MANAGEMENT OF OSTEOMYELITIS OSTEOMYEL ITIS OF JAW
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DEFINITION The word ³osteomyelitis´ ³osteomyelitis´ originates from the Ancient Greek words osteon (bone) and muelinos (marrow) and means infection of medullary portion of the bone. Osteomyelitis is Osteomyelitis i s defined as an inflammationof the bone marrow with a tendency to progression. (Peterson¶s) 4/14/2011 4/14/2011
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DEFINITION The word ³osteomyelitis´ ³osteomyelitis´ originates from the Ancient Greek words osteon (bone) and muelinos (marrow) and means infection of medullary portion of the bone. Osteomyelitis is Osteomyelitis i s defined as an inflammationof the bone marrow with a tendency to progression. (Peterson¶s) 4/14/2011 4/14/2011
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CLASSIFICATION BY HUDSON JW (J Oral Maxillofac Surg 1993 Dec;51(12):1294-301) 1.
Acute osteomyelitis a. Contiguous focus b. Progressive c. Hematogenous 2. Chronic osteomyelitis a. Recurrent multifocal b. Garre's c. Suppurative or non-suppurative d. Sclerosing 4/14/2011 4/14/2011
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CLASSIFICATION
BASED ON CLINICAL PICTURE AND
RADIOLOGY (Osteomyelitis of the jaws. J Can Dent
Assoc 1995 May;61(5):441-2 May;61(5):441-2,445-8 ,445-8 ) I. Suppurative osteomyelitis 1. Acute suppurative osteomyelitis osteomyelitis 2. Chronic suppurativ suppurativee osteomyelitis II. Nonsuppurative osteomyelitis 1. Chronic focal sclerosing osteomyelitis osteomyelitis 2. Chronic diffuse sclerosing osteomyelitis osteomyelitis 3. Garrè's Garrè' s chronic sclerosing osteomyelitis (proliferative osteomyel osteomyelitis) itis) III. Osteoradion Osteoradionecrosis ecrosis 4/14/2011 4/14/2011
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BY LEW & WALDVOGEL 1.
Suppurative
2.
Non suppurative
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MODIFEID BY TOPAZIAN 1. Suppurative Osteomyelitis - Acute Suppurative osteomyelitis - Chronic Suppurative osteomyelitis a. Primary b. Secondary - Infantile osteomyelitis 2. Nonsuppurative Osteomyelitis - Chronic Sclerosing osteomyelitis a. Focal b. Diffuse - Garre¶s sclerosing osteomyelitis - Actinomycotic osteomyelitis - Radiation osteomyelitis 4/14/2011
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The Zurich Classification System 1.
Acute Osteomyelitis (AO)
2. Secondary Chronic Osteomyelitis (SCO) 3. Primary Chronic Osteomyelitis (PCO)
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Osteomyelitis is divided into Acute or Chronic forms based on the presence of the disease for a 1-month duration.
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PREDISPOSING FACTORS 1.
Local and systemic factors altering the vascularity of bone - radiation - osteoporosis - osteopetrosis - bone malignancy - paget¶s disease - Smoking - Diabetes mellitus - Bisphosphonate induced osteochemonecrosis
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2. Systemic factors altering host defenses - Diabetes mellitus - Autoimmune disorders - AIDS - Agranulocytosis - Anemia (especially sickle cell) - Leukemia - Malnutrition - Chemotherapy - Corticosteroid and other immunosuppressive therapy - Alcohol and tobacco - Drug abuse
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Mechanisms of systemic diseases/conditions predisposing to osteomyelitis (Adapted from Marx 1991) Disease
Mechanism facilitating bone infection
Diabetes
Diminished
leukocyte chemotaxis, phagocytosis, and lifespan;
diminished vascularity of tissue due to vasculopathy, thus reducing perfusion and the ability for an effective inflammatory response; slower healing rate due to reduced tissue perfusion and defective glucose utilization
Leukemia
Deficient
Malnutrition
Reduced wound healing and reduction of immunological response
Cancer
Reduced wound healing and reduction of immunological response
Osteopetrosis
Reduction of bone vascularization due to enhanced mineralization replacement of hematopoietic marrow causing anemia and leukopenia
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leukocyte function and associated anemia
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Severe anemia (particularly sickle-cell anemia)
Systemic debilitation, reduced tissue oxygenation, bone infarction (sickle cell anemia), especially in patients with a homozygous anemia trait
IV drug abuse
Repeated septic injections, spreading of septic emboli (especially with harboring septic vegetation on heart valves, in skin or within veins)
AIDS
Impaired immune response
Immunosuppression (steroids, cytostatic drugs)
Impaired immune response
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ETIOLOGY 1)
2) 3) 4) 5) 6) 7)
Odontogenic infection - Periodontal - Periapical - Pericoronal Infection from infected dental cyst Compound fracture of Jaw. Traumatic injury Middle ear infection & upper respiratory tract infection through haematogenous route. Furuncle of chin by lymphtic route Peritonsillar abscess
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PATHOGENESIS
Osteomyelitis primarily occurs as a result of contiguous spread of odontogenic infections or as a result of trauma.
