BADJI MOKHTAR ANNABA UNIVERSITY
FACULTY OF MEDICINE
DEPARTMENT OF DENTAL MEDICINE
Department of Oral Pathology and Surgery
MAXILLARY OSTEITIS
- OSTEORADIONECROSIS
- OSTEONECROSIS OF THE MAXILLA RELATED TO BIPHOSPHONATES
Year 22/23 Pr A.BOUMAZA
Introduction.
- Maxillary and mandibular osteitis represent inflammatory conditions of the bone tissue, they are of various origins (local or general).
- Often infectious or traumatic. They can sometimes be induced by drug treatments (bisphosphonates, denosumab) or induced by a history of cervico-facial radiotherapy.
- The main symptom is pain, frequently accompanied by local swelling and trismus. However, it turns out that their clinical semiology varies according to the anatomical location, the presence or absence of suppuration, the duration of evolution as well as the etiology of the pathology.
- In the majority of cases, they cause significant bone damage, posing delicate diagnostic and therapeutic problems.
2. What you need to know:
- Osteitis causes bone demineralization leading to the eventual appearance of bone fragments isolated from the rest of the bone (sequestra).
- A sequestrum is a non-irrigated and devitalized bone fragment located in a bone or in periosteal tissue.
- Osteitis is more common in the mandible than in the maxilla due to the terminal
vascularization in the mandible. - Inflammation leads to intraosseous thrombosis which results in the formation of islands of cells which become necrotic, thus forming bone sequestra without vascularization or innervation.
- The bacteriology of osteitis includes a polymicrobial flora combining aerobic and sometimes anaerobic bacteria ( streptococci +++ and golden staphylococci).
3. Etiologies: they can be:
3.1. Triggering causes:
1/ Local cause (infectious origin):
- Dental or periodontal: This is the most common cause: “pulpitis, granuloma, periapical cyst, periodontal disease, etc.”
- Maxillofacial trauma (eg fracture)
- Iatrogenic origin: It is the consequence of a therapeutic procedure “exodontia, in particular impacted tooth, maxillary surgery, etc.”
2/ General cause: During certain infectious diseases, there may be diffuse damage to the skeleton. Hematogenous osteomyelitis often has a cutaneous (boil) or ENT (angina) origin.
3/ Exogenous cause: it can be.
- Physical :
Bone warming by rotating instruments
Ionizing radiations which are used in the treatment of cancers
- Chemical: Arsenic, phosphorus, fluoride poisoning
- Therapeutic: Anticancer chemotherapy. Radiotherapy.
3.2. Contributing causes.
- Age: Osteitis is more common in children due to successive eruptions which cause bone remodeling.
- The terrain: Certain pathologies predispose patients to infections which can take on a more serious appearance: “diabetes, AIDS, bone dystrophy, osteoporosis”
- The histological section of the alveolar rim shows us:
4. Classification
5. Clinical forms:
5.1. Circumscribed osteitis of local causes:
5.1.1. Localized osteitis : The infectious signs may be local, regional or rarely general, they reflect the spread of the infection:
5.1.1.1. Osteoperiostitis : The mildest form, more common in children
Clinic: – slight swelling of the soft parts.
– thickening of the bone tables.
– signs of acute monoarthritis.
Radio : – clear periapical radio image + desmodontal widening.
Evolution: – Healing – Diffusion
5.1.1.2. Osteoperiostosis: Common in children following chronic monoarthritis of the 1st M.
Clinic: – Facial deformity. – Non-painful thickening of the basal bone
Radio: – Apical infection lesion. – Thickening of the bone cortex.
Evolution : – Healing after either conservative treatment or extraction of the causative tooth.
5.1.1.3. Subperiosteal abscess: it occurs in children + adults in the regions where the periosteum adheres to the mucosa (palate or gum).
On the palate: – Adult+++. – Roots of: Lateral incisor, 1st PM and 1st M.
– Fluctuating, painful arch. F
– Edematous, congested mucosa.
