CHRONIC INFECTIONS CHRONIC INFECTIONS OF JAWSOF JAWS

ORORINFLAMMATOR INFLAMMATOR

DISEASES OF BONEDISEASES OF BONE

OSTEOMYELITIS.OSTEOMYELITIS.

• It is an inflammatory process of bone It is an inflammatory process of bone which involves;which involves;• bone marrowbone marrow• cancellous cancellous • cortexcortex• periosteumperiosteum

PATHOPHYSIOLOGYPATHOPHYSIOLOGY

• Infection Infection • Infected exudate → spreads throughout Infected exudate → spreads throughout

cancellous spaces of bone →Thrombosis of cancellous spaces of bone →Thrombosis of nutrient vesselsnutrient vessels

• Ischemia → Infaction → OsteomylitisIschemia → Infaction → Osteomylitis• MandibleMandible

• Reduced endosteal blood supply_ osteomylitis Reduced endosteal blood supply_ osteomylitis common common

• Maxilla Maxilla • Plexiform blood supply _osteomylitis less Plexiform blood supply _osteomylitis less

commoncommon

CLASSIFICATIONCLASSIFICATION• SUPPURATIVE (PYOGENIC) OSTOMYLITISSUPPURATIVE (PYOGENIC) OSTOMYLITIS

• ACUTEACUTE• CHRONICCHRONIC

CHRONIC SCLEROSING NON SUPPARATIVE CHRONIC SCLEROSING NON SUPPARATIVE OSTEOMYLITIS OR GARRE’S OSTEOMYLITISOSTEOMYLITIS OR GARRE’S OSTEOMYLITIS

• OSTEOMYLITIS IN SYSTEMIC DISEASESOSTEOMYLITIS IN SYSTEMIC DISEASES• TB , ACTINOMYCOSIS , SYPHILISTB , ACTINOMYCOSIS , SYPHILIS• IRRADIATION (OSTEORADIO NECROSIS)IRRADIATION (OSTEORADIO NECROSIS)• PAGETS DISEASE, OSTEOPETROSISPAGETS DISEASE, OSTEOPETROSIS• CHEMICALS, ELECTRO COAGULATION.CHEMICALS, ELECTRO COAGULATION.

ACUTE PYOGENIC ACUTE PYOGENIC OSTEOMYLITIS OSTEOMYLITIS

PREDISPOSING FACTORSPREDISPOSING FACTORS

• IMPAIRED IMMUNE DEFENCESIMPAIRED IMMUNE DEFENCES• SYSTEMICSYSTEMIC

• ACUTE LEUKAEMIASACUTE LEUKAEMIAS• AIDSAIDS• UNCONTROLLED DIABETESUNCONTROLLED DIABETES• MALNUTRITION, ALCOHLICSMALNUTRITION, ALCOHLICS

• LOCALLOCAL• IRRADIATION IRRADIATION • PAGETS DISEASEPAGETS DISEASE

ETIOLOGYETIOLOGY

• ODONTOGENIC INFECTIONSODONTOGENIC INFECTIONS• PERIAPICAL INEECTIONPERIAPICAL INEECTION• PERIODONTAL INFECTIONPERIODONTAL INFECTION• LONG_ STANDING PERICORONAL INFECTIONLONG_ STANDING PERICORONAL INFECTION• EXTRACTED WOUND INFECTIONEXTRACTED WOUND INFECTION• INFECTION OF ODONTOGENIC CYST/ TUMOUR INFECTION OF ODONTOGENIC CYST/ TUMOUR

• COMPOUND FRACTURE/GUN SHOT WOUNDSCOMPOUND FRACTURE/GUN SHOT WOUNDS• LOCAL TRAUMATIC INJURIES OF GINGIVA LOCAL TRAUMATIC INJURIES OF GINGIVA • PERI TONSILLAR ABSCESS/ MIDDLE EAR PERI TONSILLAR ABSCESS/ MIDDLE EAR

