Mandible / maxilla
Osteomyelitis
Acute suppurative osteomyelitis

Author: Annie Morrison, M.D. (see Authors page)
Editor: Kelly R. Magliocca, D.D.S., M.P.H.

Revised: 4 October 2018, last major update July 2014

Copyright: (c) 2004-2018, PathologyOutlines.com, Inc.

PubMed Search: Osteomyelitis [title] mandible maxilla

Cite this page: Morrison, A. Osteomyelitis: acute suppurative osteomyelitis. PathologyOutlines.com website. http://www.pathologyoutlines.com/topic/mandiblemaxillaacuteosteomyelitis.html. Accessed December 17th, 2018.
Definition / general
  • Early phase of osteomyelitis, usually a suppurative (purulent) condition that exists when an acute inflammatory process moves away from the site of initial infection and spreads through the medullary space of the bone
  • In most cases, insufficient time has passed for the body to react to the presence of the inflammatory infiltrate
Terminology
  • Cortical bone
    • Also called compact bone; one of two types of osseous tissue that form bones; forms the cortex, or outer shell, of most bones; denser, harder, stronger and stiffer than cancellous bone
  • Cancellous bone
    • Also called spongy bone; comprises walls of medullary cavity; lined by osteoprogenitor cells (endosteum)
  • Medullary bone / medullary cavity / marrow cavity
    • The medullary cavity (medulla, innermost part) of bone is the central cavity where red bone marrow or yellow bone marrow (adipose tissue) is stored; hence, the medullary cavity is also known as the marrow cavity
  • Periosteum
    • Connective tissue membrane lining the outer / external surface bones, except at the joints of long bones
    • Composed of an outer fibrous and an inner cambium / osteogenic layer
  • Endosteum
    • Thin layer of connective tissues lining the medullary cavity within bones
    • Contains osteoprogenitor cells including osteoblasts (build new bone) and osteoclasts (resorb bone to maintain appropriate bone thickness)
  • Periapical granuloma
    • Acute or chronic inflammation admixed with fibrous or granulation tissue locally at the apical or periapical region of a necrotic or partially necrotic tooth
    • Devoid of epithelium (i.e. no cyst lining)
Sites
  • Predominately involves the mandible
  • The maxilla has higher vascularity and thin cortical plates making it less frequently involved by osteomyelitis
Pathophysiology
  • Infection (example: dental granuloma) becomes established and spreads though bone, usually through medullary space
  • Purulent / cellular debris or edema in the medullary cavity and beneath the periosteum compromise the local blood supply; ischemia can result in necrosis and sequestration, a classical sign of osteomyelitis
Etiology and Pathogenesis, Subclassification Groups
  • Traumatic injuries, radiation and certain chemical substances may cause inflammation in the bone medullary space
  • The oral cavity harbors a large number of bacteria which may cause infection of the jawbone
  • Considering the high frequency and sometimes severity of odontogenic infections in daily dental and oral surgery practice, and the intimate relationship of dental root apices with the medullary cavity of the jawbone, it is remarkable that osteomyelitis cases are not more frequently observed
  • The low incidence of osteomyelitis of the jawbones can be explained by these primary factors which are responsible for deep bacterial invasion into the medullary cavity and cortical bone and hence establishment of the infection:
    1. Number of pathogens and virulence of pathogens
      • Although S. aureus, S. epidermidis, and Actinomyces were recently discussed as major pathogens, more recent studies favor the concept of a polymicrobic infection with several responsible pathogens
      • This shift is explained mainly by modern, sophisticated culture methods, especially involving anaerobic media, which enable identification of possible pathogens more accurately
      • Many pathogens, often found in the healthy oral flora, have been associated with jawbone osteomyelitis; however, prolonged antibiotic therapy prior to harvesting of the specimen and possible oral contamination complicate the interpretation of each result
    2. Local and systemic host immunity
      • The oral cavity, like no other part of the human body, is constantly exposed to various potential aggressors
      • Many of these bacteria, given the chance, may cause severe infection and tissue damage
      • Due to its unique environment, many potent strategies have been developed to prevent deep tissue invasion of bacteria
      • It is important for the treating physician to consider host compromise and treat any compromising condition:
        • Alcohol and tobacco, autoimmune disorders, AIDS, agranulocytosis, anemia (especially sickle cell), chemotherapy, corticosteroids and other immunosuppressive therapy, cytomegalovirus infection, diabetes, drug abuse, Herpes simplex virus (Zoster), leukemia, major surgery, malnutrition, significant periodontal disease (found in 51% in one study), syphilis
    3. Local tissue perfusion
      • Compromise of local blood supply is a critical factor in the establishment of osteomyelitis
        • Systemic and local conditions which alter the vascularity of bone predispose to osteomyelitis, and include: bisphosphonate induced osteochemonecrosis, bone malignancy (primary or metastatic), diabetes mellitus, fibrous dysplasia, florid osseous dysplasia, osteopetrosis (Albers–Schonberg Disease), osteoporosis, osteoradionecrosis, other osteonecrosis (mercury, bismuth, arsenic), Paget disease, radiation therapy, tobacco
        • In these conditions, immune cells and oxygen cannot reach the target area in an adequate manner
        • This facilitates the growth and spread of microorganisms, especially anaerobes, leading to establishment and progression of osteomyelitis
        • In many cases of acute and secondary chronic osteomyelitis, none of these factors may be detected, but they must always be considered, looked for and ultimately treated (Baltensperger 2003)
Clinical features
  • Localized pain, swelling, decreased range of motion
  • Trismus (difficulty opening mouth), dysphagia (difficulty swallowing)
  • Anesthesia or parasthesias (changes or decreased sensation) in mental nerve distribution (anterior chin, lower lip)
  • Systemic symptoms: fevers, chills, lymphadenopathy, fatigue, nausea
Diagnosis
  • Dependent on clinical and radiographic findings with confirmation by histopathology and microbiologic evaluation
Radiology description
  • Plain films: irregular radioleucency, adjacent fracture site (if present), osteomyelitis
  • CT: lytic permeative changes with soft tissue inflammation
  • Magnetic Resonance Imaging: less often affected than CT by dental amalgam artifact; if amalgam obscures, can perform MR to help detect abscess
  • Bone scintigraphy: sensitive for osteomyelitis; radiolabeled white blood cell scintigraphy has proven to be useful for detecting septic activity in the jaw bone
Radiology images

