Comprehensive Maxillofacial Osteomyelitis

Osteomyelitis of the jaws is a challenging disease for the clinicians and the patients despite many advances in the diagnosis and treatment. It was a common and dreaded disease in the past because of its prolonged course and uncertainty of outcome. It is an interesting fact to know that the oral cavity is among the most biologically dynamic tissues of human body. Any adverse change arising from any immunosuppressive systemic disease will readily manifest itself in the oral cavity. Osteomyelitis is not an exception to this. Thus, a careful evaluation of an apparently healthy individual presenting with a jaw swelling that may be associated with odontogenic infection must always be emphasized. This particular chapter will provide a brief introduction to the Osteomyelitis of the jaws so as to orient the readers towards the disease, its etiopathogenesis and clinicopathological features.

This particular chapter highlights how medical profession over the years has evolved regarding the concept of osteomyelitis of the jaws. Before the antibiotic era, it was considered as a dreaded disease. Nowadays, with the advent of antibiotics, osteomyelitis can be easily controlled. The dental science has succeeded to the heights that it is even not common for people to develop osteomyelitis often as compared to the incidence of osteomyelitis in the past. The patients opt for timely as well as better dental treatment modalities. Furthermore, dental professionals perform the dental treatment taking care of the systemic condition of the patient too. This has reduced the occurrence of osteomyelitis of the jaws. As far as the Epidemiology is concerned, Osteomyelitis of jaws is uncommon in developed countries, but it continues to be a source of significant concern in developing nations.

Osteomyelitis of jaws is a multifactorial disease. It has various etiological factors which lead to the inflammation of the medullary portion of the bone. The various predisposing factors for osteomyelitis include immunosuppressive conditions, malnutrition, metabolic bone disease, tobacco, alcohol, odontogenic infections, etc. Sometimes haematogenous dissemination of infection to healthy bones and infection associated with peripheral vascular disease may also lead to maxillofacial osteomyelitis. The process leading to osteomyelitis is initiated by acute inflammation which leads to hyperaemia, increased capillary permeability and infiltration of leukocytes which further results in destruction of bacteria and vascular thrombosis. The process also leads to release of proteolytic enzymes which causes tissue necrosis and accumulation of pus. This results in the rise of intramedullary pressure resulting in vascular collapse, venous stasis and ischemia of the concerned area. The pus then travels through the haversian and nutrient canals and accumulates beneath the periosteum of the bone leading to its elevation from the underlying cortex which further reduces the vascular supply to the bone. This is vascular impairment in the jaw which is a contributory factor in the development of osteomyelitis.

The classification of a disease is considered as a mandatory step so as to properly understand its various presentations. This also aids to formulate a favourable management plan best suited for the patient. Attributing to this fact, various researchers have proposed different classification systems of osteomyelitis in the literature. These different classification systems are based on Anatomic position, Clinical presentation, Pathological features or Radiological features of the disease. Some of the authors have even classified osteomyelitis on the basis of etiology and pathogenesis too. Henceforth there are multiple classification systems of osteomyelitis of the jaws throughout the literature. Authors also believe that these multiple classification systems has created confusion and hindered the comparative studies for the same. This in turn affects the pertinent management. This particular chapter highlights various classification systems of osteomyelitis of jaws.

Osteomyelitis is an inflammatory disease of bone. It occurs because of infection by pathogenic microorganisms. According to various authors, the disease may present as alveolar osteitis if only the alveolar bone is involved. On the contrary it is considered as osteomyelitis when the infection reaches the marrow cavity of the bone. However the disease presents various clinical features, it is sometimes difficult to diagnose this disease on the basis of clinical presentation alone. Further, delay in the diagnosis leads to progression of the disease. This can be avoided with the help of radiographic evaluation. Radiographically, the location or anatomical involvement of the affected site may help to differentiate between alveolar osteitis and osteomyelitis. Histolopathologically localized alveolar osteitis may present the same features as alveolar osteomyelitis. This may be attributed to the fact that alveolar bone possesses bone marrow too. Researchers also stressed on the early diagnosis and adequate treatment for osteomyelitis failing which, acute osteomyelitis may progress to subacute or chronic stage. Henceforth imaging modalities play a crucial role in the early diagnosis of the osteomyelitis of jaws. Various radiographic and imaging modalities which can prove to be beneficial in osteomyelitis of jaws are conventional radiography, CT Scan (Computed Tomography), MRI (Magnetic Resonance Imaging) and Ultrasonography to name a few. Researchers even quote that Nuclear medicine imaging is able to detect osteomyelitic changes 10 to 14 days in advance to their appearance on plain radiographs.