Primary hematogenous osteomyelitis is rare in the maxillofacial region, generally occurring in the very young.
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1)
Virulent
Organasim get entry winto medullary cavity via many routes.
2)
Localization of infection (Most infection are localized by a pyogenic membrane & soft tissue abscess wall).
3)
Disorganization
4)
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.
5)
Accumulation of Pus & there will be increased pressure in Medullary cavity.
6)
Pus travel through haversion & volkaman's canal & accumulation beneath the periosteum & elevating it from cortex & there by reducing the blood supply.
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7)
Reduced blood supply causes necrosis of bone.
8)
Then pus penetrate the periosteum & mucosal & cutaneous fistulae 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
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CLINICAL
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PRESENTATION
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SIGNS & SYMPTOMS Pain Swelling and erythema of overlying tissues Lymphadenopathy Fever Paresthesia of the inferior alveolar nerve Trismus Malaise Fistulas 4/14/2011
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- The pain in osteomyelitis is often described as a deep and boring pain, which is often out of proportion to the clinical picture - Fever often accompanies acute osteomyelitis, whereas it is relatively rare in chronic osteomyelitis. - Paresthesia of the inferior alveolar nerve is a classic sign of a pressure on the inferior alveolar nerve from the inflammatory process within the medullary bone of the mandible. - Trismus may be present if there is inflammatory response in the muscles of mastication of the maxillofacial region.
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GOALS OF MANAGEMENT 1)
Attenuate and eradicate proliferating pathological organisms.
2) Promote healing. 3) Reestablish vascular permeability
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TREATMENT GUIDELINES - Disrupt infectious foci - Debride any foreign bodies, necrotic tissues or sequestra. - Culture and identify specific pathogens for definitive antibiotic treatment - Drain and irrigate the region - Consider adjunctive treatment to enhance microvascular reperfusion 1 Trephination 2 Decortication 3 Vascular flaps 4 Hyperbaric oxygen therapy - Reconstruction 4/14/2011
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SUCCESSFUL TREATMENT IS BASED ON FOLLOWING FUNDAMENTAL PRINCIPLES Early diagnosis Bacterial culture and sensitivity testing Adequate, appropriate and prompt antibiotic therapy. Adequate pain control Proper surgical intervention Reconstruction
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LAB INVESTIGATIONS - Hemogram - Pus Culture & Antibiotic sensitivity - In the acute phase of osteomyelitis it is common to see a leukocytosis with left shift. - E.S.R. & C reactive protein may be seen but they are non specific
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IMAGING - The orthopanoramic view is indispensable in the initial evaluation of osteomyelitis. - One must bear in mind that radiographic images lag behind the clinical presentation since cortical involvement is required for any change to be evident. - However, one can often see the appearance of ³motheaten´ bone or sequestrum of bone, which is the classic appearance of osteomyelitis. 4/14/2011
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- The CT scan can give very detailed images as to early cortical erosion of bone in ostemyelitis. - CT scanning, like plain films, requires 3 0 to 50% demineralization of bone before changes can be seen, thus presenting an essential delay in diagnosis of osteomyelitis. - MRI can assist in the early diagnosis of osteomyelitis by loss of the marrow signal before cortical erosion or sequestrum of the bone appears
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ACUTE OSTEOMYELITIS
A 63-year-old woman 2.5 weeks after extraction of carious left lower molar with new onset of left mandibular swelling. Panoramic view does not provide any clue to the presence of osteomyelitis. The axial high-resolution bone-window CT image displays slight thinning, demineralization and endosteal resorption of lingual cortical plate. 4/14/2011
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CHRONIC
OSTEOMYELITIS
Three months later , the patient presents with sudden onset of pain and marked malocclusion. The panoramic view discloses an irregular osteolytic area, a fracture traversing the remaining basilar bone and suspicion of multiple sequester with some degree of bone radiopacity. The presence of two buccal sequesters, partial cortical plate resorption, irregular calcified periosteal apposition and cancellous bone osteolysis and distal sclerosis is shown by the axial high-resolution bone-window CT image. 4/14/2011
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- Nuclear medicine has evolved to aid in the diagnosis of osteomyelitis. - The technetium 99 bone scan is very sensitive in highlighting areas of increased bone turnover; however, the scan is not very specific to areas of infection. - With the addition of gallium 67 or indium 111 as contrast agents, one can differentiate areas of infection from trauma or postsurgical healing as these agents specifically bind to white blood cells. 4/14/2011
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Odontogenic secondary chronic osteomyelitis (axial CT view).
