Inflammatory Lesions of The JAW: Bhavika Pol Vhatkar 1 Yr PG
Inflammatory Lesions of The JAW: Bhavika Pol Vhatkar 1 Yr PG
Inflammatory Lesions of The JAW: Bhavika Pol Vhatkar 1 Yr PG
LESIONS OF THE
JAW
Dr. Bhavika pol vhatkar
1st yr pg
OSTEOMYELITIS
OSTEORADIONECROSIS
PERICORONITIS
OSTEOSCLEROSIS
INTRODUCTION
Lamellae – weight-bearing,
Osteon/ Haversian system –
column-like matrix tubes
the structural unit of
composed of collagen and
compact bone.
crystals of bone salts.
I. ACUTE –
a. Contiguous focus – trauma, surgery &
odontogenic infections
b. Progressive – burns, sinusitis, vascular
insufficiency
c. Hematogenous – metastatic (children)
7
II CHRONIC
I. Hematogenous osteomyelitis
10
IV) Actinomycotic
V) Syphilitic
VI) Tuberculous
11
ETIOLOGY
• Pulp pathosis
• Periodontal Diseases
• Pericoronitis
• Infective cyst and tumour
Local •
•
Infected extraction socket
Infected jaw fracture
Factors • Infected soft tissue injury
• Peritonsilar abscess
• Periostitis following gingival
ulceration
ETIOLOGY
• Systemic Tuberculosis
• URT infection
• Middle ear infection
Haematogenous • Mastoiditis
Factors • Furuncle of the face
• Wound on the skin
• Local
• Haematogenous
PREDISPOSING
FACTORS:
Low resistance
• Diabetes
• Agranulocytosis
• Tb, syphilis, typhoid, aids,
• Leukemia
• On steroids
Factors affecting the vascularity of the bone
• Paget’s disease
• Fibrous dysplasia
• Radiation
• Osteopetrosis
• Bone malignancy
• Bone necrosis
PATHOGENESIS
Virulent Organisms reach the depth of the bone and
set up an inflammatory reaction
Clinical features:
Extreme pain
Regional lymphadenopathy
Soreness of involved tooth, mobile
Paresthesia or anesthesia of lip
Swelling not apparent
WBC count and temperature should be evaluated
Reflex spasm of muscles attached to that part of bone
Acute osteomyelitis involving the body of the right mandible,
with initial blurring of bony trabeculae.
` RADIOGRAPHIC
FEATURES:
About 10 days after bone involvement:
D/D:
Osteosarcoma, metastatic osteoblastic carcinoma,
pagets, chondrosarcoma.
FOCAL SCLEROSING OSTEOMYELITIS
39
(condensing osteitis)
Unusual reaction of bone to infection.
OSTEOMYELITIS
Benign cementoblastoma
Osteomyelitis
affecting the maxilla
Bone destruction
seen intra orally
RADIOGRAPHIC PICTURE 49
D/D:
Ewings sarcoma, infantile cortiical
hyperostosis,Fibrous dysplasia, osteomas,
osteosarcoma
A and B, Proliferative periostitis resulting from infl ammatory
lesions. Note the multiple layers of new bone on the buccal
aspect of the mandible, resulting in an onion-skin appearance.
MANAGEMENT
Syphilitic
osteomyelitis
Actinomycotic
osteomyelitis
56
Tuberculous osteomyelitis
Results when blood borne bacilli lodge in cancellous
bone.
57
PATHOGENESIS
• Direct inoculation – through an
ulcer or break in mucosa
• Spread to bone via an extraction
Three socket or infected fracture line
possible • Hematogenous or lymphatic spread
methods of from a primary focus elsewhere in
inoculation body.
of bacteria
into the
bone
58
Usually occurs secondary to tuberculosis of
lungs.
59
Progresses slowly, with the formation of
tubercle in bone marrow.
60
If disease still progresses, periosteum gives
way & tuberculous debris are expelled into
soft tissues.
61
CLINICAL FEATURES
Sites most commonly involved are ramus & body of
mandible.
62
Closed lesions
63
Open lesions –
64
RADIOGRAPHIC FEATURES
65
Unilateral diffuse swelling Lower left buccal vestibule
on left side of mandible obliterated from 74 to 36
with draining sinus
66
Ill defined radiolucent Occlusal view showing
osteolytic lesion periosteal reaction
67
SYPHILITIC OSTEOMYELITIS
Difficult to distinguish syphilitic osteomyelitis of the jaws from
pyogenic osteomyelitis on clinical & radiographic examination.
Three species –
i. Actinomyces israeli – primarily saprophytic,
occasionally pathogenic.
ii. Actinomyces bovis – in cattle
iii. Actinimyces baudetti – cats and dogs
71
Pathogenesis
The organisms thrive in the oral cavity, especially tissues adjacent
to mandible.
