Chronic osteomyelitis and

its differential diagnosis

WHAT IS OSTEOMYELITIS?

• Osteomyelitis is an infection of the bone that can affect various

parts of the body, including the mouth. It can lead to serious
complications if left untreated, making early diagnosis crucial.

• It is either acute or chronic.

CHRONIC OSTEOMYELITIS

• Chronic osteomyelitis is a long-standing infection that can

result from improper treatment or unresolved acute
osteomyelitis.

• It commonly affects the jaw bones and can cause pain,

swelling, and difficulty in chewing or opening the mouth
 SYMPTOMS AND SIGNS OF CHRONIC
OSTEOMYELITIS
1) Persistent pain

2) Swelling and redness

3) Drainage or pus

4) Loose teeth
 Causes and risk factors

• Badly treated or untreated acute osteomyelitis

• Dental infection

• Jaw trauma

• Weakened immune system

 Types of chronic osteomyelitis
1) Suppurative osteomyelitis

2) Diffuse osteomyelitis

3) Garre’s osteomyelitis

4) Focal sclerosing osteomyelitis

5) Osteoradionecrosis
CHRONIC SUPPURATIVE
OSTEOMYELITIS

Is a long-term infection of the

bone characterized by the presence
of pus.
CAUSED BY BACTERIAL
INFECTION
Common sources of infection include :
• Open fractures
• Surgical procedures
• Hematogenous spread

Inadequate treatment of acute suppurative

osteomyelitis

Staphylococcus aureus is a frequent culprit

SYMPTOMS OF SUPPURATIVE
CHRONIC OSTEOMYELITIS

• Persistent pain: chronic and often localized

pain in the affected bone.
• Swelling
• Pus discharge: continuous drainage of pus
through sinuses.
• Fever
• Fatigue
 COMPLICATIONS OF
SUPPURATIVE CHRONIC
OSTEOMYELITIS

• Pathological fractures
• Abscess formation
• Bone deformation
• Septicemia
• Joint involvement (causing arthritis)
RADIOGRAPHIC FEATURES
OF CHRONIC SUPPURATIVE
OSTEOMYELITIS

• Bone destruction
• Sequestra formation: which are separated,
devitalized pieces of bone, is a characteristic
feature.
• Cloaca formation: openings , allowing for the
drainage of pus from the bone to the skin
surface.
• Periosteal reaction: thickening
 DIFFERENTIAL DIAGNOSIS

Chronic Osteomyeliti
suppurative CRMO
s of SAPHO
osteomyelitis syndrome
Non purulent Non purulent

In children In adults
 Case report :

A 48-year-old man with an extraorally

draining sinus in the left anteroinferior border
of mandible and a foul odor from the oral
cavity for 4.5 months. The patient also
complained of paresthesia of the left lower lip
for the previous 1.5 months.
The patient reported having pain in the lower
left back of the jaw 4.5 months previously.
 Case report :
• Location : left posterior area of the
mandible extending from the alveolar
crest to the inferior border of the
mandible
• Periphery & margin: well defined
• Internal structure: unilocular mixed
(RL&RO) due to sequestration
• Effect on surrounding structures :
loss of lamina dura of related teeth,
inferior displacement of inferior
alveolar canal, thinning and expansion
of cortical plates and bone perforation
DIFFUSE SCLEROSING OSTEOMYELITIS

Prepared by Ahmed Ali

ETIOLOGYLo
wv
i ru
• CHRONIC • Carious non vital (less common)
PERIODONTITIS

fac len
tor ce
 • Radiographic
features
• Affect a quadrant usually
• If edentulous on the crest
• Usually start ill defined
• RO (some Rl zones in early)
• Expanstion
• Differential
DIAGNOSIS (mostly
generalized multiple RO)
1.Florid Cemento osseous Dysplasia Cotton Wool
2.Paget Disease Apperance
3.Fibrous Dysplasia
4.Osteopetrosis
Florid Cemento osseous Dysplasia(Late)

