Chronic Osteomyelitis

• As soon as pus drains intra or extraorally, condition ceases to spread and chronic phase commences.
• Infection is localized but persistent as bacteria are able to grow in dead bone inaccessible to body’s defenses.

Clinical features

• Primary – insidious in onset , slight pain , gradual increase in jaw size.
• Secondary - Pain is deep pain and intermittent, temperature fluctuations , pyrexia , cellulitis eventually leading to abscess
• New bone formation leads to thickening causing facial asymmetry.
• Thickened or “wooden” character of bone in cr sec osteomyelitis.
• Eventually cures itself as the last sequestra is discharged.

Radiographic Features

• Trabeculae in the involved area become thin or appear fuzzy & then lose their continuity.
• After some time “moth eaten” appearance is seen
• Sequestra appear denser on radiographs.
• Where the subperiosteal new bone formation , the new bone is superimposed upon that of jaw, “fingerprint” or “orange peel” appearance is seen
• Cloacae seen as dark shadows passing through opacity.

Histologic features

• Areas of acute and subacute inflammation in the cancellous spaces of the necrotic bone.
• Foci of acute inflammation
• Active osteoclastic resorption of bone noted in peripheral portions

Chronic Subperiosteal Osteomyelitis

• Cortical plate deprived of its blood supply undergoes necrosis, underlying medullary bone  is slightly affected.
• Multiple small sequestra form, eventually discharged through sinuses with pus.
• Following extrusion of sequestra, healing occurs.
• Spontaneous drainage poor in submassetric area.
• Much of  body of mandible is lost due to poor central blood supply of the region.

D/D

• Paget’s disease – particularly wen periosteal bone is involved
• Fibrous dysplasia
• Osteosarcoma

Chronic sclerosing osteomyelitis

– focal

- diffuse

Focal Sclerosing Osteomyelitis

Clinical features

• Most commonly in children and young adults, rarely in older individuals.
• Tooth most commonly involved is the mandibular third molar presenting with a large carious lesion.
• No signs or symptoms other than mild pain associated with infected pulp.

Radiographic features

• Entire root outline always visible with intact lamina dura.
• Periodontal ligament space widened.
• Border smooth & distinct appearing to blend into surrounding bone

D/D for focal sclerosing osteomyelitis

• Local bone sclerosis
• Sclerosing cementoma
• Gigantiform cementoma

Treatment & prognosis

• Affected tooth may be treated endodontically or extracted.
• Sclerotic bone  not attached to tooth and remains behind after tooth is removed.
• This dense area may not get remodeled.
• Recognizable on bone years later and is referred as bone scar.

Diffuse Sclerosing Osteomyelitis

• May occur at any age, most common in older persons, esp in edentulous mandibles
• vague pain, unpleasant taste.
• Many times spontaneous formation of fistula seen opening onto mucosal surface to establish drainage
• Slowly progressive, not particularly dangerous since it is non destructive & seldom produces complications

Radiographic features

• Diffuse patchy, sclerosis of bone – “cotton wool” appearance
• Radiopacity may be extensive and bilateral.
• Due to diffuse nature, border between sclerosis & normal bone is often indistinct

D/D for DIFFUSE sclerosing osteomyelitis

FLORID OSSEOUS DYSPLASIA

SCLEROTIC CEMENTAL MASSES

TRUE CHR DIFFUSE SCLEROSING OSTEOMYELITIS

FIBROUS DYSPLASIA

Treatment & Prognosis

• Resolution of adjacent foci of chronic infection often leads to improvement.
• Usually too extensive to be removed surgically,
• Acute episodes treated with antibiotics.

• Hypogeusia Treatment: Zinc sulfate supplements above the usual recommended daily dose appear beneficial.

• Arsenic Poisoning: Characterized by "rain drop pigmentation" on the skin.

• Quincke's Edema: Commonly known as Angioneurotic Edema.

• Internal Resorption: Also known as Pink Tooth of Mummery or Odontoclastoma.

• Mercury Intoxication: Also known as Pink Disease.

• Lead Poisoning (Plumbism):

  • "Lead line" / "Burtonian line": A gray/bluish-black line of sulfide pigmentation occurring in the gingiva.

  • Peripheral neuritis: Produces a characteristic wrist drop/foot drop.

Macroglossia

• Feature: Crenated (scalloped) lateral tongue borders

Lymphangioma of Tongue

• Appearance: Tapioca pudding/Frog's egg

Geographic Tongue

• Associated With: Fissured tongue
• Histopathology: Similar to psoriasis
• Key Feature: Munro's abscesses

Median Rhomboid Glossitis

• Unique Sign: "Kissing lesion" on soft palate due to tongue contact

Hairy Tongue

• Misnomer: Elongated filiform papillae—not actual hair

Leukoplakia

• Type: Clinical term
• Histology: Hyperkeratosis ± Dysplasia

Verrucous Carcinoma

• Type: Variant of SCC
• Features:
  • Intact basement membrane
  • Parakeratin plugging
  • Broad "elephant-foot" rete ridges

Adenosquamous Carcinoma

• Features: Mixed adenocarcinoma + SCC

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.

• Schilling Test: Done to identify the deficiency of either extrinsic (dietary vitamin B12) or intrinsic factor involved in Pernicious Anemia.

• Fanconi's Syndrome: Associated with Aplastic Anemia.

• "Safety-Pin" Cells: Characteristic finding in Thalassemia / Erythroblastic Anemia.

• Radiographic Features of Anemias:

  • "Salt and Pepper" effect (Intraoral Periapical Radiograph): Found in Cooley's Anemia (Thalassemia) and Sickle Cell Anemia.

  • "Hair-on-End" pattern (Skull Radiograph): Found in Thalassemia, Sickle Cell Anemia, Congenital Hemolytic Jaundice, Chronic Iron Deficiency Anemia.

• "Rh Hump" (Erythroblastosis Fetalis): Describes a ring-like defect.

• Plummer-Vinson Syndrome: Associated with Iron Deficiency Anemia.

• Chediak-Higashi Syndrome: Giant abnormal PAS positive granules found in peripheral circulating leukocytes are basically altered lysosomes.

• Philadelphia Chromosome: Translocation of chromosomal material from chromosome 22 to chromosome 9; found in Chronic Myeloid Leukemia (CML).