مقالة علمية م.د.عماد خضير بعنوان Osteomyelitis of the jaw
تاريخ النشر: 19/11/2019
عدد المشاهدات: 7
تم نشر الموضوع بواسطة: اعلام قسم طب الأسنان
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Osteomyelitis is defined as an inflammation of the bone marrow with a tendency to progression. The incidence of osteomyelitis is much higher in the mandible due to the dense poorly vascularized cortical plates and the blood supply primarily from the inferior alveolar neurovascular bundle. Osteomyelitis has been associated with multiple medical conditions such as DM, autoimmune diseases, malignancies, malnutrition, and AIDS. Primarily occurs as a result of contiguous spread of:
1. Odontogenic infections 2. Trauma
3. Hematogenous (rare)
Osteomyelitis of the mandible, is due to polyodontogenic flora rather than only Staphylococcus aureus, which is the predominant pathogen in the long bones. Typically the odontogenic microbes become opportunistic when introduced into the marrow space via tooth debilitation or trauma.
The prime pathogens are streptococci and anaerobic bacteria. The anaerobes responsible are generally bacteroides or peptostreptococci species. Often, the infections are mixed on final culture.
Clinical features may include:
Dr. Imad al-Rifae
CABMS Oral and Maxillofacial Surgery
1. 2.
3. 4. 5. 6. 7.
Pain
Swelling and erythema of overlying tissues (indicative of the cellulitic phase of the inflammatory process of the underlying bone)
LAP
Fever
Paresthesia of the inferior alveolar nerve
Trismus
Malaise
In the
infection. The patient may also exhibit an elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). Both the ESR and CRP are very sensitive indicators of inflammation in the body but they are very nonspecific. Therefore, their main use is to follow the clinical progress of the osteomyelitis.
OPG can provide valuable information as to the radiographic changes with osteomyelitis and predisposing conditions such as fractures and underlying bone disease.
One must keep in mind that cortical involvement is required for any change to be evident. Therefore, it may take several weeks before the bony changes appear radiographically. Hence, it is possible to see a patient with acute osteomyelitis that has a normal-appearing OPG. The appearance of “moth-eaten” bone or sequestrum of bone, is the classic appearance.
CT scan can give very detailed images as to early cortical erosion of bone in ostemyelitis. MRI can assist in the early diagnosis of osteomyelitis by loss of the marrow signal before cortical erosion or sequestrum of the bone appears. Thus, MRI may benefit in identifying the earlier stages of osteomyelitis.
The clinician must be aware that malignancies can mimic the presentation of osteomyelitis and must be kept in the differential diagnosis until ruled out by tissue histopathology
The clinician must begin empiric antibiotic treatment based on the most likely pathogens. This could include penicillin and metronidazole as dual-drug therapy or clindamycin as a single- drug treatment. Definitive antimicrobial therapy should be based on the final culture and sensitivities
Empiric antibiotic treatment should be started based on Gram stain results of the exudate or the suspected pathogens likely to be involved in the maxillofacial region.
Definitive C&S reports generally require several days or longer to be obtained but are valuable in guiding the surgeon to the best choice of antibiotics.
Sequestrectomy involves removing infected and avascular pieces of bones. It is often necessary to remove teeth adjacent to an area of osteomyelitis.
Resection of the jaw bone has traditionally been reserved as a last line of treatment, generally after smaller débridements have been performed or previous therapy has been unsuccessful or to remove areas involved with pathologic fracture. This resection is generally performed via an extraoral route, and reconstruction can be either immediate or delayed based on the surgeon’s preference.
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