Long Term Complications

Question 1

What is Osteomyelitis?

Answer 1

Inflammation of the bone marrow
Clinically the term implies an infection of the bone

Question 2

How does Osteomyelitis occur?

Answer 2

Usually begins in medullary cavity involving the cancellous bone
Then extends and spreads to the cortical bone
Then eventually to the periosteum (overlying mucosa red and tender)
Invasion of bacteria into cancellous bone causes soft tissue inflammation (or necrosis of the tissues) and oedema in the closed bony marrow spaces

Question 3

How do you stop the spread of osteomyelitis?

Answer 3

Until it is arrested by antibiotics and surgical therapy

Question 4

What does oedema in an enclosed space lead to?

Answer 4

Increased tissue hydrostatic pressure- higher than blood pressure of feeding arterial vessels
Compromised blood supply results in soft tissue and the involved area becomes ischaemic and necrotic
Bacteria proliferate because normal blood borne defences do not reach the tissue

Question 5

What are the major predisposing factors in osteomyelitis?

Answer 5

Odontogenic infections
Fractures of mandible
Compromised immune system or pre-existing conditions

Question 6

What is the main bacteria involved in infections of the mandible?

Answer 6

Streptococci, anaerobic cocci (peptostreptococcus)
Anaerobic gram negative rods such as fusobacterium and prevotella

Question 7

What antibiotic treatment is used to treat osteomyelitis?

Answer 7

Penicillins (amoxicillin) 1st line drug
Longer courses than normal
At least 6 weeks after resolution of symptoms, in some cases up to 6 months

Question 8

What is the Surgical Treatment of Osteomyelitis?

Answer 8

Drain pus if possible
Remove any non-vital teeth in the area of infection
Remove any loose pieces of bone
In fractured mandible- remove any wires/plates/screws
Corticotomy- removal of bony cortex
Perforation of bony cortex
Excision of necrotic bone (until reach actively bleeding bone tissue)

Question 9

What is Osteoradionecrosis (ORN)?

Answer 9

Seen in patients who have received radiotherapy to the head and neck to treat cancer
The bone within radiation beam becomes virtually non-vital
Endarteritis- reduced blood supply
The turnover of any remaining viable bone is slow

Question 10

What can prevent ORN?

Answer 10

Scaling/Chlorhexidine mouthwash leading up to extraction
Careful extraction technique
Antibiotics, chlorhexidine mouthwash and review
Hyperbaric oxygen (to increase local tissue oxygenation & vascular ingrowth to hypoxic areas) before and after extraction

Question 11

What is the treatment for ORN?

Answer 11

Irrigation of necrotic debris
Loose sequestra removed
Small wounds (under 1cm) usually heal over a course of weeks/months
Severe cases- resection of exposed bone, margin of unexposed bone and soft tissue closure
Hyperbaric oxygen

Question 12

What is Medication Related Osteonecrosis of the Jaw (MRONJ)?

Answer 12

Occurs post extraction/following denture trauma/spontaneous
Occurs due to medication that inhibits osteoclast activity and so inhibit bone resorption and therefore bone renewal (no bone remodelling). These drugs may remain in the body for years
Ranges from small asymptomatic areas of exposed bone to extensive bone exposure/dihiscence/pus/pain

Question 13

What are some drugs to watch out for MRONJ risk?
Bisphosphonates

Answer 13

IV bisphosphonates
-Clondrate
-Pamidronate
-Zoledronate
Oral bisphosphonates
-Alendronate
-Etidronate
-Ibandronate
-Risedronate
-Tiludronate

Question 14

What are some other types of drugs that can cause MRONJ?

Answer 14

Receptor activator of nuclear factor kappa B-ligand (RANK-L) inhibitors
–Denosumab, Xgeva, Prolia (cancer drug-monoclonal antibody) stops the production of osteoclasts
Antiangiogenic
–Monoclonal antibodies that stop the receptor or growth factor (bevacizumab)
–Small molecules which determine the block by binding the tyrosine kinase receptor (sunitinib and sorafenib)

Question 15

How many years of bisphosphonate drug therapy increase the risk of MRONJ?
What else increases risk?

Answer 15

5 years
Increased dose and increased duration also increase risk

Question 16

What is the management of MRONJ?

Answer 16

Prevent invasive treatment
Extractions in primary care setting
No benefit of referral to secondary care based purely on their exposure to these drugs
Guidance considers patients in 2 groups
–initial management (prior to commencing drug or just commenced)
–continuing management (established drug regime)

Question 17

What is Actinomycosis?

Answer 17

Rare bacterial infection (Actinomyces israelli/A. Naeslundii/A. Viscosus)
The bacteria have low virulence and must be innoculated into an area of injury and susceptibility

Question 18

What does Actinomycosis appear like?

Answer 18

Thick lumpy pus- colonies of it look like sulphur granules on histology
Multiple skin sinuses and swelling
Fairly chronic

Question 19

What is the treatment for Actinomycosis?

Answer 19

I&D of pus accumulation
Excision of chronic sinus tract
Excision of necrotic bone & foreign bodies
High dose antibiotics for initial control (often IV)
Long term oral antibiotics to prevent recurrence
(penicillins, doxycycline or clindamycin)

Question 20

What is Infective Endocarditis?

Answer 20

Bacteria in the bloodstream following extraction would circulate to the heart and colonise vegetations/scarring/artificial valves and lead to the life threatening infective endocarditis

Question 21

What are the people at risk of infective endocarditis?

Answer 21

People who had rheumatic fever in the past
Some heart murmurs
Prosthetic heart valves
Some types of cardiac surgery

Question 22

What do you prescribe for infective endocarditis?

Answer 22

Amoxicillin 3g, 60 mins before procedure