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Chronic Osteomyelitis of Jaw

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Chronic Osteomyelitis of Jaw Chronic Osteomyelitis of Jaw Dr. Dhawal Goyal, 1 Dr. Nilima Malik, 2 Dr. Neha Gupta, 3 Dr. Manoj Agarwal, 4 Dr. Rajani Kalla, 5 Dr. Sanyam Agarwal 6 1. Dr. Dhawal Goyal MDS, Oral Private Practitioner 2. Dr. Nilima Malik MDS Oral and Maxillofacial Surgery 3. Dr. Neha Gupta Assistant Professor, Dept. of Prosthodontics, RUHS College of Dental Sciences, Jaipur 4. Dr. Manoj Agarwal Assistant Professor, Dept. of Conservative Dentistry & Endodontics, RUHS College of Dental Sciences, Jaipur 5. Dr. Rajani Kalla Assistant Professor, Dept. of Prosthodontics, RUHS College of Dental Sciences, Jaipur 6. Dr. Sanyam Agarwal Medical Officer, Dept. of Conservative Dentistry & Endodontics, RUHS College of Dental Sciences, Jaipur The prevalence of osteomyelitis of jaws in third Cultures, bone biopsy, conventional radiography, world country is still at a higher rate despite newer scintigraphy, CT scan are used to diagnose chronic and powerful antibiotics and advances in dental osteomyelitis of jaws. Computed Tomograph helps care. This may be due to low socio-economical in determination of cortex and medullary status, unavailability of primary health care involvement of diseased bone better as compared to services, and poor nutritional status in the rural conventional radiograph. areas. Therapy for osteomyelitis of jaws requires a Osteomyelitis may be defined as an inflammatory multidisciplinary approach. A precise condition of the bone that usually begins as an microbiologic diagnosis and adequate debridement infection of the medullary cavity, rapidly involves of necrotic tissue are essential. Acute the Haversian system and quickly extends to hematogenous osteomyelitis usually responds to periosteum of the affected area. The infection then antimicrobial therapy. becomes established in the cortical portion of the However, chronic osteomyelitis of jaws usually bone, creating ischemia and eventually causing requires surgical debridement. Surgical exploration necrosis of bone. Osteomyelitis of jaws develops and sequestrectomy & saucerization are most after a chronic odontogenic infection or a variety of frequently used to treat these cases. Radical surgery other reasons like tuberculosis or fungal infection. such as decorticotomy or resection is effective in An underlying alteration in host defence is present the treatment of extensive cases of chronic in majority of patients with osteomyelitis of jaws. osteomyelitis of the jaws. Hyperbaric oxygen is Osteomyelitis has been noted in patients with often recommended as an adjuvant in treatment of diabetes, autoimmune disease, agranulocytosis, chronic osteomyelitis of jaws. leukaemia, severe anaemia, malnutrition, syphilis, In present study, we have analyzed the etiological cancer chemotherapy, steroid drug use, sickle cell factors, age and sex prediction, site of occurence, disease, acquired immunodeficiency syndrome1 and role of CT scan and various treatment modalities with the habit of tobacco and alcohol followed in our institute over a period of 3 yrs. consumption.2 1 National Research Denticon, Vol-9 Issue No. 1, Jan. - Dec. 2020 Aims and Objectives of our study are- 3. Infantile osteomyelitis. 1. To study the various etiological factors of B. Non Suppurative Osteomyelitis chronic osteomyelitis. 1. Diffuse sclerosing osteomyelitis 2. To study the role of systemic conditions as a 2. Focal sclerosing osteomyelitis (condensing predisposing factors in chronic osteomyelitis of osteitis) jaw. 3. Proliferative periostitis (Garre's sclerosing 3. To discuss various treatment modalities osteomyelitis, periostitis ossificans) (surgical & nonsurgical) for management of 4. Osteoradionecrosis chronic osteomyelitis of jaws. Osteomyelitis of maxilla is less frequent than Topazian (2002) has classified osteomyelitis as: mandible because maxillary blood supply is more A. Suppurative osteomyelitis extensive. Thin cortical plate and a relative paucity 1. Acute suppurative osteomyelitis of medullary tissues in the maxilla preclude 2. Chronic suppurative osteomyelitis: confinement of infections within bone and permit (a) Primary- no acute phase preceding the dissipation of oedema and pus into soft tissue (b) Secondary –follows acute phase and paranasal sinuses. Acute inflammation Pus, organism (edema, pus formation) extension Increased intramedullary Haversian system Pressure involvement Vascular collapse Elevation of periosteum (Stasis, ischemia of bone) Avascular bone Disrupted blood supply In Tuberculous osteomyelitis of the maxilla or Management of osteomyelitis of jaws depends on - mandible there are 3 possible methods of • Etiology of the disease inoculation of bacteria into the bone, • Predisposing factors like altered immune status 1. Direct inoculation of bacilli into the oral mucosa of host, vascularity of bone etc. through an ulcer or a breach in continuity of the • Site and extent of the lesion. mucosa or through periodontal membrane. Osteomyelitis of jaws usually requires medical and 2. Spread to the bone through an extraction socket surgical treatment, although occasionally antibiotic or an infected fracture line. therapy alone is successful. 