CHRONIC INFECTIONS OF JAWS

OR
INFLAMMATOR DISEASES OF
BONE
OSTEOMYELITIS.
OSTEOMYELITIS.

• It is an inflammatory process of bone which involves;

bone marrow
cancellous
 cortex
 periosteum
PATHOPHYSIOLOGY
Infection --- Infected exudate → spreads
throughout cancellous spaces of bone
→Thrombosis of nutrient vessels Ischemia → ---
Infaction → Osteomyelitis
• Mandible
Reduced endosteal blood supply_ osteomyelitis
common
• Maxilla
Plexiform blood supply _ osteomyelitis less common.
CLASSIFICATION
• SUPPURATIVE (PYOGENIC) OM
ACUTE
CHRONIC

CHRONIC SCLEROSING NON SUPPURATIVE

OM OR GARRE’S OM

OSTEOMYELITIS IN SYSTEMIC DISEASES

TB , ACTINOMYCOSIS , SYPHILIS
IRRADIATION (OSTEORADIO NECROSIS)
PAGETS DISEASE, OSTEOPETROSIS
CHEMICALS, ELECTRO COAGULATION.
 ACUTE PYOGENIC
OSTEOMYELITIS
PREDISPOSING FACTORS
• IMPAIRED IMMUNE DEFENCES
SYSTEMIC
• ACUTE LEUKAEMIAS
• AIDS
• UNCONTROLLED DIABETES
• MALNUTRITION, ALCOHLICS
LOCAL
• IRRADIATION
• PAGETS DISEASE
ETIOLOGY
1. ODONTOGENIC INFECTIONS
1. PERIAPICAL INEECTION
2. PERIODONTAL INFECTION
3. LONG_ STANDING PERICORONAL INFECTION
4. EXTRACTED WOUND INFECTION
5. INFECTION OF ODONTOGENIC CYST/ TUMOUR
6.
2. COMPOUND FRACTURE/GUN SHOT WOUNDS
3. LOCAL TRAUMATIC INJURIES OF GINGIVA
4. PERI TONSILLAR ABSCESS/ MIDDLE EAR INFECTION
5. FURUNCULOSIS/ BOIL OF CHIN
6. HAEMATOGENOUS INFECTION
MICROBIOLOGY
• MIXED INFECTION
• ANAEROBES PLAYS MAJOR ROLE
• STAPHYLOCOCCUS
AUREUS (PREDOMINENT)
 ALBUS
• STREPTOCOCCUS
• BACTEROIDES
CLINICAL FEATURES (TP)2-LDS- mere pe sakht time tha
left dentistry phle long schedule
• M>F
• MAND > MAX
 LIMITED BLOOD SUPPLY
 MORE DENSE BONE
• PAIN
 SEVERE, THROBBING, DEEP SEATED
• SWELLING
 FIRM / INDURATED / MODERATE SIZE
 OVERLYING GUM RED / SWOLLEN / TENDER
• TEETH
 NO OF TEETH TENDER ON PERCUSSION
 MOBILITY OF TEETH IN AFFCTED JAW SEGMENT
 PUS EXUDATES AROUND NECK
CLINICAL FEATURES
• TRISMUS
• LABIAL PARESTHESIA
 DUE TO INCREASE PRESSURE IN INFERIOR ALVEOLAR CANAL
 DISTINGUISHED FROM ALVEOLAR ABSCESS
• DISCHARGING SINUS
 FACE
 ALVOLAR PROCESS/PERIODONTAL LIGAMENT
• PATHLOGICAL FRACTURE
• LYMPHADENOPATHY
• SIGNS OF TOXEMIA
 FEVER.CHILLS,DEHYDRATION
 ANEMIA, LEUKOCYTOSIS, INCREASED POLYS
 MATURE/IMMATURE
RADIOGRAPHIC FINDINGS
• FINDINGS APPEAR AFTER 1-3 WEEKS
 MARGINS
 APPEARANCE
• RESORPTION OF BONE
 WIDENING OF MEDULLARY SPACES
 LOSS OF SHARP TRABECULAR PATTERN OF BONE
• RADIOLUCENCY
 ILL DEFINED MARGINS
 MOTH EATEN APPERANCE
 SEQUESTURM Formation
 DEAD BONE SEPERATED FROM ADJACENT BONE BY
RADIOLUCENT AREA
• RADIOPACITY
 SUBPERIOSTEAL NEW BONE FORMATION- INVOLCURAM
 PARALLEL TO SURFACE OF CORTEX
• LINEAR/LAMINATED LIKE ONION SKIN
TREATMENT
(MEDICNAL)
• SUPPORTIVE
BED REST
DEHYDRATION
DIET / NG TUBE
BLOOD TRANSFUSIONS