5.1.1.4. Osteitis of the alveolar rim:
– Alveolitis : is due to inflammation of the alveolar wall that occurs after a traumatic dental extraction. It occurs 2 to 3 days after the extraction. Clinically, two forms of alveolitis are described:
Dry socket: it manifests itself by intense, continuous pain, insensitive to analgesics. There is often halitosis. The physical signs are dominated by: – the emptiness of the alveolus – the walls are grayish white – the peri-alveolar mucosa is inflamed. The spontaneous evolution of dry socket generally leads to healing after about ten days. However, complications such as osteitis must be feared
Suppurative alveolitis: The general signs are limited to a fever of 38 to 38.5°C. The functional signs consist of pain that is less intense than that of dry alveolitis. The physical signs are marked: – adenopathy – vestibular swelling – an alveolus filled with a bleeding brownish clot – Bone, dental or tartaric debris are often found at the bottom of the alveolus.
The evolution is not spontaneously resolved: it progresses towards complications such as osteitis
5.1.1.5. Septum syndrome: the septum may be exposed following secondary local irritation (poor interdental contact point, overflowing filling, traumatic prosthesis.
Clinical : Physical signs include an inflammatory papilla, a pseudo-periodontal pocket on probing, gingival bleeding and exposed, necrotic bone.
Radio: Blurry interdental septum “Spearhead”
5.1.1.6. Central osteitis: It is more common in the mandible: PM and symphyseal region (more spongy structure).
Clinic : – Swelling. – Marked general signs – Submental fistulization – Dental mobility – Continuous pain resistant to AT.
Radio : Diffuse bone rarefaction with irregular contours.
Evolution : Fistulization + sedation of signs
5.1.1.7. Cortical osteitis : It progresses from the periphery (cortical) towards the depth (medullary). The periosteum and cortex become necrotic.
Clinically:
– Painful bone swelling with presence of fistula
– Edema of soft parts.
– Negative Vincent sign
– No tooth mobility
Radio : Clear area of decalcification with or without sequestrum formation
Evolution : – Suppuration with or without sequestration – Diffusion
5.2. Diffuse or widespread osteitis of local causes:
5.2.1. Acute diffuse osteitis : Diffuse osteitis corresponds to the progressive extension of the process, initially circumscribed. The term diffuse osteitis is reserved for forms that are immediately widespread. They are wrongly called osteomyelitis of the jaws, because they have at the state period a symptomatology similar to hematogenous osteomyelitis. Indeed, unlike the latter which is a septicemia with secondary bone localization. They go through the following phases:
Initial stage : Manifested by intense, radiating and continuous pain and are resistant to analgesics. They are accompanied by trismus, cervical adenopathy and significant general signs (fever, pale complexion and asthenia). The endo-oral examination, objectifies the filling of the vestibule by a hard, painful swelling, adherent to the bone and dental mobility. The radiological examination reveals nothing particular at this stage.
State phase : It is characterized by a worsening of symptoms both local and general. This is the stage of purulent collection. Physical examination shows a deformation of the face with red skin. Radiological examination reveals bone rarefaction which begins to appear but no signs suggest bone necrosis.
Sequestration phase :
The painful signs disappear as well as the general signs while the trismus and the disorders of the labial sensitivity persist. The swelling and the fistulas evolve by successive inflammatory attacks, leading to the elimination of the bone sequestrum. The radiology shows a flaky bone and sequestra.
Repair phase : Begins as soon as the infectious processes disappear, bone regeneration, very slow, only concerns the basilar sector. The after-effects are linked to sequestration: tooth loss, growth disorders, temporomandibular ankylosis, bone deformations and retractile scars.
5.2.2. Chronic osteitis : This is a chronic non-purulent bone inflammation, also characterized by the absence of fistulization and bone sequestration. It follows the previous forms that were mistreated
General signs are absent. There are no dental or periodontal symptoms.
Radiology: It is suggestive, revealing a medullary opacity indicating a sclerosis reaction, sometimes associated with areas of osteolysis. Sequestra are rare.
It combines areas of destruction and areas of bone construction.
