2. OSTEOMYELITIS.OSTEOMYELITIS.
• It is an inflammatory process of boneIt is an inflammatory process of bone
which involves;which involves;
• bone marrowbone marrow
• cancellouscancellous
• cortexcortex
• periosteumperiosteum
7. 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/ TUMOURINFECTION OF ODONTOGENIC CYST/ TUMOUR
• COMPOUND FRACTURE/GUN SHOT WOUNDSCOMPOUND FRACTURE/GUN SHOT WOUNDS
• LOCAL TRAUMATIC INJURIES OF GINGIVALOCAL TRAUMATIC INJURIES OF GINGIVA
• PERI TONSILLAR ABSCESS/ MIDDLE EARPERI TONSILLAR ABSCESS/ MIDDLE EAR
INFECTIONINFECTION
• FURUNCULOSIS/ BOIL OF CHINFURUNCULOSIS/ BOIL OF CHIN
• HAEMATOGENOUS INFECTIONHAEMATOGENOUS INFECTION
8. MICROBIOLOGYMICROBIOLOGY
• MIXED INFECTIONMIXED INFECTION
• ANAEROBES PLAYS MAJOR ROLEANAEROBES PLAYS MAJOR ROLE
• STAPHYLOCOCCUSSTAPHYLOCOCCUS
• AUREUS (PREDOMINENT)AUREUS (PREDOMINENT)
• ALBUSALBUS
• STREPTOCOCCUSSTREPTOCOCCUS
• BACTEROIDESBACTEROIDES
9. CLINICAL FEATURESCLINICAL FEATURES
• M > FM > F
• MAND > MAXMAND > MAX
• LIMITED BLOOD SUPPLYLIMITED 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 NECKPUS EXUDATES AROUND NECK
10. CLINICAL FEATURESCLINICAL FEATURES
• TRISMUSTRISMUS
• LABIAL PARESTHESIALABIAL PARESTHESIA
• DUE TO INCREASE PRESSURE IN INFERIOR ALVEOLARDUE TO INCREASE PRESSURE IN INFERIOR ALVEOLAR
CANALCANAL
• DISTINGUISHED FROM ALVEOLAR ABSCESSDISTINGUISHED FROM ALVEOLAR ABSCESS
• DISCHARGING SINUSDISCHARGING SINUS
• FACEFACE
• ALVOLAR PROCESS/PERIODONTAL LIGAMENTALVOLAR PROCESS/PERIODONTAL LIGAMENT
• PATHLOGICAL FRACTUREPATHLOGICAL FRACTURE
• LYMPHADENOPATHYLYMPHADENOPATHY
• SIGNS OF TOXEMIASIGNS OF TOXEMIA
• FEVER.CHILLS,DEHYDRATIONFEVER.CHILLS,DEHYDRATION
• ANEMIA, LEUKOCYTOSIS, INCREASED POLYSANEMIA, LEUKOCYTOSIS, INCREASED POLYS
• MATURE/IMMATUREMATURE/IMMATURE
11. 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 MARGINSILL DEFINED MARGINS
• MOTH EATEN APPERANCEMOTH EATEN APPERANCE
• SEQUESTURMSEQUESTURM
• DEAD BONE SEPERATED FROM ADJACENT BONE BYDEAD 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
12. 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
13. TREATMENTTREATMENT
(SURGICAL)(SURGICAL)
• INCISION & DRAINAGEINCISION & DRAINAGE
• To relieve pain & pressureTo relieve pain & pressure
• Reduces absorption of toxic productsReduces absorption of toxic products
• ExtractionExtraction
• Extraction of offending tooth /teethExtraction of offending tooth /teeth
• SequestrectomySequestrectomy
• Introral submadibular approachIntroral submadibular approach
• SaucerizationSaucerization
• To eliminate dead spaceTo eliminate dead space
• ImmobilizationImmobilization
• To avoid pathologic fractureTo avoid pathologic fracture
14. COURSE OF DISEASECOURSE OF DISEASE
• Acute, sub acute, chronicAcute, sub acute, chronic stagesstages
• Infection resolves by proper treatment andInfection resolves by proper treatment and
never recurnever recur
• It may heal but recur after certain periodIt may heal but recur after certain period
• It may persist and continue with activeIt may persist and continue with active
suppurationsuppuration
• It may quiet down and pursue a chronicIt may quiet down and pursue a chronic
coursecourse
• Reasons--?Reasons--?