• No symptoms of
infection
• Multi quadrant
Above IAC
RL Rim some times
• Differential
DIAGNOSIS (mostly
generalized multiple RO)
1.Florid Cemento osseous Dysplasia
2.Paget Disease
3.Fibrous Dysplasia
4.Osteopetrosis
 Paget Disease (Late)
• Multiple bone
involvement
• The entire bone
affected
• High Alkaline
Phosphatase Enzyme
• Differential
DIAGNOSIS (mostly
generalized multiple RO)
1.Florid Cemento osseous Dysplasia
2.Paget Disease
3.Fibrous Dysplasia
4.Osteopetrosis
 Fibrous Dysplasia
• No symptoms of infection
• No sequestra and periosteal bone formation
• Bone enlargement from within (white and pharoah’s 897 edition )
Coronal multidetector computed tomography
for fibrous dysplasia
FIG. 22.20 Chronic Osteomyelitis. The panoramic image (A) demonstrates increased
density and size of the right mandible compared with the left side. Note the increase in
width of the mandible, periosteal new bone (white arrow) and evidence of the original
cortex (black arrow). There is a general increase in bone density on the right side (B)
as well as a loss of definition of the more low-attenuation (radiolucent) component of
the response as the disease process becomes chronic
• Differential
DIAGNOSIS (mostly
generalized multiple RO)
1.Florid Cemento osseous Dysplasia
2.Paget Disease
3.Fibrous Dysplasia
4.Osteopetrosis
 Osteopetrosis
Etiology
Genetic problems leads to osteoclastic activity

• All bones are affected by increased

sclerosing density
• Bone within Bone radiograph
Infection rate specially
osteomyelitis
• Nerogenic symptoms
Narrowing foramnea
and canals
 GARRE’S OSTEOMYELITIS

• GARRE'S OSTEOMYELITIS, PROLIFERATIVE PERIOSTITIS,

PERIOSTITIS OSSIFICANS
• Garre’s osteomyelitis is a distinctive type of chronic osteomyelitis
associated with gross thickening of the periosteum of the bones resulting
from mild irritation or infections
• The condition is seen exclusively in children or young adults
• Mandible is more often affected than the maxilla.
• CLINICAL PICTURE

There is hard bony swelling related to the inferior outer border

of the mandible producing facial asymmetry

• Arises in premolar-molar region of the mandible

There may be toothache or no pain
• Radiographic features:

Intra-oral periapical radiograph often reveals bony hard mass

It is best detected by occlusal radiograph as thin RO line parallel

to the bone surface

giving what is called double cortex.

Onion peel appearance

• DIFFERENTIAL DIAGNOSIS OF ONION SKIN APPEARANCE
• EWING SARCOMA
• OSTEOSARCOMA
• 13-year-old boy, in whom the condition arose following pulpoperiapical
infection in relation to permanent mandibular right first molar. Clinically
the patient presented with bony hard, non-tender swelling , describe the
radiographic finding.
• Location: periapical to lower right first molar
• Margin and periphery: ill defined
• Internal structure: radiolucent
• Effect on surround structure : layers of subperiosteal bone formation
(onion skin)
FOCAL SCLEROSING
OSTEOMYELITIS
• It is a lesion in which sclerotic bone is formed at the apex of non-vital tooth (mainly
mandibular first molar) as a result of low-grade infection of the dental pulp.

• 3:2 female to male ratio

• 50% of patients were below 30 years old

• Pain is characteristically mild or absent and there is no swelling, lymphadenopathy

or jaw expansion

• Most common in mandible especially mandibular first teeth and rarely occurs in
maxilla
Mandibular focal sclerosing Maxillary focal sclerosing osteomyelitis
osteomyelitis accompanied with bony mass protrusion
into the maxillary sinus
 DIFFERENTIAL DIAGNOSIS OF FOCAL
SCLEROSING OSTEOMYELITIS

Dry Socket Peri-implantitis Tooth Abscess

It has the same - Peri-implantitis is an Radiolucent
symptoms of chronic inflammation that
osteomyelitis doesn’t cause bone
clinically. resorption unless the
patient has bad habit
as smoking.
- Radiolucent in case
of resorption
 DIFFERENTIAL DIAGNOSIS OF FOCAL
SCLEROSING OSTEOMYELITIS
• Osteonecrosis

Radiolucent

• Osteosarcoma

Sunburst appearance
 DIFFERENTIAL DIAGNOSIS OF FOCAL
SCLEROSING OSTEOMYELITIS
• Cementoblastoma
Radiolucent rim surrounding radiopaque
mass.