73
According to Aird, mandible may be affected as follows
–
74
Radiographic features
No specific radiographic features
75
Differential Diagnosis
Parotitis
Parotid tumors
Cervical tuberculosis
Pyogenic osteomyelitits
77
TREATMENT 78
CONSERVATIVE METHOD:
Systemic antibiotics
Selective rinsing with topical antiseptics
Selective removal of small sequestra
Curetting & local debridement
Burring of bone until normal bleeding bone
appears.
79
RADICAL TREATMENT
Debridement
Control of infection
Hospitalisation
Hydration & nutritional supplements
Analgesics
Maintaining good oral hygiene
Frequent irrigation of wounds
Removal of exposed dead bone
Sequestrectomy
Bone resection
Hyperbaric Oxygen therapy
MALIGNANCY IN 81
OSTEOMYELITIS
Patients having long standing chronic osteomyelitis with a
sinus tract may develop malignancy.
Neoplastic transformation
Discontinuity defects
BLOOD CULTURES
AGAR MEDIUM
GRAM STAINING
FUNGAL STAINING
COMPLETE HEMOGRAM
HEMOGLOBIN
TOTAL COUNT
DIFFERENTIAL COUNT
ESR
PERIPHERAL BLOOD SMEAR
BLOOD SUGAR
Imaging 88
CONVENTIONAL
IOPA
OCCLUSAL
OPG
LATERAL OBLIQUE
OTHER EXTRA ORAL RADIOGRAPHS
89
ADVANCED
BONE SCAN
CT SCAN
MRI
POSITRON EMISSION TOMOGRAPHY
TREATMENT 90
Goal of management is –
- Attenuate & eradicate proliferating
pathological organisms
- Promote healing
- Re- establish vascular permeability
Management includes –
Conservative management
Surgical management
Treatment guidelines 91
Supportive therapy
Rehydration
Blood transfusion
Pain control
Antimicrobial therapy
93
Hyperbaric Oxygen Therapy 94
TREATMENT PLAN
FOR ACUTE ASTEOMYELITIS
Healthy host
Conservative decompression & debridement
with extraction
Drainage & irrigation if pus present
Culture & sensitivity of infected foci
Antibiotic treatment for 3 – 4 weeks
Regional bony stabilization if necessary
Compromised Host 100
Reconstruction as necessary
OSTEORADIONECROSIS
OSTEORADIONECROSIS
Inflammatory condition of bone that occurs after the
bone has been exposed to therapeutic doses of radiation,
usually given for a malignancy of the head and neck
region.
Characterized by presence of exposed bone for at least
3 months occurring at any time after the administration
of therapeutic radiation.
Doses above 50 Gy are usually required to cause this
condition.
Bone is hypocellular and hypovascular
Hypovascularity results in hypoxic environment in which
adequate healing of bone is not possible.
CLINICAL FEATURES
Mandible > Maxilla
Posterior Mandible > anterior Mandible
Posterior body of Mandible is more frequently
in the direct field of radiation treatment
because primary tumors and metastatic lesions
in the lymph nodes being treated are adjacent
to this part of mandible.
Loss of mucosal covering and exposure of bone
is the hallmark
Pathologic fracture may occur.
106
The exposed bone becomes necrotic due to
loss of vascularity from the periosteum and
later sequestrates, leading to exposure of
more bone.
Pain may or may not be present.
Intense pain may occur, with intermittent
swelling and drainage extraorally.
However, many patients experience no pain
with bone exposure.
RADIOGRAPHIC FEATURES
Similar to those of chronic osteomyelitis.
Location:
Mandible
Posterior mandible
Maxilla, sometimes.
• Periphery:
Ill defined, similar to that in osteomyelitis.
If the lesion reaches inferior border, irregular bony
resorption occurs.
A B
Oral prophylaxis.
Location:
Bone changes, when present are centered
over the follicular space or the portion of
crown still embedded in bone or in close
proximity to bone.
Mandibularthird molar region is the most
common location.
Periphery:
Ill defined
Gradual transition of the normal trabecular
pattern into a sclerotic region.
Internal structure:
Adjacent bone is most often sclerotic with thick
trabeculae.
Area of bone loss or radiolucency adjacent to
crown that enlarges the follicular space .
If this lesion spreads, internal pattern becomes
consistent with osteomyelitis.
Effects on surrounding structures:
Typical
changes of sclerosis and
rarefaction of surrounding bone.
Inextensive cases, periosteal new bone
formation may be seen at the inferior
cortex, the posterior border of ramus, and
along the coronoid notch of the mandible.
OSTEOSCLEROSIS
It is believed to be a reparatory process or a
compensatory process to stress
CLINICAL FEATURES