Infection and Osteomyelitis (Lui) I 96-173, 316 Flashcards
Osteomyelitis of the jaw is an inflammatory condition of the bone that starts where: in the medullary cavity or the periosteum?
Begins in the medullary cavity and the haversian systems of the bone
Once the osteomyelitis has begun in the medullary cavity and the haversian systems of the bone, to where will it extend next?
Extend to involve the periosteum of the affected area
When is it considered that the osteomyelitis infection is established in the calcified portion of the bone?
When pus and edema in the medullary cavity and beneath the periosteum compromises or obstructs the local blood supply
Due to the compromised or obstructed blood supply to the osteomyelitic bone, what is caused?
Ischemia, causing the osteomyelitic bone to be necrotic
What does the necrotic bone of osteomyelitis lead to?
Sequestra formation
What is a classic sign of osteomyelitis?
Sequestra formation
The acute inflammation causing pus increases inter medullary pressure and cause what in the medullary bone?
Vascular collapse which leads to compromised local blood supply
The pus from the acute inflammation that gets into haversian system and the nutrient canal does what to the periosteum and leads to what?
Elevates the periosteum
Disrupted blood supply
What is the key to the presentation of sequester in osteomyelitis?
Compromised local blood supply
Pus and organism extension into the haversian system that causes the elevation of the periosteum is more frequently found in what demographic experiencing osteomyelitis?
Children
What causes osteomyelitis-mediated inferior alveolar nerve dysfunction?
Compression of the neuromuscular bundle by the osteomyelitic infection
What is Vincent’s symptom?
Hypothesia of the IAN due to osteomyelitis
What are 4 general types of osteomyelitis?
- Chronic
- Acute
- Suppurative
- Non-supparative
What is the general type of osteomyelitis in which the inflammation regresses, granulation tissue forms, and fragments of necrotic bone (sequestra) are adjacent to viable bone?
Chronic
What is the term for a large sequestra that is isolated by a bed of granulation tissue and encased in a sheath of new bone?
Involucrum
What will be seen around the sequestrum due to increased vascularity of the adjacent vital bone in chronic osteomyelitis?
Radiolucency
Hudson JA did the studies of what 2 types of osteomyelitis?
- Chronic
2. Acute
Topazian RG did the studies of what 2 types of osteomyelitis?
- Suppurative
2. Nonsupparitive
The Zurich classification of osteomyelitis of the jaws is decided on what basis?
- Radiograph
2. Time
Of the 251 osteomyelitis cases studied in Zurich, what was the most common cause?
Odontogenic infection (173 of 251)
Of the 251 osteomyelitis cases studied in Zurich, what was the second most common cause?
trauma (42 of 251)
What is the timeframe for the Zurich classification of Acute myelitis?
Within the first 4 weeks after onset of disease (deep bacterial infection into the medullar and cortical bone)
What is the formula for determining pathogenesis of acute and secondary chronic osteomyelitis?
(The number of pathogens multiplied by the virulence of pathogens) divided by (local or systemic host immunity multiplied by local tissue perfusion)
What is the order of events of infections going from acute to secondary chronic osteomyelitis?
- Abscess formation
- Predominant osteolysis
- Fistula formation
- Sequester formation
- Periosteal reaction neoosteogenesis
- Preominant sclerosis
What is the radiographic appearance of the periosteal reaction neoosteogenesis of osteomyelitis?
Onion ring
What is one of the main systemic factors contributing to osteomyelitis?
Diabetes mellitus
Besides poor antibiotic response in diabetes mellitus, what mechanism is deficient in diabetes mellitus pt that makes them more prone to osteomyelitis?
- Diminished leukocyte chemotaxis, phagocytosis and lifespan
- Reduced tissue vascularity
What should you look for in a pt that presents with osteomyelitis?
Decreased local tissue perfusion due to systemic disease or drugs that decrease tissue perfusion (e.g. diabetes mellitus, smoking)
What are 5 anatomical openings that could predispose the patient to osteomyelitis?
- Tooth extraction
- Jaw fracture
- Acute pericornitis
- Periapical abscess
- Intraosseous injection
What is the main clinical symptom of osteomyelitis?
Deep intense pain
Will osteomyelitis be idiopathic?
No, there will be a clearly identifiable cause
What is Vincent’s symptom?
Hypesthesia / anesthesia of lower lip due to IAN compression from osteomyelitis
What are 5 things likely to happen if osteomyelitis is no controlled within 10-14 days of onset?
- Tooth mobility
- Purulent discharge, fistula, fetid malodor
- Regional lymphadenopathy
- Temp 101-102 degrees F
- Dehydration
What are the 5 most common symptoms of acute osteomyelitis?
- Pain
- Swelling
- Clinical abscess / pus
- Sequester formation
- Exposed bone
- Fracture
Is Erythrocyte Sedimentation rate (ESR) as reliable a lab value for chronic osteomyelitis as it is for acute osteomyelitis?
