OSTEOMYELITIS

OSTEOMYELITIS
DEF.: DEF It may be defined as a inflammatory condition of bone that begins as a infection of medullary cavity & haversion system & extend to envolve the periosteum of affected area. It may be develop in jaw as a result of odontogenic infection from abscessed teeth or post surgical infection.

PREDISPOSING FACTOR
Condition affecting the Host resistance 1) Diabetes Mellitus 2) Tuberculosis 3) Sever anemia 4) Leukeamia 5) Agranulocytosis 6) Acute infection- such as A) Scarlet fever B) influenza 7) Typhoiyd 8) Sickel cell anemia 9) Malnutrition 10) Chronic alcholism Condition affecting the Jaw vascularity 1) Metastasis from area of infection such as another bony site & kidney 2) Radiation 3) Osteoporosis 4) Osteopetrosis 5) Fibrous dysplasia 6) Pheriphral vascular disease.

ETIOLOGY
Periodontal 1) Odontogenic infection Periapical Pericoronal 2) Infection from infected dental cyst 3) Compound fracture of Jaw. 4) Traumatic injury 5) Middle ear infection & upper respiratory tract infection through haematogenous route. 6) Furuncle of chin by lymphtic route 7) Peritonsillar abscess

PATHOGENESIS
1) Virulent Organasim get entry winto medullary cavity via many routes. Localization of infection (Most infection are localized by a pyogenic membrane & soft tissue abscess wall). Disorganization of pyogenic membrane by micro organism & by chronic movement of unreduced fracture of Jaw. Due to chronic movement of unreduced fracture or disorganization of pyogenic membrane there will be ischemia & this will introducing the bacteria & microbes deep into under lying cavity. Accumulation of Pus & there will be increased pressure in Medullary cavity. Pus travel through haversion & volkaman's canal & accumulation beneath the periosteum & elevating it from cortex & there by reducing the blood supply. 2)

3)

4)

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7. Reduced blood supply causes necrosis of bone. 8. Then pus penentrate the periosteum & mucosal & cuteneous fisttulae develop & thereby discharging the purulent pus. 9. Small section of necrotic bone may get completely lysed while large get localized & get separated from the shell of new bone by bed of grannulation tissue. The dead bone is surrounded by the new viable bone this is called involucrum. 10.Involucrum contain one or more holes on the surface pus find its way from these orifices. 11.Beside all this microganism precipitate the thrombi formation these thrombi provided isolating barrier from the immune response & further proliferation of microbes :- Thrombi can cause systemic spread of infection

Note: Necrosis of bone with superadded infection form baseline pathogenisis of osteomyelitis. C/F M>F Site: Occur in mandibular PM area because : A) Removal of post'r Mondibular teeth causing more damage to the bone. B) Mandible is less vascular Maxilla

Note: Infentile osteomyelitis- Is more common in Maxillar because spread through hamatogenous route & maxilla has more blood supply than Mandible. Microbiology : 1) Staphyloccous areus 2) Staphyloccous albus 3) Haemolytic Streptococci Gram Negative organism 1) Klebsiella 2) Pseudomonas 3) Proteus CLAFFICATION:CLAFFICATION:4) E. coli Depending upon the presence or absence of separation : 1. Suppurative 2- Non Supprative a) Chronic non suppurative

a)Accute suppurative osteomyelitis b) Chronic Supprative osteomyelitis

b) Focal Sclerosing Diffuse sclerosing c) Radiation osteomyelitis

Primary

Secondary

d) Garre's sclerosing osteomyelitis

c) Infentile osteomyelitis

e) i) ii) iii)

Osteomyelitis due to specific infection Actinomycosis Tuberculosis Syphilis

ACUTE SUPPURATIVE OSTEOMYELITIS:

1. This is sequele of periapical infection. 2. Diffused spread of infection throughout the medullary cavity. C/F 1) Early acute supprative osteomyelitis Sym.: a) Rapid onset b) severe pain c) Parasthesia or anaesthesia of mental nerve At this stage process is intramedullary therefore swelling is absent d) Tooth is not mobile e) fistulae are not present 2.Late acute suppurative osteomyelitis

a) Deep intense pain b) Maliase c) Fever d) Regional lymphadenopathy f) Soreness of involve teeth & teeth become loose within 10-14 days.