16. COURSECOURSE
• Acute infection leading to chronicAcute infection leading to chronic
• Chronic osteomylitis may be primary,Chronic osteomylitis may be primary,
due to infection by subvirulent microdue to infection by subvirulent micro
organismsorganisms
17. CLINICAL FEATURESCLINICAL FEATURES
• Pain /dischargePain /discharge
• MinimumMinimum
• Bone / madibular enlargementBone / madibular enlargement
• Due to subperiosteal deposition of new boneDue to subperiosteal deposition of new bone
• SequestraSequestra
• Single or multipleSingle or multiple
• May shed periodicallyMay shed periodically
• Preservation of mental/ labial sensationPreservation of mental/ labial sensation
18. RADIOGRAPHIC FINDINGSRADIOGRAPHIC FINDINGS
• Areas of radiolucenciesAreas of radiolucencies
superimposed on areas of radiosuperimposed on areas of radio
opacitiesopacities
• Radiopacity is due to:Radiopacity is due to:
• Subperiosteal bone depositionSubperiosteal bone deposition
• Sequestra attracts calciumSequestra attracts calcium
19. TREATMENTTREATMENT
• Antibiotic coverAntibiotic cover
• 10 days to 2weeks10 days to 2weeks
• Metronidazole for anerobesMetronidazole for anerobes
• SequestrectomySequestrectomy
• Sequestrum removed from surroundingSequestrum removed from surrounding
granulation tissuegranulation tissue
• Removal of granulation tissueRemoval of granulation tissue
• C&SC&S
• Microbiologic studies – TBMicrobiologic studies – TB
• Histo pathological examHisto pathological exam
• DecorticationDecortication
• Done with bur/hand pieceDone with bur/hand piece
• Dense sclerosed medullary bone removedDense sclerosed medullary bone removed
• Bone removed until healthy bleeding boneBone removed until healthy bleeding bone
appearsappears
20. TREATMENTTREATMENT
• SaucerizationSaucerization
• The bony margins over hanging the cavityThe bony margins over hanging the cavity
resulting from removal of sequestrum areresulting from removal of sequestrum are
removedremoved
• Reduces dead space / haematoma FormationReduces dead space / haematoma Formation
• Drain/pressure dressingDrain/pressure dressing
• Antiseptic dressingAntiseptic dressing
• If primarily closure not possibleIf primarily closure not possible
• BiPP / whiteheads varnishBiPP / whiteheads varnish
• ImmoblilzationImmoblilzation
• IMFIMF
• Splinting adjacent teeth by arch barSplinting adjacent teeth by arch bar
• Hyperbaric oxygenHyperbaric oxygen
• Resection & secondary bone graftingResection & secondary bone grafting
21. CHRONIC NON SUPPURTIVECHRONIC NON SUPPURTIVE
SCLEROSING OSTEOMYELITISSCLEROSING OSTEOMYELITIS
• It is response to a low gradeIt is response to a low grade
infection/traumainfection/trauma
• Seen in older people/Negro femalesSeen in older people/Negro females
• Infection source usually not identifiableInfection source usually not identifiable
• Usually in mandibleUsually in mandible
• Teeth are vital with inflamed pulpTeeth are vital with inflamed pulp
• Sequestrum formationSequestrum formation
• Expansion of cortices is lackingExpansion of cortices is lacking
• RadiographicRadiographic
• Initially radiolucentInitially radiolucent
• Later radio opaqueLater radio opaque
22. TUBERCULOUS OSTEOMYLITISTUBERCULOUS OSTEOMYLITIS
• Hematogenous spread from pulmonary TBHematogenous spread from pulmonary TB
• Localized osteomylitis may follow tooth extractionLocalized osteomylitis may follow tooth extraction
performed on TB patientperformed on TB patient
• Infected socketInfected socket
• PainlessPainless
• Pus dischargePus discharge
• Bone destruction replaced by granulationBone destruction replaced by granulation
tissuetissue
• 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
23. OSTEORADIONECROSISOSTEORADIONECROSIS
• It isIt is defineddefined as Inflammatoryas Inflammatory
Conition (osteomylitis) of irradiatedConition (osteomylitis) of irradiated
bone that has been exposed and hasbone that has been exposed and has
failed to heal over a period of 3failed to heal over a period of 3
months in the absence of localmonths in the absence of local
tumor.tumor.
