Management of Osteomyelitis

Question 1

Spread of Odontogenic Infections
(2)

Answer 1

– Soft tissue/fascial spaces – More common
– Osseous structures (Osteomyelitis) – Less common

Question 2

Osteomyelitis is Inflammation and infection of the — with a tendency to progression.

Answer 2

bone marrow

Question 3

• Osteomyelitis is Inflammation and infection of the bone marrow with a tendency to progression.
• This process starts of in the medullary bone and then continues to involve adjacent (2)
• The disease if untreated progresses from inflammatory destruction of bone, to —
• In the oral region, it is usually a result of …

Answer 3

cortical plates and
often periosteum (More frequently seen in the Mandible)
necrosis (sequestra).
bacterial infection secondary to odontogenic infections, trauma.

Question 4

Osteomyelitis - Incidence
(2)

Answer 4

• Much higher in the mandible due to the dense, poorly vascularized cortical plates.
• Maxillary bone is much less dense with excellent blood supply.

Question 5

Osteomyelitis: Mandible More Affected Than Maxilla
Mandible
(2)

Answer 5

• Predominantly supplied by Inferior
  alveolar Neurovascular bundle
• Overlying cortical plate is thick

Question 6

Osteomyelitis: Mandible More Affected Than Maxilla
Maxilla
(2)

Answer 6

• Much more vascular than Mandible
  as it receives blood supply from
  several arteries.
• Less dense than Mandible

Question 7

Osteomyelitis
* This pathologic entity usually follows an — course.

Answer 7

indolent, yet progressive and persistent

Question 8

Osteomyelitis – Predisposing factors
Immuno-compromised status
(6)

Answer 8

• Diabetes Mellitus
• Malignancy
• AIDS
• Patients taking chronic Steroids, and
  chemotherapeutic agents
• Patients on Immunosuppressant’s
• Tuberculosis

Question 9

Osteomyelitis – Predisposing factors
Conditions that affect the Jaw vascularity
(5)

Answer 9

• H/O Irradiation Treatment
• Advanced Osteoporosis
• Osteopetrosis
• Late stage cemento-osseous dysplasia
• Osteitis deformans (Paget disease)

Question 10

Osteomyelitis - Pathogenesis

Answer 10

Primarily a result of odontogenic infections or trauma, which cause inoculation of
bacteria into the jaws.
Results in an inflammatory cascade that is usually self-limiting in the healthy patient.
With progression, the condition is considered pathologic.
* Infection and associated inflammation(edema) spreads into
marrow spaces and causes compression of blood vessels and
therefore causes severe compromise of blood supply.
* Pus travel through haversian & volkaman’s canal and
accumulation beneath the periosteum & elevating it from cortex
& there by reducing the blood supply.
* Ultimately, cortical bone perforates, compromising periosteal
blood supply as well.
* Reduced blood supply causes necrosis of bone.
* Small section of necrotic bone may get completely lysed while large get localized and
get separated from the shell of new bone by bed of granulation tissue.
* The dead bone is surrounded by the new viable bone this is called involucrum.
* Then pus penentrate the periosteum & mucosal & cuteneous fistulae develop and
thereby discharging the purulent pus.
* Intraoral or extraoral fistulas usually develop

Question 11

Osteomyelitis - Pathogenesis
* Bacteria then proliferates as
normal blood-borne defenses
do not reach the tissue and
the osteomyelitis process
spreads until it is stopped by
(2)

Answer 11

surgery and medical
treatment.

Question 12

Osteomyelitis - Microbiology
(3)

Answer 12

Usually a mixed infection when involving the jaws.
Alpha Hemolytic Streptococci and anaerobic bacteria (Peptostreptococcus,
Fusobacterium, Prevotella) recognized as prime pathologic species for osteomyelitis
of the jaws.
Osteomyelitis of the long bones usually caused by Staphylococcus aureus.

Question 13

Osteomyelitis - Classification
(3)

Answer 13

Many systems have been developed in the past
System developed by Hudson is the most practical today
This system divides osteomyelitis into Acute and Chronic types based on presence for a
1 month duration

Question 14

Acute osteomyelitis - Classification
(4)

Answer 14

• Contiguous focus (It is the result of the spread of infection from an adjacent soft tissue
  focus such as wound, laceration, abscess, post-operative infection)
• Progressive
• Hematogenous (spread to the bone from a source through bloodstream)
• Suppurative vs. non-suppurative

Question 15

Chronic Osteomyelitis - Classification
(5)

Answer 15

• Recurrent multifocal
• Garré’s – proliferative periostitis, periostitis ossificans
• Suppurative or nonsuppurative
• Chronic sclerosing
• Chronic refractory osteomyelitis

Question 16

Osteomyelitis - Clinical presentation
(8)

Answer 16

– Pain
– Swelling and erythema of overlying tissues
– Adenopathy
– Fever
– Paresthesia of the inferior alveolar nerve
– Trismus
– Malaise
– Fistulas

Question 17

Osteomyelitis - Laboratory work-up
(2)

Answer 17

In the acute phase, common to see leukocytosis, which is uncommon in the chronic
phases.
Elevated ESR (erythrocyte sedimentation rate) and CRP (C-reactive protein) which are
sensitive indicators of inflammation but non-specific.

