Osteomyelitis
Definition: it's an acute or chronic inflammatory
process in the medullary spaces or the cortical surface of
bone and extend away from the initial site of
.involvement
:Predisposing factors
chronic systemic diseases , immunocompromised -1
status and disorders associated with decreased
.vascularity of bone
AIDS, malnutrition, diabetes mellitus, tobacco use, -2
.alcohol abuse
some bone diseases as late paget's diseases, -3
osteoporosis, end-stage cemento-osseous dysplasia that
result in hypovascularizated bone that is predisposing to
.necrosis and inflammation
:Types of osteomyelitis
:acute suppurative osteomyelitis-1
This type occurs when an acute inflammatory process
spreads through the medullary spaces of the bone and
insufficient time has passed for the body to react to the
.presence of the inflammatory infiltrate
:Clinical features
Age: all ages can be affected
Sex: male predominance
Site: mandible more than maxilla
:Clinically
The patient complains of fever, leukocytosis, -1
lymphadenopathy, swelling of the affected area may be
. present
Paresthesia of the lower lip, drainage or exfoliation of -2
.fragments of necrotic bone may be found
A fragment of necrotic bone that has separated from -3
the adjacent vital bone is termed sequestrum. It exhibits
.spontaneous exfoliation
Fragment of necrotic bone may become surrounded -4
.by new vital bone known as involucrum
:Radiographically
May be unremarkable or an ill-definied radioluency may
.be demonstrated
:Histological features
Necrotic bone shows a loss of osteocytes from their
lacunae. Peripheral resorption and bacterial colonization
The periphery of the bone and the haversian canals
contain necrotic debris and an acute inflammatory
.infiltrate consisting of polymorphnuclear leukocytes
:Treatment
The treatment of acute osteomyelitis consist of
antibiotic medications after doing microbiologic
.sensitivity and drainage
:chroinc suppurative osteomyelitis-2
This type exists when the defensive response leads
to the production of granulation tissue, which
subsequently forms dense scar tissue ia an attempt
to wall off the infected area.
The encircled dead space act as a reservoir for
bacteria, and antibiotic medications have a great
difficulty reaching the site.
This pattern begins to evolve about one month
after the spread of initial acute infection and results
in a smoldering process that is difficult to manage
unless the problem is approached aggressively.
If acute osteomyelitis is not resolved, chronic
osteomyelitis occur.
Or the process may arise without a pervious acute
episode.
Clinical features:
Swelling , pain, sinus formation, purulent discharge.
Sequestrum formation, tooth loss, pathologic
feature.
Patient may experience acute exacerbations or
periods of decreased pain associated with chronic
smoldering progression.
Radiographically:
Patchy, ragged, and ill-defined radiolucency that often
contains central radiopaque sequestra.
Histological features:
Biopsy material demonstrates a significant soft
tissue component that consist of chronically
inflamed fibrous connective tissue filling the
intertrabecular areas of bone.
Scattered sequestra and pockets of abcess
formation are common.
Treatment:
Chronic suppurative osteomyelitis is difficult to
manage medically because pockets of dead bone
and organisms are protected from antibiotics by
the surrounding wall of fibrous connective tissue.
Antibiotics must be given intravenously in high
doses.
Surgical intervention is mandatory with removal of
all infected material down to good bleeding bone.
Hyperbaric oxygen is recommended for the rare
patient who dose not respond to strandard therapy
or for disease arising in hypervascularized bone.
focal sclerosing osteomyelitis-3
:)condensing osteitis(
Localized areas of bone sclerosis associated with the
.apices of teeth with pulpitis or pulpal necrosis
:Clinical features
Age: children and young adult, but also occur in older
.adult
.Sex: no sex predilection
.Site: premolar and molar areas of the mandible
:Radiographically
the classic alteration consists of a localized, uniform
zone of increased radiodensity adjacent to the apex
of a tooth that exhibits a thickened periodontal
ligament space or an apical inflammatory lesion.
The lesion does not exhibit a radiolucent border as
is seen in cases of focal cement-osseous dysplasia.
The radiopacity is not separated from the apex as
in cases of idiopathic osteosclerosis.
Treatment:
Elimination of the odontogenic focus of infection by
extraction or endodontic therapy.
4- Diffuse sclerosing osteomyelitis:
This term should be used only when an obvious
infectious process directly is responsible for sclerosis of
bone. In these cases, chronic intraosseous bacterial
infections creates a smoldering mass of chronically
inflamed granulation tissue that incites sclerosis of the
surrounding bone.
Clinical features:
Age: adulthood.
Sex: no sex predilection.
Site: mandible.
No pain or swelling
An increased raidodensity develops around sites of
chronic infection.
The sclerosis centers on the crestal portions in areas of
the tooth-bearing alveolar ridge and does not appear to
originate in the areas of attachment of the masseter or
digastric muscle.
Histological features:
it demonstrates sclerosis and remodeling of bone.
Scanty marrow spaces and little or no inflammatory
infiltrate , through adjacent to area of
inflammation.
Treatment:
Elimination of originating source of inflammation,
however, sclerotic areas remain radiographically.
5- Osteomyelitis with proliferative
periostitis:
Proliferative periostitis represents a periosteal reaction
to the presence of inflammation. The affected
periosteum forms several rows of reactive vital bone
that parallel to each other and expand the surface of the
altered bone.
In 1893 a Swiss physician, Carl Garre, reported in
the German literature on patterns of acute
osteomyelitis.
Since that time, numerous articles have been
written that associate Garre's report with a form of
inflammatory periosteal hyperplasia demonstrating
on onion-skin like reduplication of the cortical
plate.
However, nowhere in the original publication is
there any mention of periostitis, periosteal
duplication or onion skinning. Therefore, the term
Garre's osteomyelitis is an improper designation
that should be disassociated with the entity
described osteomyelitis with proliferative
periostitis.
Clinical features:
Age: children and young adult.
Sex: no sex predilection.
Site: most cases arise in the premolar-molar area
of the mandible.
Etiology:
The most frequent cause is dental caries with associated
periapical inflammatory disease, secondary to
periodontal infections and fractures.
Radiographic examination:
Radiopaque laminations of bone that parallel each other
and the underlying cortical surface.
Histological features:
Specimens often reveal parallel rows of highly cellular
and reactive woven bone in which the individual
trabecule are oriented perpendicular to the surface.
Between the cellular trabecule, uninflamed fibrous
connective tissue is evident.
Treatment:
Most cases are associated with periapical inflammatory
lesions and treatment includes extraction of the
offending tooth or endodontic therapy.
After the focus of infection is removed and the
inflammation has resolved, the layers of bone will
consolidate in 6-12 months as the overlying muscle
action helps to remodel the bone to its original state.