• Osteoradionecrosis

It looks like chronic osteomyelitis in case of

exposure to radiation.
Case study :
A 27-year-old woman reported with complaint of recurring episodes of intermittent pain in the lower left jaw in
the entire left side and paresthesia of the left lower lip for 1 month. She was apparently asymptomatic 3 years
previously when she experienced pain on the left side of her lower jaw. The pain had recurred intermittently over
the last 3 years. She had no history of trauma, infection or systemic disease. She had undergone drug therapy
many times for her complaint but with little benefit. On clinical examination, no abnormalities were detected. On
intra-oral examination, there were no abnormalities detected but pain was present on palpation. There were no
signs of infection, periodontitis or caries. She has a symmetrical face and normal quality of life. Portal of entry
of infection is generally through periodontium
 Case study :
• Location : Mandibular left posterior area extending from mesial root of second
mandibular molar to the distal root of third mandibular molar

• Periphery and margin : Periapical well defined margin with sclerotic border

• Internal structure : Periapical radiopaque

• Effect on surrounding structure : Loss of lamina dura of distal root of

mandibular second left molar and mesial root of mandibular third left molar
OSTEORADIONECR
OSIS OF THE
JAW(ORN)
 Introduction:

• OSTEORADIONECROSIS (ORN) IS A SIGNIFICANT

COMPLICATION THAT CAN OCCUR IN THE JAWS
FOLLOWING RADIATION THERAPY FOR HEAD
AND NECK CANCER.
• IT IS CHARACTERIZED BY THE PROGRESSIVE
DEATH OF BONE TISSUE IN THE IRRADIATED
AREA, LEADING TO PAIN, EXPOSURE OF BONE,
AND POTENTIAL INFECTION.
• THE PRESENTATION OF OSTEORADIONECROSIS
IN THE JAWS CAN VARY DEPENDING ON SEVERAL
FACTORS, INCLUDING THE DOSE OF RADIATION,
THE TIME ELAPSED SINCE RADIATION THERAPY,
AND INDIVIDUAL PATIENT FACTORS.
 CLINICAL
PICTURE:
• SITE: THE MANDIBLE IS MORE COMMONLY
AFFECTED THAN THE MAXILLA DUE TO
MICROANATOMY AND LESS VASCULATURE
• POSTERIOR MANDIBLE IS MORE COMMONLY
AFFECTED THAN THE ANTERIOR REGION DUE
TO TREATMENT FOR TUMORS IN THIS REGION.
• PAIN: PERSISTENT OR INTERMITTENT PAIN IN
THE JAW, WHICH MAY BE DULL, ACHING, OR
THROBBING IN NATURE.
• SWELLING: SWELLING OF THE JAW OR
SURROUNDING TISSUES.
• NON-HEALING ULCERS: DEVELOPMENT OF
NON-HEALING ULCERS OR SORES IN THE
MOUTH OR ON THE GUMS.
 CLINICAL
PICTURE:
• EXPOSED BONE: THE PRESENCE OF EXPOSED
BONE IN THE ORAL CAVITY.
• INFECTION: RECURRENT OR CHRONIC
INFECTIONS IN THE AFFECTED AREA.
• DIFFICULTY IN CHEWING OR OPENING THE
MOUTH: DUE TO PAIN OR LIMITED RANGE OF
MOTION.
• ALTERED SENSATION: NUMBNESS OR TINGLING
IN THE JAW OR SURROUNDING AREAS.
 • RADIOGRAPHIC IMAGING: SUCH AS PANORAMIC
RADIOGRAPHI RADIOGRAPHS OR COMPUTED TOMOGRAPHY (CT) SCANS,

