Bone 2

Question 1

What is the definition of Osteomyelitis?

Answer 1

It is inflammation of the bone and bone marrow of the jaws most frequently from extension of dental infection.

Question 2

What are the main etiologies of Osteomyelitis?

Answer 2

• Periapical abscess, periapical granuloma or periapical cyst\n* Physical injury as fracture or surgical procedure\n* Hematogenous spread (from bacteremia)

Question 3

What are the main causative organisms for Osteomyelitis?

Answer 3

Staphylococcus aureus and staphylococcus albus and streptococci, specific microorganisms as in TB and ACTINOMYCOSIS.

Question 4

What are the types of osteomyelitis mentioned?

Answer 4

• Acute Suppurative Osteomyelitis\n* Chronic Suppurative Osteomyelitis\n* Focal Sclerosing Osteomyelitis (Condensing Ostitis)\n* Diffuse (bacterial) Sclerosing Osteomyelitis\n* Chronic Osteomyelitis with proliferative periostitis (Garre’s osteomyelitis)\n* Chronic Tendoperiostitis\n* Osteoradionecrosis\n* Dry socket

Question 5

What are some considerable factors influencing osteomyelitis?

Answer 5

• Virulence of microorganism\n* Host resistance\n* Anatomic location\n* Patient’s age\n* Pre-existing systemic factors (e.g., Paget’s disease, osteopetrosis, sickle cell disease, bone irradiation therapy)\n* Tobacco, smoking, malignancy, alcohol abuse, drug abuse, diabetes mellitus, malaria, anemia, malnutrition, AIDS, NUG (necrotizing ulcerative gingivitis), immunocompromised status.

Question 6

What are the clinical features of Acute Suppurative Osteomyelitis?

Answer 6

Swelling, lancinating pain, pyraxia, painful lymphadenopathy, leukocytosis.

Question 7

What are the radiographic features of Acute Suppurative Osteomyelitis?

Answer 7

Moth shape radiolucency, ill-defined radiolucent area.

Question 8

What are the histopathological features of Acute Osteomyelitis?

Answer 8

Empty lacunae of osteocytes (dead bone = sequestrum), absence or scarce osteoblasts and osteoclasts, predominance of acute inflammatory cells, homogeneous exudate of purulent material.

Question 9

How is Acute Suppurative Osteomyelitis treated?

Answer 9

Drainage of pus, selective antibiotics after culture, and sequestrectomy.

Question 10

What are the clinical features of Chronic Osteomyelitis?

Answer 10

Swelling, variable painful reaction, pyrexia, sinus tract.

Question 11

What are the radiographic features of Chronic Osteomyelitis?

Answer 11

Radiolucent lesion with focal areas of mottled opacification, with indistinct margins.

Question 12

What are the histopathological features of Chronic Osteomyelitis?

Answer 12

Dense sclerotic bone with fibrous bone marrow, and mostly chronic inflammatory cells.

Question 13

What is a treatment option for difficult cases of Chronic Osteomyelitis?

Answer 13

Hyperbaric Oxygen, which stimulates vascular proliferation, collagen synthesis, and osteogenesis.

Question 14

In which cases is Hyperbaric Oxygen contraindicated?

Answer 14

Viral disease, optic neuritis, residual or recurrent malignancies, lung disease.

Question 15

What are other names for Focal Sclerosing Osteomyelitis?

Answer 15

Focal Sclerosing Ostities, Condensing Ostitis, Boney Scare, Sclerotic Bone.

Question 16

What are the clinical and radiographic features of Focal Sclerosing Osteomyelitis?

Answer 16

Confluent or lobulated opaque masses related to the apex of one or both roots of molar teeth. The root outline is visible and blends with surrounding bone. It is asymptomatic or has mild pain, mostly discovered during routine x-ray, in young adults before 20 years, related to the lower molar area.

Question 17

What are the histopathological features of Focal Sclerosing Osteomyelitis?

Answer 17

Dense sclerotic bone with osteoblastic and osteoclastic activity, fibrous bone marrow and accentuated reversal lines of bone.

Question 18

What are the clinical features of Diffuse Sclerosing Osteomyelitis?

Answer 18

Black females of middle age are more affected, but it can affect any race, age, or sex. There is vague pain, a bad taste, and positive microbiological culture.

Question 19

What are the radiographic features of Diffuse Sclerosing Osteomyelitis?

Answer 19

Ill-defined extensive lesion with periosteal thickening of the jaw.

Question 20

What are the histological features of Diffuse Sclerosing Osteomyelitis?

Answer 20

Irregular bone trabeculae showing reversal lines of intermittent resorption followed by repair. Proliferating fibrous tissue and chronic inflammatory cells are present in marrow spaces.