INFECTION INFECTION • FURUNCULOSIS/ BOIL OF CHINFURUNCULOSIS/ BOIL OF CHIN• HAEMATOGENOUS INFECTIONHAEMATOGENOUS INFECTION

MICROBIOLOGYMICROBIOLOGY

• MIXED INFECTION MIXED INFECTION • ANAEROBES PLAYS MAJOR ROLE ANAEROBES PLAYS MAJOR ROLE • STAPHYLOCOCCUS STAPHYLOCOCCUS

• AUREUS (PREDOMINENT)AUREUS (PREDOMINENT)• ALBUSALBUS

• STREPTOCOCCUSSTREPTOCOCCUS• BACTEROIDESBACTEROIDES

CLINICAL FEATURESCLINICAL FEATURES• M > FM > F• MAND > MAXMAND > MAX

• LIMITED BLOOD SUPPLY LIMITED BLOOD SUPPLY • MORE DENSE BONEMORE DENSE BONE

• PAINPAIN• SEVERE, THROBBING, DEEP SEATEDSEVERE, THROBBING, DEEP SEATED

• SWELLINGSWELLING• FIRM / INDURATED / MODERATE SIZEFIRM / INDURATED / MODERATE SIZE• OVERLYING GUM RED / SWOLLEN / TENDEROVERLYING GUM RED / SWOLLEN / TENDER

• TEETHTEETH• NO OF TEETH TENDER ON PERCUSSIONNO OF TEETH TENDER ON PERCUSSION• MOBILITY OF TEETH IN AFFCTED JAW SEGMENTMOBILITY OF TEETH IN AFFCTED JAW SEGMENT • PUS EXUDATES AROUND NECK PUS EXUDATES AROUND NECK

CLINICAL FEATURESCLINICAL FEATURES• TRISMUSTRISMUS• LABIAL PARESTHESIALABIAL PARESTHESIA

• DUE TO INCREASE PRESSURE IN INFERIOR ALVEOLAR DUE TO INCREASE PRESSURE IN INFERIOR ALVEOLAR CANALCANAL

• DISTINGUISHED FROM ALVEOLAR ABSCESSDISTINGUISHED FROM ALVEOLAR ABSCESS• DISCHARGING SINUSDISCHARGING SINUS

• FACE FACE • ALVOLAR PROCESS/PERIODONTAL LIGAMENTALVOLAR PROCESS/PERIODONTAL LIGAMENT

• PATHLOGICAL FRACTUREPATHLOGICAL FRACTURE• LYMPHADENOPATHYLYMPHADENOPATHY• SIGNS OF TOXEMIASIGNS OF TOXEMIA

• FEVER.CHILLS,DEHYDRATIONFEVER.CHILLS,DEHYDRATION• ANEMIA, LEUKOCYTOSIS, INCREASED POLYS ANEMIA, LEUKOCYTOSIS, INCREASED POLYS • MATURE/IMMATUREMATURE/IMMATURE

RADIOGRAPHIC FINDINGSRADIOGRAPHIC FINDINGS• FINDINGS APPEAR AFTER 1-3 WEEKSFINDINGS APPEAR AFTER 1-3 WEEKS

• MARGINSMARGINS• APPEARANCEAPPEARANCE

• RESORPTION OF BONERESORPTION OF BONE• WIDENING OF MEDULLARY SPACESWIDENING OF MEDULLARY SPACES• LOSS OF SHARP TRABECULAR PATTERN OF BONELOSS OF SHARP TRABECULAR PATTERN OF BONE

• RADIOLUCENCYRADIOLUCENCY• ILL DEFINED MARGINS ILL DEFINED MARGINS • MOTH EATEN APPERANCEMOTH EATEN APPERANCE

• SEQUESTURM SEQUESTURM • DEAD BONE SEPERATED FROM ADJACENT BONE BY DEAD BONE SEPERATED FROM ADJACENT BONE BY

RADIOLUCENT AREARADIOLUCENT AREA• INVOLUCRUMINVOLUCRUM

• SUBPERIOSTEAL NEW BONE FORMATIONSUBPERIOSTEAL NEW BONE FORMATION• RADIOPACITYRADIOPACITY

• PARALLEL TO SURFACE OF CORTEX LOWER BORDERPARALLEL TO SURFACE OF CORTEX LOWER BORDER• LINEAR/LAMINATED LIKE ONION SKINLINEAR/LAMINATED LIKE ONION SKIN

