Gentamicin impregnated polymethylmethacrylate (PMMA) beads in the treatment of primary chronic osteomyelitis of the mandible

The Necessity of Antibiotics in the Management of Surgically Treated Mandibular Osteomyelitis: A Systematic Review

OBJECTIVES

Mandibular osteomyelitis remains an incompletely understood entity, and treatment of its various presentations remains diverse. The purpose of this study was to review the necessity of antibiotic therapy after surgical treatment of mandibular osteomyelitis.

STUDY DESIGN

A systematic review of published articles on surgical management of mandibular osteomyelitis with or without postoperative antibiotic therapy was performed to answer the question, "Does the use of postoperative antibiotics compared with surgery alone alter the success rate in treating mandibular osteomyelitis?" The most recent evidence was sought by searching PubMed, Embase, and Scopus databases. Article appraisal was performed by 2 reviewers.

RESULTS

Forty-five articles were found that met the inclusion criteria, with all studies being retrospective cohort or case series designs. Only 13 articles used Zurich classification designations of acute osteomyelitis, secondary chronic osteomyelitis, or primary chronic osteomyelitis, and the general heterogeneity of these articles made comparison difficult. No study made an intentional statistical assessment of various antibiotic protocols.

CONCLUSIONS

Limited evidence suggested that resection may have better success rates than other forms of surgical intervention, regardless of antibiotic therapy. This systematic review questions the perceived necessity of intermediate- or long-term antibiotic therapy in the management of mandibular osteomyelitis after surgical resection.

Improving Outcomes for Osteomyelitis After Partial Bone Resection: A Preliminary Report

Following partial bone resection for osteomyelitis, continued osteomyelitis in the remaining bone is common and problematic. Shortcomings in available surgical techniques to combat this also contribute to this problem. Presented are two case studies using a solution to this problem with a different type of bone void filler as a carrier vehicle for delivering antibiotics into the remaining infected bone to eradicate any residual bacteria in the remaining bone.

Comparing Clinical and Radiographic Characteristics of Chronic Diffuse Sclerosing Osteomyelitis and Craniofacial Fibrous Dysplasia in the Mandible

PURPOSE

Differential diagnosis of chronic diffuse sclerosing osteomyelitis of the mandible (DSOM) and craniofacial fibrous dysplasia (CFD) involving the mandible is challenging. The purpose of this study was to explore the differences of the clinical and radiographic characteristics between these 2 conditions.

PATIENTS AND METHODS

In this retrospective cross-sectional, blinded, comparative study, clinical and imaging data of patients with DSOM and CFD at the Peking University Hospital of Stomatology from 2012 to 2018 were retrieved. Clinical characteristics, mainly pain, swelling, and trismus, and radiographic findings, including sclerosis, lysis, and subperiosteal bone formation, were evaluated. The t test, χ² test, and Fisher-Freeman-Halton test were used to determine differences.

RESULTS

Thirty-seven patients with DSOM and 32 patients with CFD were included (mean ages, 24.2 and 28.4 years, respectively); both groups showed a female predilection. DSOM (91.9%) and CFD (84.4%) were mainly unilateral. Patients with DSOM mainly presented with pain (94.6%), soft-tissue swelling (100.0%), and trismus (54.1%), whereas those with CFD did not experience pain (90.6%) and showed bone enlargement (87.5%) without trismus (6.3%). Panoramic radiographs and computed tomography scans of patients with DSOM showed subperiosteal bone formation, cortex lysis, and poorly demarcated cortex, whereas those patients with CFD mainly showed moderate-to-severe bone expansion, well-demarcated cortex, and tooth and mandibular canal displacement.

CONCLUSIONS

These findings emphasize the importance of clinical and radiographic features in differentiating between DSOM and CFD. Pain, soft-tissue or bone-tissue swelling, subperiosteal bone formation, clarity of the boundary of the cortex and medulla, and continuity of the cortical bone are key points facilitating differentiation.