3. Hematogenous spreads from primary focus Chronic osteomyelitis of jaw bones can be elsewhere in the body. This primary focus may be managed by active or quiescent, apparent or latent either in the 1. Medical management lungs or in the lymph glands of the mediastenum, 2. Surgical management mesentery, and cervical region or in the kidney or in other viscera. MEDICAL MANAGEMENT: It includes- MANAGEMENT • Adequate fluid and dietary intake 2 National Research Denticon, Vol-9 Issue No. 1, Jan. - Dec. 2020 • Evaluation and correction of host immune - Osteomyelitis is more common in mandible system deficiencies due to odontogenic infection as compared to • Systemic Antibiotic therapy maxilla, whereas fungal osteomyelitis was • Anti tubercular therapy-Whenever required more common in maxilla (which confirms its • Antifungal therapy- Whenever required route of transmission ie. Inhalation) as • Hyperbaric oxygen therapy compared to mandible. Tuberculous SURGICAL MANAGEMENT: It includes osteomyelitis was seen only in mandible. One • Local antibiotic therapy- Closed wound case of diffuse sclerosing osteomyelitis or irrigation-suction & Antibiotic impregnated primary chronic osteomyelitis was seen in the beads mandible. - Retrospective correlation between CT scan • Sequestrectomy and Saucerization finding and surgical intervention was carried • Decortication out. It was suggestive that patients whose CT • Resection and Reconstruction scan showed sclerosis pattern, they underwent RESULTS decortication and patients with mixed pattern The study was conducted in the department of Oral CT scan underwent curettage. One resection and Maxillofacial surgery, Nair Hospital Dental was carried out in mixed pattern patient. College, Mumbai. 40 patients were examined. 32 CASE REPORT patients out of 40 were suffering from osteomyelitis A 55 years old female patient reported to due to odontogenic cause. Three patients had Maxillofacial Dept., Nair Hospital Dental College etiologic factor as fungal infection, whereas 4 with the chief complaint of discharge of pus from patients had tuberculous osteomyelitis of jaw. One right infraorbital region and discharge of pus patient had primary chronic osteomyelitis of intraorally since 8 months. mandible and etiology was unknown. There was h/o extraction of upper molar tooth on In our study right side, later patient noticed extraoral - Mandible was more commonly affected as discharging sinus in right infraobital region and compared to maxilla. Both bones had discharge of pus intraorally in right upper buccal predilection for right side more as compared to vestibule. She had consulted to family doctor for left side the same and taken treatment for 3 months but there - Patients having systemic disorders required was no improvement in symptoms. Then patient more time for recovery as compared to patients was referred to Nair Hospital Dental College for who did not have any systemic disorders definite management. - Surgical method used primarily for Patient gave past history of diabetes since 6 years osteomyelitis was sequestrectomy and and was on Inj. Human insulin 10 units before saucerization. It was carried out in 19 patients breakfast, 8 units before dinner subcutaneously. and curettage was carried out in only 16 She gave H/O hypertension and was taking Tab. patients. Decortication was carried out in 4 Amlodipine 5 mg in morning. There was no other patients and one patient underwent resection significant past medical history. Patient was a home followed by reconstruction. maker. - CT scans of 20 patients were evaluated. The Patient’s general condition was fair. Vital CT scan pattern showed was classified into 4 parameters were brought within normal limits. Face categories; sclerotic, lytic, mixed and was asymmetrical. One extraoral discharging sinus sequestrum. The most common pattern seen was seen in right infraorbital region. On intra oral was mixed pattern. 9 patients had mixed CT examination, necrotic maxilla could be appreciated scan pattern and 5 patients had lytic pattern and extending from right tuberosity and crossing 3 patients each showed sclerosis and midline till 25. Grade II mobile teeth sequestrum pattern. 11,12,13,21,22,23,24, 25 were noted. Mouth 3 National Research Denticon, Vol-9 Issue No. 1, Jan. - Dec. 2020 opening was adequate. Patient`s oral hygiene was powder which was supposed to be mixed with 200 very poor. ml of normal
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