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Corresponding
bone scan
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TREATMENT - The management of osteomyelitis of the maxillofacial region requires both medical and surgical interventions. - The tentative diagnosis is made from clinical evaluation, radiographic evaluation, and tissue diagnosis. - Medical evaluation and management in defining and treating any immunocompromised state is indicated and often helpful. 4/14/2011
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Medical Management 1. Complete bed rest 2. Supportive therapy
Nutritional support ± High protein diet
High caloric diet Adequate multivitamins 3.
Rehydration
- Hydration orally - Administration of I. V. fluids
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4.
Blood transfusion
- If RBC, Hb% are low 5.
Control of Pain
- Analgesic and sedation 6. Antibiotic therapy
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SURGICAL OPTIONS 1)
Incision and drainage
2) Extraction of offending teeth 3) Sequestrectomy 4) Saucerisation 5) Decortication (Mowlem¶s decorticotomy) 6) Resection and Reconstruction:
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The aim is to debride the necrotic or poorly vascularized bony sequestra in the infected area and improve blood flow. Sequestrectomy involves removing infected and avascular pieces of bone²generally the cortical plates in the infected area.
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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. Decortication (Mowlem 1945) involves removal of the dense, often 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. 4/14/2011
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- The key element in the above procedures is determined clinically by cutting back to good bleeding bone - It is often necessary to remove teeth adjacent to an area of osteomyelitis.
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Secondary chronic osteomyelitis of the left mandible: The Infection originated from the decayed lower left second molar and spread anteriorly to the second left premolar; posteriorly the affected bone reaches the ascending ramus 4/14/2011
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Buccal incision along the gingival margin with vestibular extensions distally and mesially b). Note that the subperiosteal newly formed bone 4/14/2011
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Subperiosteal dissection and exposure of the affected region 4/14/2011
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Removal of the odontogenic focus and the teeth in the affected region and removal of sequestrum 4/14/2011
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The margins of the intended area of decortication are marked with a burr. 4/14/2011
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A long burr is used to perform multiple monocortical decortication osteotomies on the buccal cortex When performing the osteotomies it should be stressed that they are strictly limited to the buccal cortex of the mandible to avoid damage to the inferior alveolar nerve 4/14/2011
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The buccal cortical bone and the inferior border are then removed with a chisel, until bleeding bone is encountered. 4/14/2011
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Mobilization of the interior alveolar nerve is performed to allow access to the surrounding deeper areas of affected bone. 4/14/2011
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Meticulous removal of affected bone and granulation tissue is performed. The curettage is completed when vital bone is visible. 4/14/2011
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Mandible after completed decortication and surgical debridement. The remaining bone represents the remaining vital bone tissue 4/14/2011
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If necessary, additional burr holes and perforations can be performed to facilitate contact better in vascularized deeper bone compartments or to the lingual periosteum 4/14/2011
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Resection of affected buccal periosteum with areas of neoosteogenesis 4/14/2011
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The remaining bone is suspected to be prone to fracture, appropriate stabilization and reconstruction should be performed. 4/14/2011
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Primary closure is achieved to ensure close contact of the bone bed to the well-vascularizedsoft tissue.
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The maxillaryímandibular fixation for 6 weeks with wire stents was additionally performed for sufficient Stabilization and immobilization of the operated left mandible to ensure healing without complication 4/14/2011
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HYPERBARIC OXYGEN THERAPY - Hyperbaric oxygen (HBO is defined in the European Code of Good Practice as the inhalation of pure oxygen (FiO2=1) under a pressure above the ambient pressure. - In medicine,HBO is used within the range of 100±
300 kPa. Above this pressure, oxygen presents an increased risk of central nervous toxicity
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Monoplace hyperbaric oxygen chamber
Multiplace hyperbaric oxygen chamber
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