Question 21

How is Diffuse Sclerosing Osteomyelitis treated?

Answer 21

Treatment of carious tooth or periodontitis, hyperbaric oxygen and low dose of corticosteroids.

Question 22

What is another name for Chronic Osteomyelitis with proliferative periostitis?

Answer 22

Garré’s disease.

Question 23

What are the clinical features of Garré’s Osteomyelitis?

Answer 23

Most frequently associated with advanced acute caries (mostly in badly decayed deciduous D or E or lower first molar teeth) in young patients. It occurs when the free gingival margin remains above the height of contour of the tooth, resulting in food impaction. There is unilateral asymptomatic hard bony swelling at the posterior part of the mandible.

Question 24

What are the radiographic features of Garré’s Osteomyelitis?

Answer 24

Expanded cortex with concentric parallel opaque layers perpendicular to the cortex ("onion skin" layers).

Question 25

What are the histological features of Garré’s Osteomyelitis?

Answer 25

Perpendicular orientation of new trabeculae to redundant cortical bone, parallel arrangement of lamellar bone trabeculae.

Question 26

How is Garré’s Osteomyelitis treated?

Answer 26

Extraction of the causative tooth, antibiotics. The mandible will remodel without needing surgical intervention.

Question 27

What are the clinical features of Chronic Tendoperiostitis?

Answer 27

Swelling of the cheek, trismus, recurrent pain, mean age of 40 years, negative microbiological culture, and non-responsive to antibiotics.

Question 28

What are the predisposing factors for Chronic Tendoperiostitis?

Answer 28

Bruxism, clenching of the jaws, nail biting, inability to relax jaw musculatures.

Question 29

What are the radiographic features of Chronic Tendoperiostitis?

Answer 29

Radiolucent areas within areas of radiodensity.

Question 30

What are the histological features of Chronic Tendoperiostitis?

Answer 30

Sclerosis and remodeling of cortical and subcortical bone with resultant increase in bone volume.

Question 31

How is Chronic Tendoperiostitis treated?

Answer 31

Resolution of muscle overuse.

Question 32

Why is bone receiving irradiation therapy susceptible to infection?

Answer 32

Because of decreased vascularity due to narrowing of blood vessels.

Question 33

What happens to osteoblasts and osteoclasts in Osteoradionecrosis?

Answer 33

Osteoblasts and osteoclasts show destruction.

Question 34

What are typical precipitating events for Osteoradionecrosis?

Answer 34

* Periapical inflammation from non-vital teeth\n* Extraction\n* Periodontal disease

Question 35

What is seen in the blood vessels, sequestrum, and inflammatory cells in Osteomyelitis and Osteoradionecrosis?

Answer 35

Blood vessels have thick walls, and there is sequestrum and chronic inflammatory cells.

Question 36

What are other names for Dry Socket?

Answer 36

Alveolar osteitis, Fibrinolytic alveolitis.

Question 37

Describe the normal healing process after tooth extraction.

Answer 37

Healing starts with blood clot formation which is rich in Plasminogen. The blood clot is organized by granulation tissue (Fibrin), which is then replaced by coarse fibrillar bone, and finally by mature bone.

Question 38

What factors can alter the normal healing mechanism after extraction and lead to dry socket?

Answer 38

Certain factors may alter this physiologic mechanism and lead to lysis of plasminogen into Plasmin. Plasmin will cause lysis of fibrin (fibrinolytic alveolitis), leading to the formation of kinins which are potent pain mediators.

Question 39

What are some causative factors for Dry Socket?

Answer 39

* After vigorous, traumatic extraction\n* Oral contraceptive use\n* Tobacco products\n* Inadequate irrigation during surgery\n* Presurgical infections

Question 40

What are the clinical features of Dry Socket?

Answer 40

Throbbing pain in the area of tooth extraction. The socket is filled with a dirty grey clot leaving a bare bony socket. The bone is extremely sensitive to probing. There is a foul odor. Swelling and lymphadenopathy may be present. These signs and symptoms may last from 10 to 40 days.

Question 41

What is the recommended treatment for Dry Socket?

Answer 41

* X-ray is recommended to detect any tooth fragment.\n* Irrigation with warm saline (not hot to promote blood clotting) and local antiseptic (chlorhexidine).\n* Lightly packing the socket with iodoform gauze.\n* Packing the socket with local antibiotic, the most effective being tetracyclines.\n* Topical use of Antifibrinolytics (Alvogel) is very helpful. Alveogyl is an ideal dry socket dressing that rapidly eases pain.\n* Systemic antibiotics are also highly recommended.\n* Packing is repeated every 24 hours for 3 days, then every 2 days, until granulation tissue fills the exposed bone, which may take 3-4 weeks.\n* No ointment should be used as it acts as a foreign body and prevents healing.