No
Primary chronic osteomyelitis is common in what age demographic?
11-20 years old
What is the difference between Early-onset primary chronic osteomyelitis of the Jaw (POC) and adult-onset primary chronic osteomyelitis of the Jaw (POC)?
Age, early onset occurs in children
What is a major difference in the radiographic findings between Early onset primary chronic osteomyelitis (POC) and Adult onset POC?
Early onset will show a strong periosteal reaction / pseudotumor
Syndrome that is characterized by chronic recurrent multifocal osteomyelitis, synovitis(inflammation of the synovial membrane in joints), acne, pustulosis(inflammatory skin condition with large fluid-filled blisters on the palms of hands and soles of feet), hyperostosis(excessive bone growth), and osteitis (ear infections)?
Sapho syndrome
What its he most common microbiologic cause of osteomyelitis?
Cariogenic streptococci
What common bacteria are associated with osteomyelitis after extra oral trauma?
Staphylococcus aureus
What is the consideration when one considers that the microbiologic cause of osteomyelitis might be another organism, e.g. Eikenella, Ike and Tina, Klebsiella, Psuedomona, Proteus, Myobacterium tuberculosis, Treponema pallidum, or Actinomyces?
Normal antibiotics will not cover it
Osteomyelitis with microbiology of actinomyces will require what treatment?
Long-term oral antibiotics
What percentage of bone is lost before significant radiographic changes will be seen on a panorex, occlusal, or PA(?
30-60%
What is the minimum amount of time after onset of acute osteomyelitis will radiographic changes be seen on the panorex, occlusal, or PA?
Minimum of 4-14 days
How long after initiation of osteomyelitis will full extent of bone dissolution be seen ragiographically?
3 weeks after initiation
What radiographic changes are seen with osteomyelitis?
- Scattered areas of bone destruction with moth-eaten appearance
- Sequestra, involucrum
- Stippled / granular densification of bone due to subperiosteal deposition of new bone
- Central sequestra in marrow space
What type of osteomyelitis has the following on radioraphs:
Increased radiolucency
Loss of trabecular structure
Loss of contour of the mandible
Pseudo-widening of the mental foramen and IAN canal
Erosion of cortical bone
Acute osteomyelitis 1-2 weeks
What type of osteomyelitis has the following on radiograph:
Areas of increased radiopacity with loss of bone trabeculae
Effacement of cortical-cancellous bone junctions affecting a hemimandible
Minor spots of radiolucency
Rarely have a periosteal reaction
Temporomandibular joint reaction
Acute osteomyelitis 3-4 weeks
The following are radiographic signs of what type of osteomyelitis
Areas of increased radiopacity with loss of bone trabeculae
Minor areas of radiolucency, and interruption of cortical bone
Sequester formation
Calcified periosteal reaction
Possible pathologic fractures
Secondary Chronic Osteomyelitis
The following are the radiographic signs of what type of osteomyelitis:
Areas of increased radiopacity with loss of bone trabeculae
Effacement of cortical-cancellous bone junctions affecting a hemimandible
Minor spots of radiolucency
Rarely have a periosteal reaction
Temporomandibular joint reaction
Primary chronic osteomyelitis
What is the major radiographic difference between acute osteomyelitis and chronic osteomyelitis?
Acute has increased radiolucency while chronic has increased radiopacity
Of the 2 chronic osteomyelitis types (primary and secondary) which one rarely has a periosteal reaction (onion skinning)?
Primary chronic osteomyelitis
What radiograph is first indicated with osteomyelitis?
Conventional, i.e. panoramic
If the panoramic is negative for osteomyelitis, but osteomyelitis is highly suspected, what is the next imagineg modality based on algorithm in the powerpoint?
Technetium bone scan
What is a disadvantage of a bone scan?
Not specific, only shows something is going on in that area
If a bone scan shows no positive osteomyelitis, but osteomyelitis is still highly suspected, what can be done?
MRI or CT scan
How does Dr Lui prefer to order his imaging for osteomyelitis?
Panoramic first. If that is negative then CT because it is more diagnostic.
Of acute osteomyelitis, secondary chronic osteomyelitis, and primary chronic osteomyelitis, which 2 will result in a suppurative infection with sequestration?
- Acute
2. Secondary chronic
Will primary chronic osteomyelitis result in a suppurative or non-suppurative infection?
Non suppurative
Of acute osteomyelitis, secondary chronic osteomyelitis, and primary chronic osteomyelitis, which 2 have osteoblastic activity?
- Secondary Chronic
2. Primary Chronic
Of acute osteomyelitis, secondary chronic osteomyelitis, and primary chronic osteomyelitis, which 2 involve osteolysis(?
- Acute
2. Secondary Chronic
When beginning treatment for osteomyelitis, what is the goal of evaluating pt’s immune system?