C EVALUATION: CAN AID IN THE DIAGNOSIS OF OSTEORADIONECROSIS. IT

CAN HELP IDENTIFY CHANGES IN BONE DENSITY,
PRESENCE OF SEQUESTRA (DEAD BONE), AND EXTENT
OF INVOLVEMENT.
 CASE REPORT
• A 38-YEAR-OLD MALE
COMPLAINED SEVERE PAIN IN
THE POSTERIOR RIGHT
MANDIBULAR REGION. PAST
MEDICAL HISTORY REVEALED
THAT HE UNDERWENT
RADIOTHERAPY FOR THE
MANAGEMENT OF CARCINOMA IN
THE HEAD AND NECK REGION
• Location: right posterior
region of the mandible
• Extending from alveolar crest
till inferior border of mandible
• Periphery and margin: ill
defined margin
• Internal structure:
unilocular, mixed(RO-RL)
due to sequestra formation.
• Effect on surrounding
structure:
• loss of lamina dura of related
teeth
• Widening of pdl space of
related teeth Differential diagnosis:
• Inferior displacement of IAC
• Subperiosteal bone formation Bone resorption stimulated by high-level
• Expansion and thinning irradiation: differentiated by the presence of exposed bone
(perforation)of buccal and Chronic osteomyelitis: history of radiation therapy
lingual cortical plates
 References :
• Gomes D, pereira M. Osteomyelitis: an overview of antimicrobial therapy. Braz J pharm sci 2013;49:13-27.
• Topazian rg. Osteomyelitis of the jaws. In: oral and maxillofacial infections. Ch. 10. Philadelphia, PA: WB
saunders; 2002.
• Hudson jw. Osteomyelitis of the jaws: A 50-year perspective. J oral maxillofac surg 1993;51:1294-301.
• Stafne ec. Infections or the jaws. Philadelphia, PA: saunders; 1985. P. 86.
• Marx RE. Osteoradionecrosis: A new concept of its pathophysiology. J oral maxillofac surg. 1983;41(5):283-
288. Doi:10.1016/0278-2391(83)90270-22. Delanian S, lefaix JL. The radiation-induced fibroatrophic process:
therapeutic perspective via the antioxidant pathway.
• Radiother oncol. 2004;73(2):119-131. Doi:10.1016/j.Radonc.2004.08.0153. Ruggiero SL, dodson TB,
fantasia J, et al. American association of oral and maxillofacial surgeons position paper on medication-related
osteonecrosis of the jaw--2014 update. J oral maxillofac surg. 2014;72(10):1938-1956.
Doi:10.1016/j.Joms.2014.04.031
 References :
• Https://journals.Lww.Com/armh/fulltext/2019/07020/chronic_sclerosing_osteomyelitis__a_case_report_on.21.
Aspx
• https://pubmed.ncbi.nlm.nih.gov/8378050/
• https://www.jstage.jst.go.jp/article/omp/15/3/15_3_91/_pdf/-char/ja
• https://www.jcdronline.org/admin/Uploads/Files/63ae69b2868b90.53909011.pdf#:~:text=Marx%20and%20M
ercuri%20defined%20acute%20osteomyelitis%20as%20lasting,to%20decreased%20inferior%20alveolar%20
nerve%20sensation%20%28Vincent%27s%20symptom%29
.
• White and pharous for oral radiology.
• Oral pathology clinical and pathological correlation
• Ahmed Aly : Diffuse osteomyelitis

• Ahmed Qais : Suppurative osteomyelitis

• Ahmed Maher : Focal sclerosing osteomyelitis

• Ahmed Mohammed Abo Etab : Garre’s osteomyelitis

• Ahmed Mohammed Mahmoud : Osteoradionecrosis

THANK YOU