TREATMENTTREATMENT(MEDICINAL)(MEDICINAL)

• SUPPORTIVESUPPORTIVE• BED RESTBED REST• DEHYDRATIONDEHYDRATION• DIET / NG TUBEDIET / NG TUBE• BLOOD TRANSFUSIONSBLOOD TRANSFUSIONS

• ANTIBIOTICSANTIBIOTICS • CULTURE & SENSITIVITYCULTURE & SENSITIVITY• AMOXYCILLIN 500MG /8 HRLY / I / VAMOXYCILLIN 500MG /8 HRLY / I / V• CLINDAMYCIN 300MG 6 HRLYCLINDAMYCIN 300MG 6 HRLY• DURATIONDURATION

• 2 WEEKS TO 8 WEEKS2 WEEKS TO 8 WEEKS• ERTHROMYCIN, LINCOMYCIN, CEPHLOSPORINSERTHROMYCIN, LINCOMYCIN, CEPHLOSPORINS

TREATMENTTREATMENT(SURGICAL)(SURGICAL)

• INCISION & DRAINAGEINCISION & DRAINAGE • To relieve pain & pressure To relieve pain & pressure • Reduces absorption of toxic products Reduces absorption of toxic products

• ExtractionExtraction • Extraction of offending tooth /teeth Extraction of offending tooth /teeth

• SequestrectomySequestrectomy• Introral \ submadibular approach Introral \ submadibular approach

• Saucerization Saucerization • To eliminate dead space To eliminate dead space

• ImmobilizationImmobilization• To avoid pathologic fracture To avoid pathologic fracture

COURSE OF DISEASE COURSE OF DISEASE

• Acute, sub acute, chronicAcute, sub acute, chronic stages stages• Infection resolves by proper treatment and Infection resolves by proper treatment and

never recur never recur • It may heal but recur after certain period It may heal but recur after certain period • It may persist and continue with active It may persist and continue with active

suppurationsuppuration• It may quiet down and pursue a chronic It may quiet down and pursue a chronic

course course • Reasons--? Reasons--?

CHRONIC CHRONIC OSTEOMYLITISOSTEOMYLITIS

COURSECOURSE

• Acute infection leading to chronic Acute infection leading to chronic • Chronic osteomylitis may be primary, Chronic osteomylitis may be primary,

due to infection by subvirulent micro due to infection by subvirulent micro organisms organisms

CLINICAL FEATURES CLINICAL FEATURES

• Pain /discharge Pain /discharge • Minimum Minimum

• Bone / madibular enlargement Bone / madibular enlargement • Due to subperiosteal deposition of new bone Due to subperiosteal deposition of new bone

• Sequestra Sequestra • Single or multiple Single or multiple • May shed periodically May shed periodically

• Preservation of mental/ labial sensation Preservation of mental/ labial sensation

RADIOGRAPHIC FINDINGS RADIOGRAPHIC FINDINGS

• Areas of radiolucencies Areas of radiolucencies superimposed on areas of radio superimposed on areas of radio opacities opacities

• Radiopacity is due to: Radiopacity is due to: • Subperiosteal bone depositionSubperiosteal bone deposition• Sequestra attracts calcium Sequestra attracts calcium

TREATMENT TREATMENT • Antibiotic coverAntibiotic cover

• 10 days to 2weeks 10 days to 2weeks • Metronidazole for anerobes Metronidazole for anerobes