• ANTIBIOTICS
CULTURE & SENSITIVITY
AMOXYCILLIN 500MG /8 HRLY / I/V
CLINDAMYCIN 300MG 6 HRLY
DURATION
• 2 TO 8 WEEKS
• ERTHROMYCIN, LINCOMYCIN, CEPHLOSPORINS
TREATMENT
(SURGICAL)
• INCISION & DRAINAGE
To relieve pain & pressure
Reduces absorption of toxic products
• Extraction
 Extraction of offending tooth /teeth
• Sequestrectomy
Introral \ submadibular approach
• Saucerization
To eliminate dead space
• Immobilization
To avoid pathologic fracture
COURSE OF DISEASE
• Acute, sub acute, chronic stages
• Infection resolves by proper treatment and never
recur
• It may heal but recur after certain period
• It may persist and continue with active
suppuration
• It may quiet down and pursue a chronic course
• Reasons--?
CHRONIC
OSTEOMYELITIS
COURSE
• Acute infection leading to chronic
• Chronic osteomylitis may be primary, due to infection
by subvirulent micro organisms
CLINICAL FEATURES
• Pain /discharge
Minimum

• Bone / madibular enlargement

Due to subperiosteal deposition of new bone

• Sequestra
Single or multiple
May shed periodically

• Preservation of mental/ labial sensation

RADIOGRAPHIC FINDINGS
• Areas of radiolucencies superimposed on areas of
radio opacities
• Radiopacity is due to:
Subperiosteal bone deposition
Sequestra attracts calcium
TREATMENT
• Antibiotic cover
10 days to 2weeks
Metronidazole for anerobes
• Sequestrectomy
Sequestrum removed from surrounding granulation
tissue
• Removal of granulation tissue
C&S
Microbiologic studies – TB
Histo pathological exam
• Decortication
Done with bur/hand piece
Dense sclerosed medullary bone removed
Bone removed until healthy bleeding bone appears
TREATMENT
• Saucerization
The bony margins over hanging the cavity resulting
from removal of sequestrum are removed
Reduces dead space / haematoma Formation
Drain/pressure dressing
• Antiseptic dressing
If primarily closure not possible
BiPP / whiteheads varnish
• Immoblilzation
IMF
Splinting adjacent teeth by arch bar
• Hyperbaric oxygen
• Resection & secondary bone grafting
CHRONIC NON SUPPURTIVE
SCLEROSING OSTEOMYELITIS
• It is response to a low grade infection/trauma
• Seen in older people/Negro females
• Infection source usually not identifiable
• Usually in mandible
• Teeth are vital with inflamed pulp
• Sequestrum formation
• Expansion of cortices is lacking
• Radiographic
Initially radiolucent
Later radio opaque
TUBERCULOUS OSTEOMYLITIS
• Hematogenous spread from pulmonary TB
• Localized osteomylitis may follow tooth extraction
performed on active TB patient
• Infected socket
Painless
Pus discharge
Bone destruction replaced by granulation tissue
No sequestrum formation
If untreated it extends in soft tissues
Diagnosis-Biopsy for tubercle bacilli
Treatment-
• Local surgery
• Anti tuberculous drug
OSTEORADIO NECROSIS
• It is defined as Inflammatory Conition
(osteomylitis) of irradiated bone that has been
exposed and has failed to heal over a period of 3
months in the absence of local tumor.
• Doses above 60Gy (6500 rads) are required to
cause osteoradionecrosis.
 Radiation injury and osteoradionecrosis

 Radiation, as part of the therapy of oral malignancy, affects the

vascularity of the bone by causing a proliferation of the intima of the
blood vessels (endarteritis obliterans). This can have serious
consequences in the mandible with its end-artery supply, and the
inferior dental artery or its branches may become thrombosed.

 The non-vital bone which results from the reduction in blood

supply is sterile and asymptomatic but is very susceptible to infection and
to trauma from a denture.