• Doses above 50Gy are required toDoses above 50Gy are required to
cause this irreversible damagecause this irreversible damage
24. PATHOGENESISPATHOGENESIS
• HypoxiaHypoxia
• HypovascularityHypovascularity
• Endarteritis ObliteransEndarteritis Obliterans
• HyocellularityHyocellularity
• Marrow DamageMarrow Damage
• Periosteum DamagePeriosteum Damage
• Decrease Production of osteoblasts &Decrease Production of osteoblasts &
osteoclastsosteoclasts
25. CLINICAL FEATURESCLINICAL FEATURES
• Sever deep boring pain-InitiallySever deep boring pain-Initially
• Alveolar boneAlveolar 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
• RadiographRadiograph
• Moth eaten appearance Of devitalized boneMoth eaten appearance Of devitalized bone
27. PROPHYLACTIC MEASURESPROPHYLACTIC MEASURES
• Dental Extractions / osseous surgeryDental Extractions / osseous surgery
should be avoided duringshould 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 prognosisExtract all teeth with dubious prognosis
lying with in radiation fieldlying with in radiation field
• At least 7-10 days before commencement ofAt least 7-10 days before commencement of
RadiotherapyRadiotherapy
• Within 7-10 days after commencement ofWithin 7-10 days after commencement of
radiotherapy with antibiotic coverradiotherapy with antibiotic cover
28. 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 ofcharacterized by formation of
multiple sinuses & widespreadmultiple sinuses & widespread
fibrosis.fibrosis.
29. 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, humanInjuries, fracture, extraction, human
bitebite
30. CLINICAL FEATURESCLINICAL FEATURES
• Males more affected, 30-60 yearsMales more affected, 30-60 years
• SwellingSwelling
• Soft tissue / angle, neckSoft tissue / angle, neck
• Dusky red, purplish in colourDusky red, purplish in colour
• Firm, slightly tenderFirm, slightly tender
• Skin- fixed to under lying tissuesSkin- fixed to under lying tissues
• Multiple discharging sinusesMultiple discharging sinuses
• Pain is mild or absentPain is mild or absent
• Healing with scarring & puckering of skinHealing with scarring & puckering of skin
• TrismusTrismus
• Lymph nodes usually not enlargedLymph nodes usually not enlarged
• Actinomycotic osteomylitis occurs if soft tissueActinomycotic osteomylitis occurs if soft tissue
infection spreads to underlying boneinfection spreads to underlying bone
31. DIAGNOSISDIAGNOSIS
• Sulphur granules In discharging pusSulphur granules In discharging pus
• Sulphur granules are colonies ofSulphur granules are colonies of
actinomycesactinomyces
• Anaerobic culture for 10 days may beAnaerobic culture for 10 days may be
required for identificationrequired for identification
• RadiographyicallyRadiographyically
• In actinomycotic osteomylitis Moth eaten /In actinomycotic osteomylitis Moth eaten /
irregular areas of bone destruction similar toirregular areas of bone destruction similar to
pyogenic osteomylitispyogenic osteomylitis
32. TREATMENTTREATMENT
• Prolonged antibiotic therapyProlonged antibiotic therapy
• Organisms survive in depth of lesionOrganisms survive in depth of lesion
and causes relapse after a shortand causes relapse after a short
course of antibiotics.course of antibiotics.
• Penicillin -2gm / day, 6 weeks to 6Penicillin -2gm / day, 6 weeks to 6
monthsmonths
• In actinomycotic osteomylitisIn actinomycotic osteomylitis
treatment is same as for pyogenictreatment is same as for pyogenic
osteomylitis.osteomylitis.