• SequestrectomySequestrectomy • Sequestrum removed from surrounding granulation Sequestrum removed from surrounding granulation

tissue tissue • Removal of granulation tissueRemoval of granulation tissue

• C&S C&S • Microbiologic studies – TB Microbiologic studies – TB • Histo pathological exam Histo pathological exam

• DecorticationDecortication• Done with bur/hand piece Done with bur/hand piece • Dense sclerosed medullary bone removed Dense sclerosed medullary bone removed • Bone removed until healthy bleeding bone appears Bone removed until healthy bleeding bone appears

TREATMENT TREATMENT • SaucerizationSaucerization

• The bony margins over hanging the cavity resulting The bony margins over hanging the cavity resulting from removal of sequestrum are removed from removal of sequestrum are removed

• Reduces dead space / haematoma Formation Reduces dead space / haematoma Formation • Drain/pressure dressing Drain/pressure dressing

• Antiseptic dressingAntiseptic dressing • If primarily closure not possible If primarily closure not possible • BiPP / whiteheads varnishBiPP / whiteheads varnish

• ImmoblilzationImmoblilzation • IMF IMF • Splinting adjacent teeth by arch barSplinting adjacent teeth by arch bar

• Hyperbaric oxygen Hyperbaric oxygen • Resection & secondary bone grafting Resection & secondary bone grafting

CHRONIC NON SUPPURTIVE CHRONIC NON SUPPURTIVE SCLEROSING OSTEOMYELITISSCLEROSING OSTEOMYELITIS

• It is response to a low grade It is response to a low grade infection/trauma infection/trauma

• Seen in older people/Negro females Seen in older people/Negro females • Infection source usually not identifiable Infection source usually not identifiable • Usually in mandible Usually in mandible • Teeth are vital with inflamed pulp Teeth are vital with inflamed pulp • Sequestrum formation Sequestrum formation • Expansion of cortices is lacking Expansion of cortices is lacking • Radiographic Radiographic

• Initially radiolucent Initially radiolucent • Later radio opaque Later radio opaque

TUBERCULOUS OSTEOMYLITISTUBERCULOUS OSTEOMYLITIS • Hematogenous spread from pulmonary TBHematogenous spread from pulmonary TB• Localized osteomylitis may follow tooth extraction Localized osteomylitis may follow tooth extraction

performed on TB patient performed on TB patient • Infected socket Infected socket

• PainlessPainless• Pus dischargePus discharge• Bone destruction replaced by granulation tissueBone destruction replaced by granulation tissue• No sequestrum formationNo sequestrum formation• If untreated it extends in soft tissuesIf untreated it extends in soft tissues• Diagnosis-Biopsy for tubercle bacilliDiagnosis-Biopsy for tubercle bacilli• Treatment-Treatment-

• Local surgeryLocal surgery• Anti tuberculous drugAnti tuberculous drug

OSTEORADIONECROSISOSTEORADIONECROSIS

• It is It is defineddefined as Inflammatory as Inflammatory Conition (osteomylitis) of irradiated Conition (osteomylitis) of irradiated bone that has been exposed and has bone that has been exposed and has failed to heal over a period of 3 failed to heal over a period of 3 months in the absence of local months in the absence of local tumor.tumor.

• Doses above 50Gy are required to Doses above 50Gy are required to cause this irreversible damagecause this irreversible damage

PATHOGENESISPATHOGENESIS

• HypoxiaHypoxia• HypovascularityHypovascularity

• Endarteritis ObliteransEndarteritis Obliterans• Hyocellularity Hyocellularity

• Marrow DamageMarrow Damage• Periosteum DamagePeriosteum Damage• Decrease Production of osteoblasts & Decrease Production of osteoblasts &

osteoclastsosteoclasts

CLINICAL FEATURESCLINICAL FEATURES• Sever deep boring pain-InitiallySever deep boring pain-Initially• Alveolar bone Alveolar bone

•Mandible more affectedMandible more affected•Exposed, black, Dark Brown in colorExposed, black, Dark Brown in color•Sequestrum formation – slowSequestrum formation – slow•No involcurum formationNo involcurum formation