Sign : 1) 2) 3) R/F 1) 2) Pus exudate around the gingival sulcus cutaneous fistulae present. Firm cellulitis of cheek Abscess formation

Multiple redioleuciences Saucer shaped destruction with irregular margin.

HISTOPATHOLOGY:-

Medullary space are filled with inflammatory exudates that may or may not contain the pus. Inflammatory cells are chiefly neutrophilic, polymorphonuclear leucocytes. Rarely -1) Lymphocytes 2) Plasma cells

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CHRONIC SUPPURATIVE OSTEOMYELITS It occurs without initial acute stage Virulence is low grade. Chronic osteomyelitis is persistant absecess of bone, characterized by complex inflammatory process including necrosis of mineralised tissue & marrow tissue. 2- Secondary Types: It is secondary to incompletely treated acuteosteomyelitis a) Local Tenderness & swelling develop over the bone in the area of abscess. b) Development of sinus.

1. Primary type Sym:a) Insidous onset b) Slow increase in Jaw size gradual c) development of sequestra without fistula formation

Sign- a) Formation of fistulae b) Indurations of soft tissue. c) Pain & tenderness d) Regional lymphadenopathy HISTOPATHOLOGY :- 1. Chronically inflamed
2. reactive fibrous connective tissue filling the intertrabecular space

R/F:Single of Multiple radio leuciences of variable size. Margins are irregular Moth eaten appearance

C. INFANTILE OSTEOMYELITIS
It is rare type of osteomyelitis infant few weeks after birth. It usually involve the maxilla. Route of infection: 1) Haematogenous route 2) Trauma - prenatal trauma of oral mucosa from obstetrician's finger. 3) Infection- Infection from mucosal bulb use to clear the air way immediate after birth 4) Infected nipple -

C/F

Sign:

a) b) c) d) a) b) c) d) e)

Fever Anoroxia Dehyration Occasionly - convulsion, vomiting Redness Edema of eyelid Intracanthal swelling Proptosis Sinus will develop

R/F 1) Multiple radioleuciencies 2) Saucershaped destruction with irregular margin CHRONIC NON SUPPURATIVE OSTEOMYELITIS Diffused sclerosing Localise sclerosing * Reactive proliferation Cause:often seen in dentolous jaw * Occurs due to low grade Condition occurs when the resistante of C/F at any ageF > M the alveolar bone is high Site - Specially in edentolous virulence of organism is low Mandibular Condition is characterized by focal Sym. area of sclerosis around. During the period of growth patient the roots of teeth may complain of pain & tenderness. Site:- Occurs around the root of Molars. R/F :-Well circumscribe radiopaque. Usually asmptomatic Sign. Slight enlargement of jaw Apical Mass - root out line is always on the affected side. visible. R/F Histopathology :- Dense bony There is presence osteolytic & trabaculae with very little fibrous tissue osteonecrotic bone. Margins -illdefined Histopathology 1. Dense irregular trabucula of the bone 2. Bone shows mosaic pattern 3. Lymphocytes 4. Plasma cell

 jaw. C/F : Age > 30 years. M>F Site : Mostly involve the ant'r surface of tibia & femer. Mandible > Maxilla. Sign : Hyper pyrexia. Leucocytosis Lymphadenophy. R/F : Onion skin apperance.

GARRE'S OSTEOMYELITIS Describe by carl Garre in 1893. Also K/a proliferalitives periostitis. Characterise by formation of hard bony swelling at the periphery of the

Histopathology : Supra cortical & supraperiosteal mass. Composed xcof much reactive osteoid tissue. Lymphocyte & Plasma cell.

RADIATION OSTEOMYELITIS
It is an infection of irradiate bone. C/F : Occur with triad .

Trauma

Radiation Osteomyelitis

Site :Mandible > Maxilla Sex :M>F Sym.:- Intense pain, fistula R/F Osteolytic region & appearance of late forming sequestra INVESTIGATION FOR OSTEOMYELITIS Gram's staining Culture & sensitivity W.B.C. count & complete hemogram Radiograph Blood Sugar Sincitgraphy MANAGEMENT OF OSTEOMYELITIS : Inscision & Drianage Irrigation & Debriment of the necrotic area. Sequestromy Saucerization Closed wound irrigation & suction Decortication Hyper baric oxygen

a) b) c) d) e) f)

a. b. c. d. e. f. g.