Chronic Osteomyelitis (COM) or Non-Diffuse Sclerosing Osteomyelitis (Non-

DSO)

A modified protocol for early treatment of osteomyelitis and

osteoradionecrosis of the mandible.
Aitasalo K, Niinikoski J, Grenman R, Virolainen E.

Department of Otorhinolaryngology, Turku University Central Hospital, Finland.

Head Neck 1998 Aug;20(5):411-7

http://www.ncbi.nlm.nih.gov/entrez/PubMed&list_uids=9663669&dopt=Abstract

BACKGROUND: The treatment of osteoradionecrosis (ORN) and early chronic osteomyelitis (COM) of
the mandible and maxilla is controversial. Hyperbaric oxygen (HBO) at two to three times the
atmospheric pressure at sea level can result in tissue oxygen tension of almost 400 mmHg. Herewith
HBO increases oxygen supply in hypoxic tissue, thus inducing fibroblastic proliferation and capillary
formation. METHODS: From 1981 to 1991, we used a monoplace chamber and since 1992, we have
also had a multiplace chamber for HBO treatment. Hyperbaric oxygen was given at 2.5-2.8
atmosphere absolute pressure (ATA) for 90-120 minutes, once per day. The patients had five to 10
preoperative and five to seven postoperative sessions. Surgical therapy consisted of decortication of
the affected bone, subsequently covered with a free periosteal transplant from the tibia. RESULTS:
Thirty-six patients with ORN and 33 with COM of the mandible and maxilla was treated with this
protocol. The median follow-up time in this material is 34 months, with a minimum of 10 months.
Thirty-six ORN patients (92%) and 26 COM patients (79%) have remained symptom-free after the
first treatment period. Three failed ORN patients were successfully treated with a free microvascular
flap. The seven failed COM patients have been retreated, and five of them have occasional clinical
symptoms. CONCLUSIONS: Hyperbaric oxygen is a promising adjunct to surgery in the treatment of
mandibular and maxillary ORN and COM. Using this protocol, the necessary HBO treatment sessions
have been reduced from earlier protocols, without adverse effect on the outcome.

INTRODUCTION: Chronic osteomyelitis (COM) continues to be a serious clinical problem even in this
antibiotic era; it has been observed to develop in 5% to 25% of patients after acute hematogenous
osteomyelitis (6). Chronic osteomyelitis of the jaws is characterized by an inflammatory reaction of
the bone tissue. It is a disease that usually occurs in the mandible. The etiology and pathogenesis
of the disease are not fully understood. The most important factors for the progression and
development of the disease probably are the virulence of the causative microorganisms, the
anatomic possibilities for the infection to spread, the immunologic response. Osteoradionecrosis and
COM are complex metabolic and homeostatic deficiencies due to irradiation or infection-induced
tissue injury.

Osteoradionecrosis and COM affect wound healing with the following pathological sequence:
hypovascularization, hypocellularization, tissue hypoxia, tissue breakdown, nonhealing wound. The
treatment of ORN or COM is well established with a proven protocol of hyperbaric oxygen (HBO),
surgery, and antibiotics. In this protocol, HBO is used for several reasons. It is mainly used to
revascularize radiated or infected tissue and improve fibroblastic density. Therefore, the target tissue
for HBO is not necrotic bone but the soft tissue and bone still undamaged and viable. Necrotic bone
can only be surgically removed. Therefore, HBO is used to limit surgical bone removal to nonviable
bone, to enhance healing for the surgical wound, and to prepare the tissue for reconstruction.
FIGURE 4. A 48-year-old man who has mandibular osteomyelitis in the right side. (A) Preoperative
x-ray picture before treatment. (B) Postoperative x-ray picture 5 years after treatment.

DISCUSSION: The surgical treatment of COM and ORN consisted of intra- or extraoral decortation
with complete removal of affected bone. Diseased bone was removed until healthy, bleeding bone
was encountered. Tooth extractions and other adjunctive procedures were carried out at the same
time.

During the operation, we took 10-12 bone specimens for broth-enrichment microbiologic cultures.
The infections in our ORN cases were polymicrobial, with both aerobic and anaerobic organisms.
Candida and Actinomyces were found in some cases. In our COM material, the infection was
monomicrobial. The most common organisms isolated were Staphylococcus, Streptococcus, and
Enterococcus species. The most important finding was that both the broth-enrichment cultures and
PCR with DNA sequencing yielded the same results. Negative results were obtained in cases where
the histological finding diffuse sclerosing osteomyelitis (DSO). In this disease, immunologic factors
seem to play an important role and further investigations in this field are needed.

