Facilitates washings
- Samples for culture can be taken
Caldwell-Luc
- In chronic maxillary sinusitis with irreversible lesions
- Wide opening of the anterolateral wall of the sinus
- Excision, curettage of the mucosa
OROANTRAL COMMUNICATIONS
- Lack of continuity between oral cavity and
maxillary sinus. - 3 planes affected:
– Sinus mucosa
– Maxillary bone and/or palate bone
– Oral mucosa - Canal covered by epithelium
ETIOLOGY
1)Proximity of the apex
2)Sinus pathologies causing communications
3)Iatrogenic cause
4)Infectious cause
TREATMENT
- First: resolution of the maxillary sinusitis. If it is not
treated the perforation will recur
▪ - Consists of two phases:
▪ 1- Maxillary sinus intervention
▪ 2- Closure of oroantral communication
1- Maxillary sinus intervention
a- Caldwell Luc approach
– Indicated in chronic sinusitis, polyps, cysts, mucoceles,
communications and trauma
b- Cleaning with imaging techniques: sinuscope
A micro camera is introduced in the nasoantral meatus and throught an
antrostomy of the anterior wall the diseased sinus mucosa is removed.
A- Caldwell Luc approach
Removal of diseased sinus mucosa, providing ventilation of the antrum
that makes the reepithelialization easier
1-Incision
2-Flap reflection
3-Osteotomy
4-Removal of the sinus mucosa
5-Nasoantral perforation
6-Nasoantral drainage
7-Suture