• Persistent draining sinusPersistent draining sinus• TrismusTrismus• Pathological FracturePathological Fracture• Radiograph Radiograph

• Moth eaten appearance Of devitalized boneMoth eaten appearance Of devitalized bone

TREATMENTTREATMENT

• AIM :- To Promote neovascularity & AIM :- To Promote neovascularity & NeocellularityNeocellularity

• AntibioticsAntibiotics• Hyperbaric Oxygen therapyHyperbaric Oxygen therapy• Sequestrectomy Sequestrectomy • Local flap cover Local flap cover • Resection / Reconstruction.Resection / Reconstruction.

PROPHYLACTIC MEASURESPROPHYLACTIC MEASURES

• Dental Extractions / osseous surgery Dental Extractions / osseous surgery should be avoided during should be avoided during • active radiotherapyactive radiotherapy• In early post irradiation Period (9 Months)In early post irradiation Period (9 Months)

• Extract all teeth with dubious prognosis Extract all teeth with dubious prognosis lying with in radiation fieldlying with in radiation field• At least 7-10 days before commencement of At least 7-10 days before commencement of

RadiotherapyRadiotherapy• Within 7-10 days after commencement of Within 7-10 days after commencement of

radiotherapy with antibiotic coverradiotherapy with antibiotic cover

ACTINOMYCOSISACTINOMYCOSIS

It is a chronic, Suppurative cervico- It is a chronic, Suppurative cervico- facial infection of soft tissues, facial infection of soft tissues, characterized by formation of characterized by formation of multiple sinuses & widespread multiple sinuses & widespread fibrosis.fibrosis.

ETIOLOGYETIOLOGY• It is a bacterial infection.It is a bacterial infection.• G + Bacteria – Actinomyces IsraeliG + Bacteria – Actinomyces Israeli• Normal oral commencalNormal oral commencal• Injuries, fracture, extraction, human Injuries, fracture, extraction, human

bitebite

CLINICAL FEATURESCLINICAL FEATURES• Males more affected, 30-60 yearsMales more affected, 30-60 years• Swelling Swelling

• Soft tissue / angle, neckSoft tissue / angle, neck• Dusky red, purplish in colourDusky red, purplish in colour• Firm, slightly tender Firm, slightly tender

• Skin- fixed to under lying tissuesSkin- fixed to under lying tissues• Multiple discharging sinusesMultiple discharging sinuses

• Pain is mild or absent Pain is mild or absent • Healing with scarring & puckering of skinHealing with scarring & puckering of skin• TrismusTrismus• Lymph nodes usually not enlarged Lymph nodes usually not enlarged • Actinomycotic osteomylitis occurs if soft tissue Actinomycotic osteomylitis occurs if soft tissue

infection spreads to underlying boneinfection spreads to underlying bone

DIAGNOSISDIAGNOSIS

• Sulphur granules In discharging pus Sulphur granules In discharging pus • Sulphur granules are colonies of Sulphur granules are colonies of

actinomycesactinomyces• Anaerobic culture for 10 days may be Anaerobic culture for 10 days may be

required for identificationrequired for identification• Radiographyically Radiographyically

• In actinomycotic osteomylitis Moth eaten / In actinomycotic osteomylitis Moth eaten / irregular areas of bone destruction similar to irregular areas of bone destruction similar to pyogenic osteomylitispyogenic osteomylitis

TREATMENTTREATMENT

• Prolonged antibiotic therapy Prolonged antibiotic therapy • Organisms survive in depth of lesion Organisms survive in depth of lesion

and causes relapse after a short and causes relapse after a short course of antibiotics.course of antibiotics.

• Penicillin -2gm / day, 6 weeks to 6 Penicillin -2gm / day, 6 weeks to 6 monthsmonths

• In actinomycotic osteomylitis In actinomycotic osteomylitis treatment is same as for pyogenic treatment is same as for pyogenic osteomylitis.osteomylitis.

FUNGAL INFECTIONFUNGAL INFECTION