Thisis already discussed in the previous chapter that various classification systemsand nomenclatures of this disease have evolved with time. This is attributed to the fact that authors have classified osteomyelitis based on etiology, pathogenesis, clinical presentation, course, radiology, and histopathology. Osteomyelitis of the jaws presents with a varying clinical picture and henceforth it sometimes presents as a dilemmato the oral physician. This particular chapter highlights the various clinical features of different types of osteomyelitis as projected by the researchers from time to time. This will help the students as well as researchers to derive the facts about the superimposingclinical features of the types of osteomyelitis classified separately as wellas different clinical presentation of similar type of osteomyelitis highlighted by different authors in the literature.

As it has been already discussed, osteomyelitis can be defined as the inflammation in the medullary portion of the bone. But this does not mean that the osteomyelitis of the jaws will be similar to that of long bones. According to several authors there exists a difference in the pathogenesis of osteomyelitis of long bones when compared with the jaws. This is considered important because the management of a particular disease depends upon the pathogenesis. Since the pathogenesis of osteomyelitis of jaws is considered different by certain authors as compared to the osteomyelitis of long bones, the treatment protocol of both these entities cannot be similar. This particular chapter will highlight the difference in the pathogenesis of osteomyeliis of long bones and the jaws.

The management of osteomyelitis was an issue of great debate and research since long. The treatment of osteomyelitis has been practiced by various clinicians. Literature also reveals that the treatment of osteomyelitis of jaws was practiced since the year1900. There are three treatment protocols advocated for osteomyelitis which vary from simple non-invasive approach like antimicrobial therapy to more invasive and radical treatment like surgical removal of the affected part. The nonsurgical approach includes various medicinal treatment options including antibiotics,antiinflammatory and muscle relaxants. There is evidence of certain other conservative non surgical management approaches like hyperbaric oxygen therapy and bisphosphonate treatment too. If the dental professional considers that the non surgical approach may not fetch required results; then a surgical intervention is considered. This may include decortications alone or with bone grafting and partial or segmental resection. Unfortunately, there still exist dilemmas as to what approach to be followed in certain cases of osteomyelitis of jaws. This is because of the evidence of multiple recurrences of the disease. Further it is also reported that sometimes aggressive management may lead to significant co-morbidity with subsequent need for reconstructive surgery. Literature also reveals that symptomatic treatment may also be necessary in some cases. Such symptomatic treatment may include debridement of necrotic tissues and foreign materials along with skin closure of unhealed wounds. This present chapter highlights the various treatment protocols instituted and adopted by various researchers worldwide with recommendations for better treatment protocol for the dental professionals.

Besides discussing the osteomyelitis of the jaws, this particular chapter highlights the analysis of classification system as well as analysis of certain older terms regarding osteomyelitis which have been used in the literature. As it is well understood that Zurich system of classification has various advantages as compared to other different classification systems used in the literature, there still exist certain older terms for osteomyelitis which are actually misnomers. These include Condensing Osteitis and Focal sclerosing Osteomyelitis. Further, there are certain other rare types of osteomyelitis in which it is very difficult to trace the actual reason or causative agent. Those kinds of osteomyelitis may have a separate position in the classification system. One such example is tuberculous osteomyelitis in which sometimes it becomes difficult to trace the cause.