Radiographic evaluation of possible etiology of diffuse sclerosing

osteomyelitis of the mandible.
Suei Y, Taguchi A, Tanimoto K.

Department of Oral and Maxillofacial Radiology, Hiroshima University, School of Dentistry, Japan.

Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997 Nov;84(5):571-7

http://www.ncbi.nlm.nih.gov/entrez/PubMed&list_uids=9394391&dopt=Abstract

To examine the cause and site of origin of diffuse sclerosing osteomyelitis of the mandible, we
compared various radiographic findings for the mandibular lesions in 20 patients with diffuse
sclerosing osteomyelitis with those in 48 patients with osteomyelitis caused by bacterial infection. In
osteomyelitis of infectious origin, a typical radiographic feature was a radiolucent lesion spreading in
the cancellous bone, with cortical bone perforation and lamellated periosteal reaction. In diffuse
sclerosing osteomyelitis, intermingled sclerotic and osteolytic lesions with solid periosteal reaction or
external bone resorption were a common finding, and in some patients the cortical bone was initially
affected by the fresh or recurrent lesion. Based on these distinct differences, we suggest that the
cause of diffuse sclerosing osteomyelitis is not bacterial infection and that the site of origin is not in
the bone but in the periosteum.
Fig. 12. A, A panoramic radiograph in a patient with non-DSO affecting the right mandibule reveals
osteolytic change (large arrows) as well as disappearance of the bony wall of the mandibular canal
(small arrows). B, A panoramic radiograph obtained 2 years and 6 months after decortation.

Bacteriologic and serologic investigation in diffuse sclerosing

osteomyelitis (DSO) of the mandible.
Jacobsson S, Dahlen G, Moller AJ.

Oral Surg Oral Med Oral Pathol 1982 Nov;54(5):506-12

http://www.ncbi.nlm.nih.gov/entrez/PubMed&list_uids=6757825&dopt=Abstract

An attempt was made to clarify the obscure origin of diffuse sclerosing osteomyelitis (DSO) of the
mandible. Bacteriologic investigations of specimens from diseased mandibles were performed with
special attention to anaerobic culture technique. Propionibacterium acnes and Peptostreptococcus
intermedius were in some patients found to be of etiologic importance. Sampling techniques and
associated problems are discussed. An examination was made for antibodies in the patients' sera
against antigens prepared from bacterial isolates. ASTA, IgM, IgG, and IgA were determined.
Lymphocyte-stimulation tests were performed. The inflammatory events and chronicity of the
disease could not be explained by the immunologic findings.

Diffuse sclerosing osteomyelitis of the mandible.

Jacobsson S.

Int J Oral Surg 1984 Oct;13(5):363-85

http://www.ncbi.nlm.nih.gov/entrez/PubMed&list_uids=6437998&dopt=Abstract

The medical care of patients with diffuse sclerosing osteomyelitis (DSO) of the mandible has been
unsatisfactory. The main reasons for this have been insufficient knowledge of the disease and its
natural history, difficulties in establishing the correct diagnosis, and the unknown etiology. The
clinical features and natural history of the disease were studied by means of repeated radiographic
and scintigraphic recordings. The biopsy technique was improved by using a slowly rotating coarse
trepan bur. Histological and enzyme histochemical investigations were performed for determination
of the histopathological diagnosis. Orthopantomograms in combination with intraoral views and
99mTc-scintigraphy were used for the radiographic diagnosis and follow-up studies. Bacteriological
and serological investigations were performed in attempt to clarify the obscure etiology. The
occurrence in the patients' sera of antibodies to antigens prepared from cultured bacteria was
studied. ASTA, IgM, IgG, and IgA were determined and lymphocyte stimulation tests were
performed. The investigations made it possible to distinguish DSO as a separate entity with rather
characteristic clinical, histological and radiographic features. The histological diagnosis was facilitated
by an improved biopsy technique and enzyme histochemical recordings. Different rather unspecific
tissue reactions were together found to form a pattern which was strongly indicative of DSO. The
radiographic and scintigraphic investigations gave valuable findings which increased the diagnostic
accuracy and improved the prognostic and therapeutic judgements. The bacteriological and
serological investigations indicated that propionibacterium acnes and peptostreptococcus intermedius
were of etiological importance but could not explain the chronicity of the disease. The results of the
different investigations gave a better understanding of DSO and made it possible to provide more
appropriate care for patients in different stages of the disease. Long-term antibiotic therapy was
found to have a positive influence on the course of the disease in its early stages, while cortisone
therapy, and sometimes decortication, were found to be more effective in chronic stages.