Radiology : Clear geodic radio image
5.3. Osteitis of general causes
5.3.1. Common hematogenous osteitis “osteomyelitis”
5.3.1.1. Acute osteomyelitis : It is more common in children than in adults. Clinically
– Intense, continuous pain
– Lockjaw
– Inflammatory cervical adenopathies
– Bone swelling masked by soft tissue edema
– Red, tight and shiny skin
– Swelling becomes fluctuating within a few days
Radiology : Bone rarefaction
5.3.1.2. Chronic osteomyelitis : It is very rare, located at the level of the lower mandibular border.
Clinically: – Asymmetry, trismus – Never fistulization – Little or no cervical adenopathy, nor general signs
Radiology : – Periosteal reaction – Osteolysis zone – Bone thickening in height and width – Resorbed dental roots
5.3.2. Specific osteitis :
5.3.2.1. Actinomycotic osteitis : It manifests itself in the form of chronic cellulitis, the germ responsible is “Actinobacterium israilie”
5.3.2.2. Mycotic osteitis : It is very rare in the jaws. It occurs in immunocompromised patients. The germ responsible is “Candida Albican”
5.3 .2.3.Syphilitic osteitis : They appear as an inflammatory swelling and specific serology allows the diagnosis to be made: TPHA, VDRL
5.3.2.4. Tuberculous osteitis : They have an insidious onset and the bacteriological examination and the histological appearance allow the diagnosis “IDR” to be made with tuberculin.
5.4. Osteitis of therapeutic causes
5.4.1. Osteitis under bisphosphonates (OMN):
The clinical appearance of osteonecrosis is highly variable, it can be asymptomatic or cause significant pain or loss of sensation usually in the region of the inferior alveolar nerve, depending on the extent of the necrosis. The exposed bone is hard, rough and yellowish-white in color. This denuded area is painless, does not bleed, and may nevertheless be accompanied by a mucous and/or cutaneous fistula with or without purulent discharge.
The gingiva and peripheral oral mucosa may be normal or slightly inflamed. There is usually a history of trauma; most commonly dental extraction.
Characteristics of ONM:
Bisphosphonate-induced osteonecrosis is a rare condition defined by the following four characteristics:
- Persistent bone exposure in the oral cavity, lasting more than 8 weeks.
- Patients who have been treated or are currently being treated with bisphosphonates. ⎫
- No history of cervicofacial radiotherapy. ⎫
- Absence of metastatic localization in the area of osteonecrosis objectified by the systematic performance of a histopathological examination.
5.4.2. Osteoradionecrosis :
It manifests itself by bone necrosis secondary to ionizing radiation used for therapeutic purposes, causing an alteration of the defense and healing capacities of the mandibular or maxillary bone tissue.
ORN develops more frequently in the mandible than in the maxilla (predominant centromedullary vascularization at the level of the angle and the horizontal branch), most often unilateral.
There may be bilateral forms complicating the therapeutic strategy when they are asynchronous.
Clinically, chronic bone exposure is inconsistent; the bone has a grayish, insensitive, soft appearance, sometimes associated with mucosal necrosis or a bone fracture or a cutaneous fistula.
More rarely, the ORN can be located at the maxillary level, and the functional repercussions are less serious, apart from a possible bucco-sinus or bucco-nasal communication.
MAXILLARY OSTEITIS
6. Treatment:
6. I. Prophylactic treatment : Includes:
- Motivation for Oral Hygiene.
- Antibiotic prophylaxis.
- Restoration of the oral cavity.
- Non-traumatic extraction.
- Systematic revision of the alveolus.
6.2. Curative treatment : it is medical and surgical
- Medical treatment : it allows:
- Against infection: ATB based on an antibiogram.
- For pain: analgesic + mouthwash.
- Against muscle contraction.
- Ground strengtheners.
- Hyperbaric oxygen therapy.
Aims to: – Early treatment. – Avoid complications. – Limit after-effects.
- Surgical treatment : it is.
- Etiological (conservative treatment, apical resection, extraction)
- Endo or exobuccal drainage.
- Sequestrectomy.
- Treatment of after-effects.
- Prosthetic restoration.
MAXILLARY OSTEITIS
- Therapeutic indications
MAXILLARY OSTEITIS
Conclusion
- Osteitis is a serious condition, but fortunately rare;
- Their rarity is the result of preventive treatment, improved oral hygiene and advances in antibiotic therapy.
- Treatment of proven maxillary osteitis must be early. It is medical or medico-surgical. Its aim is to cure the condition and limit its after-effects.
MAXILLARY OSTEITIS
Wisdom teeth can cause infections if not removed.
Dental crowns restore the function and appearance of damaged teeth.
Swollen gums are often a sign of periodontal disease.
Orthodontic treatments can be performed at any age.
Composite fillings are discreet and durable.
Composite fillings are discreet and durable.
Interdental brushes effectively clean tight spaces.
Visiting the dentist every six months prevents dental problems.