Question 18

Osteomyelitis - Imaging
Radiographic images lag behind the clinical presentation since cortical involvement is
required for any change to be evident.
Acute osteomyelitis often appears — radiographically
Till at least —% destruction of mineralized portion of bone takes place – this
destruction is not visible on radiograph.
Chronic osteomyelitis – —appearance

Answer 18

normal
30-60
moth eaten

Question 19

Osteomyelitis - Imaging
– Orthopanoramic view is recommended initially
(2)

Answer 19

– Easily obtainable
– Gives information of possible sources and progression

Question 20

Osteomyelitis - Imaging
* C.T scans have become standard
(3)

Answer 20

– Provide detailed 3 dimensional views.
– Require 30-50% demineralization before changes are seen.
– Allow assessment of the cortices

Question 21

Osteomyelitis -
MRI (Magnetic Resonance Imaging)
(2)

Answer 21

• It can assist in early diagnosis by detection of bone marrow changes prior to cortical
  involvement.
• Bone marrow changes and soft tissue changes are seen more accurately in MRI when
  compared to a CT scan

Question 22

Osteomyelitis - Imaging
Nuclear medicine -Technetium 99 highlights areas of increased
bone turnover.
92)

Answer 22

A technetium bone scan is more sensitive than plain film imaging
in detecting early infections and may be positive as early as three
days.
However, bone scans in general are sensitive for bone turnover, but
are generally not specific for osteomyelitis. There is a high
incidence of false positive osteomyelitis nuclear medicine studies.
of soft tissue infections.

Question 23

Osteomyelitis - Treatment
(4)

Answer 23

Both medical and surgical interventions are required.
Medical therapy alone will not suffice, and will only delay appropriate treatment.
Tissues from the affected site should be sent for microbiological exam, culture and
sensitivity, and histopathological examination.
Immunocompromised states should be controlled medically to achieve optimum
response to therapy

Question 24

Osteomyelitis – Medical Treatment
(6)

Answer 24

• Begin empiric antibiotic treatment based on Gram stain(microbiological exam) results.
• Best choice of antibiotic can be determined following C & S results, which can take
  several days
  IV antibiotic therapy for 6 weeks is routinely used
  Treatment may include carbapenems, cephalosporins, fluoroquinolones, Clindamycin,
  Metronidazole, or combination therapy.
  Infectious disease consult may be considered
  HBO therapy for chronic refractory osteomyelitis may be considered

Question 25

Hyperbaric Oxygen Therapy(HBOT)
(4)

Answer 25

Hyperbaric oxygen is indicated in treatment of “Chronic Refractory osteomyelitis”
Chronic refractory osteomyelitis is a persistent or recurrent bone infection lasting longer than six
months despite appropriate surgical and medical treatment.
* HBOT involves placing a patient
in a chamber where they
breathe 100% oxygen at
increased atmospheric pressure.
* A typical course of treatment for
Chronic refractory osteomyelitis
consists of a 90 minute session
for five days per week for 20 to
60 treatments based on their
condition

Question 26

Hyperbaric Oxygen Therapy for Chronic Refractory osteomyelitis
Hyperbaric oxygen treatment – Mechanism of action
(4)

Answer 26

• Enhanced leukocyte oxidative killing
• Neo-Angiogenesis
• Osteogenesis
• Synergistic antibiotic activity

Question 27

Osteomyelitis – Surgical Treatment
Sequestrectomy
(2)

Answer 27

• Sequestrectomy is the removal of infected and avascular pieces of bone.
• Since the sequestrum is avascular, antibiotics will not be able to penetrate into it

Question 28

Osteomyelitis – Surgical Treatment
Saucerization
(2)

Answer 28

Saucerization involves the removal of the adjacent bony cortices and open packing to permit healing by
secondary intention after the infected bone has been removed.
Here the margins of the bone which lodge the sequestra are trimmed down. This create a saucer shaped
defect instead of a deep hollow cavity. This saucer shaped defect can’t accumulate a large clot

Question 29

Osteomyelitis – Surgical Treatment
Decortication
(2)

Answer 29

• Decortication – involves removal of the dense, chronically infected, and poorly
  vascularized bony cortex and placement of the vascular periosteum adjacent to the
  medullary bone to allow increased blood flow and healing in the affected area.
• Key element is cutting back to healthy bleeding bone – clinical judgement

Question 30

Osteomyelitis – Surgical Treatment
Additional considerations
(2)

Answer 30

• May support weakened mandible using external fixation, reconstruction plate, or MMF.
• Segmental resection usually a last resort following multiple attempts at more
  conservative debridement