Efficacy of eluted antibiotics through 3D printed femoral implants

Costs associated with musculoskeletal diseases in the United States account for 5.7% of the Gross Domestic Product (GDP) (Weinstein et al. 2018). As such, there is a need to pursue new ideas in orthopaedic implants that can decrease cost and improve patient care. In the recent years, 3D printing of polymers using Fused Deposition Modeling (FDM) and metals using Direct Metal Laser Sintering (DMLS) has opened several exciting possibilities to create customized orthopaedic implants. Such implants can be engineered to release antibiotics in a controlled manner by infusing the drug into the material during manufacturing stage. However, the prevalence of high temperature could impact the anti-bacterial effectiveness of the eluted antibiotics in such implants. An alternative approach to circumvent this issue would be to modify the implant geometry to incorporate built-in design features such as micro-channels and reservoirs in which antibiotics can be introduced prior to the surgical procedure. Irrespective of the approach used, the ability of 3D printed orthopaedic implants to elute antibiotics, and the rate of elution are not well understood. The purpose of this article is to study the elution of doxycycline through 3D printed femoral implants using three different materials: Poly-Lactic Acid (PLA), Poly-Caprolactone (PCL) and Titanium grade Ti-6Al-4V. The PLA and Ti-6Al-4V implants were designed with built-in reservoirs and micro-channels in which doxycycline was introduced post the manufacturing stage. However, the PCL implants were printed from a PCL spool that was infused with doxycycline using an extruder. The PLA and Ti-6Al-4V experiments were run for a period of 31 days and the PCL experiment for one day. The antibacterial ability of eluted doxycycline from all implants were examined using Kirby-Bauer test on the bacteria E.coli k-12. The results show that most of doxycycline eluted through the three materials in the first 24 hours. After the initial spike, a steady release was achieved for the PLA and Ti-6Al-4V implants for 30 days. During this timeframe, Ti-6Al-4V implants released more doxycycline than the PLA implant. The eluted antibiotics through all the implants demonstrated the ability to kill bacteria in the subsequent Kirby-Bauer test. These outcomes show that irrespective of how the antibiotics were introduced, 3D printed polymeric and metallic implants have great potential in orthopaedic applications.

Exfoliation and simultaneous formation of condylar process following chronic osteomyelitis of the mandible

A 26-year-old physically challenged man with a history of 7 months' infection and pus discharge was referred to the oral and maxillofacial department. He had undergone right mandibular teeth extraction 1 year ago, which was followed by pus discharge from an extraoral submandibular fistula after 2 months. Again, incision and drainage and wide-spectrum antibiotic were prescribed, which subsided the symptoms for a short period but did not cure the condition. So, sequestrectomy, complete debridements, and antibiotic therapy were planned for him. In the operating room, it was revealed that the sequestrum was the condylar process, and in follow-up cone-beam computed tomography scan, the condyle was being regenerated simultaneously. One-year follow-up showed successful treatment of the condition.

Chronic haematogenous osteomyelitis in children: an unsolved problem

From a global point of view, chronic haematogenous osteomyelitis in children remains a major cause of musculoskeletal morbidity. We have reviewed the literature with the aim of estimating the scale of the problem and summarising the existing research, including that from our institution. We have highlighted areas where well-conducted research might improve our understanding of this condition and its treatment.

Osteomyelitis of maxilla in poorly controlled diabetics in a rural Indian population

OBJECTIVES

To retrospectively analyze all patients who were diagnosed with Osteomyelitis of jaws in our unit.

STUDY DESIGN

31 patients with Osteomyelitis of jaws were analyzed retrospectively from 2002 to 2008 at the Department of Oral & Maxillofacial Surgery, S.D.M College of dental sciences and hospital, Dharwad, India. Parameters considered were age, gender, jaws involved, clinical features, surgical management & complications.

RESULTS

Of the 31 patients, maxilla was involved in 16 patients and mandible was involved in the remaining 15. 11 out of the 16 patients with maxillary osteomyelitis were immuno-compromised. The predominant etiology noted was odontogenic infection. With the treatment protocol we have adopted, all our patients showed satisfactory resolution of the condition by 6 weeks.

CONCLUSION

Incidence of maxillary osteomyelitis & their association with diabetes mellitus was higher in our series compared to others. The cause for this high incidence was analyzed in our study. Based on our results we conclude that a conservative surgical method with an attempt to preserve vital bone and an appropriate antibiotic therapy with the correction of the underlying medical problems is adequate to treat Osteomyelitis of jaws.