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Osteomyelitis of mandible

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Absorption of cortical bone

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CT scan

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Various images

Prognostic factors
  • Pathologic fracture associated with more protracted / complicated recovery
    • Requires antibiotics
    • Often requires surgical debridement
    • Risk of persisting into a chronic osteomyelitis if delay in diagnosis / treatment, extensive bone necrosis, inadequate duration of antibiotic therapy, inadequate surgical debridement, decreased host ability to fight infection
  • Recurrences reduced with treatment of contributing risk factors (ex: diabetes, immunocompromise, poor oral hygiene)
Case reports
Treatment
  • Surgical debridement
  • Cultures and antibiotic sensitivity
  • Infectious disease consultation if considering an extended antibiotic regimen; may require augmentation if antibiotic resistance develops (common)
Gross description
  • Fragments of irregular bone (+/- teeth) with purulent to necrotic marrow
Gross images

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Various images

Microscopic (histologic) description
  • According to the Zurich classification on osteomyelitis of the jaws, pathology is considered a secondary classification criterion - pathology confirms the diagnosis of osteomyelitis if clinical judgment and diagnostic imaging are not conclusive
  • Histology of jaw osteomyelitis should always be complemented and interpreted in conjunction with clinical and radiological findings and should not be used independently
  • Importantly, histology is an essential tool to exclude differential diagnoses
  • Predominantly acute inflammation and fibrin are common but may have a variable degree of plasma cell infiltration with marrow fibrosis
  • A distinction between acute and chronic solely based on histopathology is not always possible
  • Utilizing the context with clinical presentation and imaging studies will provide a more specific diagnosis
Microscopic (histologic) images

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H&E and GMS

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Neutrophils and bone resorption

Differential diagnosis