Acute and Chronic Osteomyelitis of the Jaws PDF

Acute and chronic osteomyelitis of the jaws. Dr.Saleem  The purpose of the lecture: To introduce modern concepts of etiology and pathogenesis of odontogenic and other forms of acute osteomyelitis of the jaws. To analyze and il...

Acute and chronic osteomyelitis of the jaws. Dr.Saleem  The purpose of the lecture: To introduce modern concepts of etiology and pathogenesis of odontogenic and other forms of acute osteomyelitis of the jaws. To analyze and illustrate existing theories of its origin and evaluation of peculiarities of its course depending on localization. To analyze main principles of diagnostics, methods of treatment, mechanisms of complication development and their prevention.  The plan of the lecture: Definition and analysis of contemporary theories of etiopathogenesis of acute osteomyelitis. Statistics and classification of osteomyelitis of the jaws. Clinical, morphological and laboratory characteristics of acute osteomyelitis. Main principles of diagnostics and treatment of acute odontogenic osteomyelitis. Possible complications, their prevention and treatment.  The term osteomyelitis was introduced by an English scientist Norard in 1834, later in 1879 a French scientist Lannelongue at the International Congress of Surgeons suggested that all types of inflammation of bone be defined as osteomyelitis. In spite of the fact that according to contemporary views, the process is defined as a lesion of all structures of the bone, i.e. ostitis, panostitis, the term osteomyelitis still persists, for the basis of the disease is predominantly lesion of the bone marrow.  Now any osteomyelitis is regarded primarily as an infectious purulent and necrotic inflammatory process of the osseous tissue, developing under various aggressive biological, chemical, and physical factors with underlying preliminary sensibilization, bone necrosis being implied from the very beginning  “foci of purulent infiltration of the bone marrow, thrombosis, and purulent liquefaction of clots, hemorrhage, osteo-myelonecrosis are typical for acute osteomyelitis and are not found in periodontitis and periostitis”. According to the cause, osteomyelitis of the jaws is classified as follows: odontogenic – up to 90% of all observed cases; traumatic – 7-8% (gunshot wounds included); specific – 0.9-1.5%; radial (radionecrosis) – 0.3-0.5%.  Thus, in the clinic of oral and maxillofacial surgery dominates osteogenic acute osteomyelitis, predominant in male at the age of 18-40.  Moreover, anatomical and physiological features and functions of the jaws, determining characteristics of osteomyelitis development also matter. Thus, mandible molars, most commonly affected by caries, as sources of osteomyelitis account for up to 50%, whereas analogous maxillary molars – up to 15%. Impacted third molars and their complications cause osteomyelitis respectively in 17% and 3% of cases.  Clinical manifestations of osteomyelitis vary greatly and depend upon numerous internal (state of response, age, sex, underlying disorders) and external (type of microflora, medical and geographical conditions, nutrition, season etc) causes. Local changes quickly increase with the development of the disease are common. The patient usually complains of a sharp pain in the tooth (then the pain subsides in the affected tooth but spreads to the adjacent teeth with irradiation along the jaw), tooth mobility, and foul smell from the mouth. The complaints combined with the symptoms of systemic intoxication give evidence of developing acute osteomyelitis. While the process progresses, tender swelling of soft tissues in the focal area increases, and opening the mouth becomes difficult. The dense, painful infiltrate, unlike periostitis, enclosing the jaw body like a coupling is objectively observed. From 2 to 4 teeth respond to percussion, which sometimes hinders detecting an affected tooth. The mucosa is hyperemic, edematic, interdental areas and dentogingival sockets discharge pus. The process involves lymphoid apparatus which may well result in the development of purulent lymphadenitis and adenophlegmons. The intensity degree of these signs and symptoms depends to a large extent on the type of inflammation development (normergic, hyper- and hypergic), and also on localization and extent of the lesion and the terms of the disease. Diagnostics of acute odontogenic osteomyelitis is based, as a rule, on evaluating the data of the anamnesis, clinical signs of the disease, and additional methods of investigation.  They are greatly increased leukocyte number with shift of the blood count to the left, elevated ESR, altered protein level, increased leukocytic index of intoxication, changes in number and correlation of immunocompetent cells, etc. These changes are not specific, but the level of the changes can indicate the degree of the process intensity.  