Infantile Osteomyelitis

• Osteomyelitis Maxillaries Neonatarum, Maxillitis of infancy
• Osteomyelitis in the jaws of new born infants occurs almost exclusively in maxilla.

Etiology

• Trauma – through break in mucosa cause during delivery.
• Infection of maxillary sinus
• Paunz & Ramon et al  believe that disease caused through infection from the nose.
• Hematogenous spread through streptococci & pneumococci

Clinical features

• Fever, anorexia & intestinal disturbances.
• swelling or redness below the inner canthus of the eye in lacrimal region.
• Followed by marked edema of the eyelids on the affected side.
• Next, alveolus & palate in region of first deciduous molar become swollen.
• Pus discharge from affected sites

D/D for Infantile Osteomyelitis

• Dacrocystitis neonatarum
• Orbital cellulitis
• Ophthalmia neonatarum
• Infantile cortical hyperostosis

TREATMENT

• Intravenous antibiotics, preferably penicillin.
• Culture & sensitivity testing
• Incision & drainage of fluctuant areas
• Sequestrectomy
• Supportive therapy

Osteoradionecrosis

Clinical features

A reduction in vascularity, secondary to endarteritis obliterans, and damage to osteocytes as a consequence of ionising

Radiotherapy can result in radiation-associated osteomyelitis or Osteoradionecrosis. The mandible is much more  commonly affected than the maxilla, because it is less vascular. Pain may be severe and there may be pyrexia. The overlying oral mucosa often appears pale because of radiation damage. Osteoradionecrosis in the jaws arises most often following radiotherapy for squamous cell carcinoma.
 

Scar tissue will also be present at the tumour site, often in close relation to the necrotic bone.

Radiology
 

Osteoradionecrosis appears as rarefying osteitis within which islands of opacity (sequestra) are seen. Pathological

fracture may be visible in the mandible.

Pathology
The affected bone shows features similar to those of chronic osteomyelitis. Grossly, the bone may be cavitated

And discoloured, with formation of sequestra.
Acute inflammatory infiltrate may be present on a background of chronic inflammation, characterized by formation

Of granulation tissue around the non-vital trabeculae.

Blood vessels show areas of endothelial denudation and obliteration of their lumina by fibrosis.

Small telangiectatic vessels lacking precapillary sphincters may be present.

Fibroblasts in the irradiated tissues lose the capacity to divide and often become binucleated and enlarged.

Management

Prevention of Osteoradionecrosis is vital. Patients who  require radiotherapy for the management of head and

neck malignancy should ideally have teeth of doubtful prognosis extracted at least 6 weeks prior to treatment.

The dose of radiation,
The area of the mandible irradiated and
the surgical trauma involved in the dental extractions.
Surgical management of Osteoradionecrosis is similar to osteomyelitis.

Infective osteomyelitis

• Tuberculous osteomyelitis
• Syphilitic osteomyelitis
• Actinomycotic osteomyelitis

Tuberculous osteomyelitis

• Non healing sinus tract formation
• Age group affected is around 15 – 40 years.
• Commonly seen in phalanges and dorsal and lumbar vertebrae.
• Usually occurs secondary to tuberculosis of lungs.
• Cases have been reported where mandibular lesions were not associated with pulmonary disease.
• Another common entrance is through a carious tooth via open pulp.
• Usually affects long bones and rare in jaws.
• Results when blood borne bacilli lodge in cancellous bone. Usually in ramus , body of mandible. may mimic parotid swelling or submassetric abscess.

Syphilitic osteomyelitis

• Difficult to distinguish syphilitic osteomyelitis of the jaws from pyogenic osteomyelitis on clinical & radiographic examination.
• Main features are progressive course & failure to improve with usual treatment for pyogenic osteomyelitis.
• Massive sequestration may occur resulting in pathologic fracture.
• If unchecked, eventually causes perforation of the cortex.