So any host defense deficiency can be corrected
Why is gram staining and culturing important for treatment of osteomyelitis?
To give stain guided and culture guided empirical antibiotic treatment
What should be done with any loose teeth, sequestra, infected hardware or foreign bodies in the area of osteomyelitis?
Remove it all
What is consideration of placement to aide the drainage of infection?
Placing irrigation drains and polymethylmethacrylate antibiotic beads
What is the key to have after surgery involving any or all of the following: sequestrectomy, debridement, saucerization, decortications, resection, reconstruction?
Remove until you have bleeding bone at all margins
What is placed if discontinuity defect of the mandible after surgery?
IMF or external fixation
What is indicated for refractory cases?
Hyperbaric oxygen (HBO) therapy in order to improve wound healing by improving oxygen tension
What are the 3 columns of therapy for acute and secondary chronic osteomyelitis?
- Surgery
- Hyperbarie Oxygen (HBO) therapy
- Antibiotics
What are the 3 goals of therapy for acute and secondary chronic osteomyelitis?
- Decompression of the intramedullary space and drainage of subperiosteal abscess formation
- Surgical debridement of infected tissue and removal of infectious focus
- Bringing well-perfused tissue adjacent to the infected area
What is a major difference in the surgical treatment of scute versus secondary chronic osteomyelitis?
Acute will have a local incision and drainage or local curettage while secondary chronic will have a more invasive surgery that is guided by the extent of the lesion
How far is the bone removed during a decortication surgery to treat osteomyelitis?
1-2 cm beyond the affected bone
Should every exposed bone be considered osteomyelitis?
No, differential should include tumors, metastasis, osteoradionecrosis
What is the difference in antibiotics for osteomyelitis not very much invasive versus and osteomyelitis that goes to the inferior border of the jaw and requires surgery?
2 wks for the less invasive
IV antibiotics for 6 wks for more invasis
The antibiotic therapy for acute and chronic osteomyelitis should last for how long?
At least 6 weeks after resolution of symptoms in acute
Up to 6 months in refractory chronic
What is the term for when you sound like you have something in your voice when you are trying to speak (lots of saliva and coughing)?
Dysphonia
What spaces are associated with truisms and fever and where swelling can come from mandibular wisdom teeth?
Pterygomandibular and submasseteric spaces
What space obliterates the ear when swollen and you are looking directly at the patient?
Parotid space
What is the term for difficulty swallowing?
Dysphagia
What space swelling is associated with dysphagia, deviation of the uvula, fullness of side of airway?
Lateral Pharyngeal Space
What spaces are “potential” in that they don’t normally exist but will fill up when there is an infection?
.1 Right pterygomandibular space
- Right submasseteric space
- Right lateral pharyngeal space
- Submental space
- Bilateral submandibular spaces
- Bilateral sublingual space
How long does it take for clinical evidence of osteomyelitis to become apparent?
4-14 days
How long does it take for radiographic evidence of osteomyelitis to become evident?
3 weeks
Why is it best to refer osteomyelitis to a specialist?
It may resolve with antibiotics but the sequestra will still require surgical removal
What usually presents as a swelling or mass in the submandibular region?
Actinomycosis (cervicofacial)
What sort of history is usually present with actinomycosis?
History of trauma (i.e. recent extraction)
What phase of actinomycosis manifests as a chronic purulent discharge?
The well-established phase
What does the purulent exudate of actinomycosis classically contain?
Sulfur granules
What is the treatment for actinomycosis?
Antibiotics, I and D and (if necessary) excision of the fistulous tract
A definitive diagnosis of actinomycosis depends upon what?
Laboratory identification of the organism
Is actinomyces gram positive or gram negative?
Gram positive
How is actinomyces cultured?
Incubated in an anaerobic environment, usually on brain-heart agar or blood agar, for 4 to 6 days
What is the duration of antibiotics for actinomycosis?
IV antibiotics for 4-6 weeks
Oral therapy for 6-12 months
What are effective antibiotics against actinomycosis?
- Penicillin
- Macrolides
- Doxycycline
- Ceftriaxone
- Clindamycin
What two types of factors are responsible for immune compromise leading to candidiasis?
- Naturally occurring
2. Iatrogenic
What are some natural factors that can lead to candidiasis?
- Organ failure (especially kidney, liver and lungs)
2. HIV infection
What are some iatrogenic factors that could lead to candidiasis?
- Long-term antibiotic therapy
- Immunosuppression for neoplastic disease
- Immunosuppression for allograft preservation or organ transplant
- Corticosteroid therapy
- Head and neck radiation therapy
What is the most common source of exposure to the thrush organism?
The birth canal
What is the main treatment for candidiasis?
Treat the underlying cause of immunosuppression
How are mild to moderate candidiasis infections treated?
Topical medications (nystatin, clotrimazole)
How are more severe candidiasis infections treated?
Systemic drugs (fluconazole, diflucan) and possibly hospitalization
