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osteomyelitis Flashcards

1
Q

how commonly do odontogenic infections spred via bone

A

less common than soft tissue

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2
Q

Osteomyelitis - Definition
* Osteomyelitis def? tendency to?
* This process starts where in bone? spreads to?
* The disease if untreated progresses?
* In the oral region, it is usually a result of?

A
  • 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 cortical plates and often periosteum (More frequently seen in the Mandible)
  • The disease if untreated progresses from inflammatory destruction of bone, to necrosis (sequestra).
  • In the oral region, it is usually a result of bacterial infection secondary to odontogenic infections, trauma.
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3
Q

Osteomyelitis - Incidence
* which arch? why?

A
  • Much higher in the mandible due to the dense, poorly vascularized cortical plates.
  • Maxillary bone is much less dense with excellent blood supply.
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4
Q

Mandible blood supply/ bone

A
  • Predominantly supplied by Inferior
    alveolar Neurovascular bundle
  • Overlying cortical plate is thick
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5
Q

Maxilla
* vascular supply
* density?

A
  • Much more vascular than Mandible
    as it receives blood supply from
    several arteries.
  • Less dense than Mandible
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6
Q

sequestra

A

necrotic bone

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7
Q

osteomyelitis course?

A

This pathologic entity usually follows an indolent, yet progressive and persistent

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8
Q
A

osteomyelitis

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9
Q

Microstructure of Bone

A
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10
Q

Osteomyelitis – Predisposing factors

A

Immuno-compromised status
and Conditions that affect the Jaw vascularity

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11
Q

Osteomyelitis - Pathogenesis
in mandible

A
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12
Q

Osteomyelitis - Pathogenesis
Primarily a result of? allows?
Results in an? limiting?
With progression, the condition is considered?

A
  • 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
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13
Q

Osteomyelitis - Pathogenesis
* Infection and associated inflammation(edema) spreads into?
* Pus travel through? accumulates where?
* Ultimately, cortical bone will? result?
* Reduced blood supply causes?

A
  • 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.
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14
Q

Osteomyelitis - Pathogenesis
* Small section of necrotic bone may get completely? what if larger?
* The dead bone is surrounded by the new viable bone this is called?
* Then pus penentrate the?
* fistulas?

A
  • 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.
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15
Q

Osteomyelitis - Pathogenesis
* Bacteria then proliferates as what cannot reach site? spreads until?

A
  • Bacteria then proliferates as normal blood-borne defenses do not reach the tissue and the osteomyelitis process spreads until it is stopped by surgery and medical treatment
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16
Q

Osteomyelitis - Microbiology
Usually a?
Osteomyelitis of the long bones usually caused by?

A

Usually a mixed infection when involving the jaws.

Osteomyelitis of the long bones usually caused by Staphylococcus aureus

17
Q

Osteomyelitis - Classification
Many systems?
System developed by ? is the most practical today
This system divides osteomyelitis into what types based on?

A

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

18
Q

Acute osteomyelitis - Classification
* Contiguous focus?
* Progressive?
* Hematogenous ?
* Suppurative vs. non-suppurative?

A
  • 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
19
Q

Chronic Osteomyelitis - Classification
* Recurrent multifocal?
* Garré’s?
* Suppurative or nonsuppurative?
* Chronic sclerosing?
* Chronic refractory osteomyelitis?

A
  • Recurrent multifocal
  • Garré’s – proliferative periostitis, periostitis ossificans
  • Suppurative or nonsuppurative
  • Chronic sclerosing
  • Chronic refractory osteomyelitis
20
Q
A

garres osteomyelitis

21
Q

Osteomyelitis - Clinical presentation, which is highlighted?

A

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

22
Q

Osteomyelitis - Laboratory work-up
In the acute phase, common to see?

sensitive indicators of inflammation but non-specific?

A

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.

23
Q

Osteomyelitis - Imaging
Radiographic images lag? why?
Acute osteomyelitis often appears?
Till at least ?% destruction of mineralized portion of bone takes place – this destruction is not visible on radiograph?
Chronic osteomyelitis app?

A

Radiographic images lag behind the clinical presentation since cortical involvement is required for any change to be evident.
Acute osteomyelitis often appears normal radiographically
Till at least 30-60% destruction of mineralized portion of bone takes place – this destruction is not visible on radiograph.
Chronic osteomyelitis – moth eaten appearance

24
Q

Osteomyelitis - Imaging
– what is recommended initially?
– Gives information of?

A

– Orthopanoramic view is recommended initially
– Easily obtainable
– Gives information of possible sources and progression.

25
Q
A

chronic osteomyelitis-moth eaten

26
Q

Osteomyelitis - Imaging
* what have become standard?
– Provide detailed?
– Require ?% demineralization before changes are seen.
– Allow assessment of ?

A
  • C.T scans have become standard
    – Provide detailed 3 dimensional views.
    – Require 30-50% demineralization before changes are seen.
    – Allow assessment of the cortices
27
Q

Osteomyelitis - MRI
* It can assist in? how?
* what are seen more accurately in MRI when compared to a CT scan?

A
  • 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.
28
Q

Osteomyelitis - Nuclear medicine highlights areas of?
A technetium bone scan is more sensitive than? in detecting?
However, bone scans in general are sensitive for? but not?
There is a high incidence of false positive?

A

Nuclear medicine -Technetium 99 highlights areas of increased
bone turnover.
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

29
Q

Osteomyelitis - Treatment
Both what interventions are required?
Medical therapy alone?
Tissues from the affected site should be sent for?
Immunocompromised states should be?

A

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

30
Q

Osteomyelitis – Medical Treatment
* Begin abx based on?
* Best choice of antibiotic can be determined following?

A
  • 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
31
Q

Osteomyelitis – Medical Treatment
IV antibiotic therapy?
Treatment may include what agents?
Infectious disease consult?
HBO therapy for?

A
  • 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
32
Q

Hyperbaric Oxygen Therapy (HBOT)
Chronic refractory osteomyelitis is?

A
  • 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.
33
Q

Hyperbaric Oxygen Therapy(HBOT)
* HBOT involves placing a patient
in a chamber where they
breathe ?% oxygen at ? atmospheric pressure.
* A typical course of treatment for
Chronic refractory osteomyelitis
consists of a ? minute session
for ? days per week for ? to
? treatments based on their condition

A
  • 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
34
Q

Hyperbaric oxygen treatment – Mechanism of action
- Enhanced?
- Angiogenesis?
- Osteo?
- Synergistic?

A
  • Enhanced leukocyte oxidative killing
  • Neo-Angiogenesis
  • Osteogenesis
  • Synergistic antibiotic activity
35
Q

Osteomyelitis – Surgical Treatment
Sequestrectomy

A
  • 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.
36
Q

Osteomyelitis – Surgical Treatment Saucerization
* removal of?
* permit healing by?
* defect shape and clot?

A

Saucerization involves:
* the removal of the adjacent bony cortices and open packing
* 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

37
Q

Osteomyelitis – Surgical Treatment: Decortication
* removal of?
* periosteum role?
* key element?

A

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

38
Q

Osteomyelitis – Surgical Treatment
Additional considerations
* May support weakened mandible using?
* Segmental resection usually a?

A
  • May support weakened mandible using external fixation, reconstruction plate, or MMF.
  • Segmental resection usually a last resort following multiple attempts at more conservative debridement
39
Q
A

OS II (14 decks)

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