Infection may spread rapidly through the irradiated bone, resulting in

extensive osteomyelitis and painful necrosis of the bone,often
associated with sloughing of the overlying oral and occasionally
facial soft tissues. Modern methods of radiotherapy have greatly
reduced the
 incidence of this condition
PATHOGENESIS
• Hypoxia
• Hypovascularity
Endarteritis Obliterans
• Hyocellularity
Marrow Damage
Periosteum Damage
Decrease Production of osteoblasts & osteoclasts
CLINICAL FEATURES
• Sever deep boring pain-Initially
• Alveolar bone
•Mandible more affected
•Exposed, black, Dark Brown in color
•Sequestrum formation – slow
•No involcurum formation

• Persistent draining sinus

• Trismus
• Pathological Fracture
• Radiograph
 Moth eaten appearance Of devitalized bone
TREATMENT
• AIM :- To Promote neovascularity &
Neocellularity
• Antibiotics
• Hyperbaric Oxygen therapy
• Sequestrectomy
• Local flap cover
• Resection / Reconstruction.
PROPHYLACTIC MEASURES
TO AVOID OSTEORADIO NECROSIS
• Dental Extractions / osseous surgery should
be avoided during
 active radiotherapy
In early post irradiation Period (9 Months)

• Extract all teeth with dubious prognosis lying

within radiation field
At least 7-14 days before commencement of
Radiotherapy. Safely after 3 weeks.
With antibiotic cover.
With HBO (hyperbaric oxygen therapy)
 3 dives preoperatively & 10 dives postoperatively.
MANEGMENT OF PATIENT
UNDERGOING CHEMOTHERAPY
Haemtopoietic \ Non Haemtopoietic Neoplasm
After chemotheray cell count improves in non
haemtopoietic neoplasms
CELL COUNT (For routine Rx)
WBC
 2000/mm3 with 20% Polys

PLATELETS
 50000/mm3

Antibiotics if dental Rx starts within 3 weeks of

chemotherapy.
 ACTINOMYCOSIS
It is a chronic, Suppurative cervico- facial infection of
soft tissues, characterized by formation of multiple
sinuses & widespread fibrosis.
 ETIOLOGY
• It is a bacterial infection.
• G + Bacteria – Actinomyces Israeli
• Normal oral commencal
• Injuries, fracture, extraction, human bite
 CLINICAL FEATURES
• Males more affected, 30-60 years
• Swelling
 Soft tissue / angle, neck
 Dusky red, purplish in colour
 Firm, slightly tender
• Skin- fixed to under lying tissues
 Multiple discharging sinuses
• Pain is mild or absent
• Healing with scarring & puckering of skin
• Trismus
• Lymph nodes usually not enlarged
• Actinomycotic osteomylitis occurs if soft tissue infection
spreads to underlying bone
 DIAGNOSIS
• Sulphur granules In discharging pus
• Sulphur granules are colonies of actinomyces
• Anaerobic culture for 10 days may be required for
identification
• Radiographyically
In actinomycotic osteomylitis Moth eaten / irregular
areas of bone destruction similar to pyogenic
osteomylitis
 TREATMENT
• Prolonged antibiotic therapy
• Organisms survive in depth of lesion and causes
relapse after a short course of antibiotics.
• Penicillin -2gm / day, 6 weeks to 6 months
• In actinomycotic osteomylitis treatment is same as for
pyogenic osteomylitis.
Oral candidosis
(Candidiasis)
ETIOLOGY /PREDISPOSING FACTORS
Candida albicans
 Normal oral commensal
Local or systemic predisposing factors
Classification
Acute Candidosis
Acute pseudomemberanous (Thrush)
Acute atrophic

Chronic Candidosis
Chronic Atrophic (denture Stomatitis)
Angular cheilitis
Median rhomboid glossitis
Chronic hyperplasic (candidal Leukoplakia)
Chronic mucocutaneous.
Acute pseudomembraneous
Candidosis(Thrush )
Common in immunoSuppressed /debilitated
individuals.
Creamy lightly adherent plaques on erythematous
oral mucosa.
Cheek , plate, oropharynx
Symptomless, slight discomfort on eating
Gently stripped off leaving raw under surface.
Nystatin suspension 100,000 units/rinse/
swallowed -10 days
Fluconazole 50 mg/OD
Acute atrophic candidosis
Opportunistic infection/ Broad spectrum antibiotic
/inhaled steroids
Painfull by hot and spicy foods.
Oral mucosa red, shiny ,atrophic in appearance.
Augular Cheilitis
Combined Staph, strep, and candidal infection
Under lying precipitating factor, iron deficiency
anemia
Red, cracked, macerated skin of angles of mouth.
Miconazole cream active against all three orgms.
Rx Upto 10 days after resolution of clinical lesion
Chronic Hyperplasic Candidosis
Dense, white, adherent, keratotic patches
Often confused with leukoplakia
Increased risk of malignant change/ biopsy.