Osteomyelitis of the maxilla secondary to osteopetrosis: Report

of a case
Conor P. Barry, BA(Mod) BDentSc,a and C. David Ryan, MB, BDentSc, FFD, FRCSI,b
Dublin, Ireland
DUBLIN DENTAL HOSPITAL
Osteomyelitis of the maxilla is extremely rare. When it occurs, there is invariably an
underlying predisposing
condition. We describe a 28-year-old woman whose presentation with osteomyelitis of
the maxilla led to a diagnosis
of generalized osteopetrosis. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2003;95:12-5)
The incidence of osteomyelitis has dramatically declined
since the introduction of antibiotics. When it
now occurs in western society, the possibility of predisposing
immunosuppressive conditions or underlying
bony disease, such as Pagets disease or osteopetrosis,
should be considered.
Osteopetrosis (marble bone disease, Albers-Schonberg
disease), is a congenital sclerosing disease of bone
characterized by osteoclastic dysfunction. There is normal
production of bone with lack of physiologic resorption.
Bone involved with osteopetrosis is thought to
have a compromised vascular supply. Local infection
such as odontogenic infection is more likely to lead to
osteomyelitis, which is a complication in 10% of reported
cases of osteopetrosis.1 These cases have occurred
almost exclusively in the mandible.
Osteomyelitis of the maxilla is very rare, probably
because of the thin cortical bone and rich collateral
blood supply. This article reports a case of aggressive
unresolved osteomyelitis of the maxilla in an adult
patient.
CASE REPORT
The dental practitioner of a marginally intellectually
challenged 28-year-old woman was alerted by her caregivers
that she had severe halitosis and that they were finding
blood on her pillow every morning. Several teeth were
periodontally and cariously involved; in particular, the
prognosis for both maxillary first molars was deemed
hopeless and they were extracted accordingly. Healing was
extremely slow and her caregivers continued to complain
of the offensive odor and blood on her pillow. Courses of
ampicillin and metronidazole provided only temporary relief
from the halitosis.
The patient was referred to the oral surgery department
with a letter revealing a previous medical history of multiple
fractures attributed to osteogenesis imperfecta. Examination
revealed a poorly healing extraction socket in the upper left
quadrant with bony sequestra. There was a large oroantral
fistula (1 _ 2 cm) in the upper left buccal sulcus. Mucopurulent
discharges were noted from both middle meatuses. A
panoramic radiograph (Fig 1), showed relative radiopacity of
the left maxillary sinus. There was loss of bony outlines of the
lateral wall of the nasal cavity, the lateral wall of the sinus,
and the palate on the left side. The extraction socket and
surrounding bone in the region of the maxillary left first molar
had a moth-eaten appearance, and there was evidence of
sequestrum formation. There was loss of the lamina dura of
the maxillary left central incisor and canine (the remaining
teeth in the quadrant). Computed tomography scans (Fig 2)
showed extensive bony destruction of the left nasal cavity and
maxillary sinus extending inferiorly to the hard palate and
laterally into the infratemporal fossa. There was evidence of
sequestrum formation. There appeared to be a reactive bony
sclerosis in the vicinity of the left ethmoidal air sinuses. In
addition, there was a soft tissue mass in the region of the left
maxillary sinus extending into the left nasal cavity. A differaJunior
House Officer, Department of Oral Surgery, Oral Medicine,
Oral Pathology and Oral Radiology, Dublin Dental Hospital.
bConsultant Oral and Maxillofacial Surgeon, Department of Oral
Surgery, Oral Medicine, Oral Pathology and Oral Radiology, Dublin
Dental Hospital.
Received for publication Mar 4, 2002; returned for revision Apr 8,
2002; accepted for publication Jul 10, 2002.
2003, Mosby, Inc.
1079-2104/2003/$30.00 _ 0
doi:10.1067/moe.2003.25