Actinomycotic Osteomyelitis

• The organisms thrive in the oral cavity, especially tissues adjacent to mandible.
• May enter the bone through a fresh wound, carious tooth or a periodontal pocket at the gingival margin of erupting tooth.
• Soft or firm tissue masses on skin, which have purplish, dark red, oily areas with occasional zones of fluctuation.
• Spontaneous drainage of serous fluid containing granular material.
• Regional lymph nodes occasionally enlarged.
• Mimics parotitis / parotid tumors

Garre’s Osteomyelitis (Chronic Osteomyelitis with Proliferative Perosteitis)

• Chronic Non Suppurative Sclerosing Osteitis/ Periostitis Ossificans.
• Non suppurative productive disease characterized by a hard swelling.
• Occurs due to low grade infection and irritation
• The infectious agent localizes in or beneath the periosteal covering of the cortex & spreads only slightly into the interior of the bone.
• Occurs primarily in young persons who possess great osteogenic activity of the periosteum.

Clinical Features

• Uncommonly encountered, described in tibia and in the head and neck region, in the mandible.
• Typically involves the posterior mandible & is usually unilateral.
• Patients present with an asymptomatic bony, hard swelling with normal appearing overlying skin and mucosa.
• On occasion slight tenderness may be noted
• pain is most constant feature
• The increase in the mass of bone may be due to mild toxic stimulation of periosteal osteoblasts by attenuated infection.

Radiographic features

• Laminations vary from 1 – 12 in number, radiolucent separations often are present between new bone and original cortex. (“onion skin appearance”)
• Trabeculae parallel to laminations may also be present.

Histologic Features

• Reactive new bone.
• Parallel rows of highly cellular & reactive woven bone in which the individual trabeculae are oriented perpendicular to surface.
• Osteoblasts predominate in this area.

D/D for Garre’s Osteomyelitis

• Ewing's sarcoma
• Caffey’s disease
• Fibrous dysplasia
• Osteosarcoma

Treatment

• Removal of the offending cause.
• Once inflammation resolves, layers of the bone consolidate in 6 – 12 months, as the overlying muscle helps to remodel.
• If no focus of infection evident, biopsy recommended.

Acute suppurative osteomyelitis

• Serious sequela of periapical infection.
• Leads to spread of pus through the medullary cavities of bone.
• Depending upon the main site of involvement of bone, can be of two types-

1. Acute intramedullary
2. Acute subperiosteal

Acute Intramedullary Osteomyelitis

CLINICAL FEATURES:

• Patient experiences dull , continuous pain , indurated swelling forms over the affected region of jaw involving the cheek , febrile.
• When mandible involved, loss of sensation occurs on lower lip on affected side due to involvement of inferior alveolar nerve.
• Teeth become loose later along with tender on percussion
• Pus discharge , trismus , foul smell , regional lymphadenopathy , weakness

RADIOGRAPHIC FEATURES

• Earliest radiographic change is that trabeculae in involved area are thin, of poor density & slightly blurred.
• Subsequently multiple radiolucencies appear which become apparent on radiograph.
• In some cases there is saucer shaped area of destruction with irregular margins.
• Loss of continuity of lamina dura, seen in more than one tooth.

HISTOLOGIC FEATURES:

• Dense infiltration of marrow by polymorphonuclear leukocytes.
• Bone trabeculae in involved site (sequestrum) are devoid of cells in the lacunae.
• separation of considerable portions of devitalized bone.

Acute Subperiosteal Osteomyelitis

CLINICAL FEATURES

• Pain , febrile condition , i/o and e/o swelling , parasthesia
• Bone involvement limited to localized areas of cortex.
• Pus ruptures rapidly through the overlying cortex, tracks along the surface of mandible under the periosteal sheath.
• Elevation of periosteum from cortex is followed eventually by minute cortical sequestration.

Nasopalatine cyst

Radiology

The nasopalatine cyst appears as a well-defined, round radiolucency in the midline of the anterior maxilla . Sometimes it appears to be 'heart-shaped' because of super-imposition of the anterior nasal spine.

Radiological assessment should include examination of the lamina dura of the central incisors (to exclude a radicular cyst) and assessment of size (the nasopalatine foramen may reach a width of as much as 10 mm).

Pathology

The cyst is lined by a layer of pseudostratified ciliated columnar epithelium and/or stratified squamous epithelium. The capsule of the cyst is fibrous and may include the incisive canal neurovascular bundle.

Nasolabial cyst

Radiology

'Bowing' inwards of the anterolateral margin of the nasal cavity has been recorded

Pathology

The nasolabial cyst is lined by non-ciliated pseudostratified columnar epithelium, which is often rich in mucous cells.