Radiographic signs of the process in the bone in the acute stage are not pronounced, this investigation can only help in complicated cases to discover the affected tooth. The diagnostics must be based on an integral analysis of all discovered changes, because correct and timely diagnosis determines the foundation, choice of treatment, management, and outcome.  The purpose of treating acute odontogenic osteomyelitis consists in solution of the two main problems. Elimination of local purulo-necrotic processes by exposure and drainage of foci. Decrease of the intoxication degree with further normalization of all affected functions of vital systems and organs. One of the main components of the surgical stage of treating acute odontogenic osteomyelitis is the extraction of the causative tooth.  Аdequate medication and physiotherapy are to be provided consisting of the complex measures including antibacterial therapy with the obligatory investigation of the microflora sensitivity; immunomodulation, hyposensibilization, desintoxication therapy with appropriate drugs and dosage. Infusion methods of administering medication are preferred.  The main complication of acute purulent odontogenic osteomyelitis is purulent processes in perignathic soft tissues (phlegmons and abscesses) of various localization. Their clinic, diagnostics and treatment are the subject of the next lectures.  Оther complications, development of acute sepsis, toxic lesions of the kidneys, liver, and heart, metastatic purulent foci in remote regions (the brain, mediastinum), postoperative scars can be mentioned.  The clinical picture of chronic osteomyelitis is determined basically by the extent of bone lesion during the acute stage. The mechanism of the development of the process can be schematically represented as follows. Impaired endo- and extraosseous blood circulation determines the area of necrotic tissues, i.e. extent and depth of the lesion of bone marrow and osseous structures.  At the same time osteoclasts form new osseous tissue against the background of granulation development; fistulas are formed, filled in with granulations, draining onto the skin of the face and in submandibular and submaxillary areas, and in the oral cavity. Pus is discharged through them. Under influence of osteoclasts and proteolytic enzymes of the pus, a gradual separation of necrotic areas of the bone (sequestra) occurs.  In the sequestral (fistulous) form, clinically against the background of relatively satisfactory general condition, functioning fistula or scarred indrawn areas of the skin (mucosa) replacing the former fistula are observed. The skin color is changed, quaggy hypertrophic bleeding granulations with purulent discharge bulge from the fistula.  The main component of the diagnostics of chronic odontogenic osteomyelitis is radiography of different kinds ranging from conventional radiographs to CT and MRI.  Treatment Extent and term of the necrsequestrectomy are determined radiographically. Sequestrectomy is rarely used in oral surgery. Access, margins of excision of the affected tissues, tactics concerning granulations of the sequestral capsule, usage of particular compositions to fill in the bone defects and cavities resulting from the operation are determined individually in each particular case.  Complications of chronic osteomyelitis, depending on the form and extent of the lesion, can be systemic and local. The former case may result in anemia, renal amyloidosis, sepsis in exacerbation, malignization of prolonged chronic process, exacerbation of accompanying disorders, such as pyelonephritis, myocarditis, hepatitis, diabetes etc. The treatment is determined by the character and location of the complications.  Local complications manifest as pathologic mandibular fracture with impaired consolidation and possible formation of a false joint, lesions of the temporomandibular joint up to ankylosis, especially in childhood, development of various deformities and contractures, which should be treated according to standard methods. Preventive means in any types of odontogenic osteomyelitis can be reduced to the following: Sanation of the oral cavity, i.e. prevention of the development of complicated caries and, in particular, acute and chronic granulating periodontitis; Radical treatment of all forms of chronic periodontitis with tooth extraction or use of modern methods of conservative surgery; Radical and adequate treatment of acute periostitis; Timely diagnostics and radical treatment of acute and chronic osteomyelitis. Thank you