Chronic haematogenous osteomyelitis in children: a retrospective review of 167 patients in Malawi

We present a retrospective review of 167 patients aged 18 years and under who were treated for chronic haematogenous osteomyelitis at our elective orthopaedic hospital in Malawi over a period of four years. The median age at presentation was eight years (1 to 18). There were 239 hospital admissions for treatment during the period of the study. In 117 patients one admission was necessary, in 35 two, and in 15 more than two. A surgical strategy of infection control followed by reconstruction and stabilisation was employed, based on the Beit CURE radiological classification of chronic haematogenous osteomyelitis as a guide to treatment. At a minimum follow-up of one year after the end of the study none of the patients had returned to our hospital with recurrent infection. A total of 350 operations were performed on the 167 patients. This represented 6.7% of all children's operations performed in our hospital during this period. One operation only was required in 110 patients and none required more than three. Below-knee amputation was performed in two patients with chronic calcaneal osteomyelitis as the best surgical option for function. The most common organism cultured from operative specimens was Staphylococcus aureus, and the tibia was the bone most commonly affected. Polyostotic osteomyelitis occurred in four patients. We believe this is the largest reported series of patients treated for chronic haematogenous osteomyelitis.

Garré's chronic diffuse sclerosing osteomyelitis of the sacrum: a rare condition mimicking malignancy

Garré's chronic diffuse sclerosing osteomyelitis (DSOM) is a rare disease that occurs most commonly in the mandible. We present a case of sacral DSOM that simulated an expanding destructive sacral tumour. Treatment was conducted on the basis of the available experience with the mandibular form of the disease, with partial symptomatic relief, but progressive sclerosis of the sacral lesion. To the best of our knowledge, this is the first case initially presenting in the sacrum. As an osteolytic expanding lesion simulating malignancy, it is important to recognize this entity in the sacrum.

Treatment with infliximab: Implications in oral surgery?

Infliximab is a tumour necrosis factor-alpha (TNF-alpha) inhibitor (neutralising antibody), which is increasingly being used as an immunosuppressant to manage inflammatory conditions including rheumatoid arthritis, ankylosing spondylitis and Crohn's disease. Its side effects include diabetes mellitus, an increased incidence of lymphoma and greater susceptibility to infections such as pulmonary tuberculosis. In patients on infliximab, the oral cavity may act as a bacterial reservoir leading to unwanted local or systemic complications. To date no report describes the potential implication/s of infliximab in patients having oral surgery. This case report may be the first in the English language to report the development of mandibular osteomyelitis after surgical extraction in a patient on infliximab.

A new method of monitoring osteomyelitis

Chronic infections of bone such as osteomyelitis are frequent events, especially in immunocompromised or diabetic patients, and costly on a national level. Incorrect treatment or delayed diagnosis may lead to loss of the affected extremity or mandible. The aim of this study was to assess the possible value of urinary lysylpyridinoline (LP) and hydroxylysylpyridinoline (HP) concentrations in the monitoring of mandibular osteomyelitis. Patients were assigned to the following groups: group 1 (n=85), control; group 2a (n=38), patients with active disease; group 2b (n=25), patients of group 2a 6 months after successful treatment; group 2c (n=7), patients of group 2a with ongoing osteomyelitis 6 months after treatment. The range and upper limit of normal values (HP(max) and LP(max)) were determined in group 1. Levels of LP and HP were measured by high-performance liquid chromatography and fluorescence detection. There was a significant decrease (mean 45.43% for HP and 32.12% for LP) in samples of group 2b compared to 2a (P<0.001 for HP and LP). There was a significant increase in HP values in samples from group 2c compared to 2a (P=0.018). The urinary concentrations of HP and LP appear to act as a marker of disease activity, with a decrease reflecting treatment success and an increase or stable values indicating persistent disease. An inexpensive tool (US$5 per analysis) for the monitoring of osteomyelitis is described.

Diagnosis and classification of mandibular osteomyelitis

To establish a unified classification system for mandibular osteomyelitis, various diagnostic terms were critically assessed and clinicopathologic findings of the lesions were carefully reviewed. We recommend classifying mandibular osteomyelitis into bacterial osteomyelitis and osteomyelitis associated with the synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome. Other diagnostic terms were excluded because they were not appropriate for classification. Diagnostic criteria for bacterial osteomyelitis are suppuration and osteolytic change. The lesions are easily cured by antibiotic treatments. Mandibular osteomyelitis in SAPHO syndrome is characterized by nonsuppuration and a mixed pattern on radiography, with solid type periosteal reaction, external bone resorption, and bone enlargement. The presence of osteomyelitis in other bones, arthritis, or skin diseases (palmoplantar pustulosis, pustular psoriasis, and acne) strongly suggests this syndrome. Antibiotic therapy is usually ineffective and the symptoms of SAPHO syndrome are often persistent.

Florid cemento-osseous dysplasia and chronic diffuse osteomyelitis Report of a simultaneous presentation and review of the literature

BACKGROUND

Infection, neoplasia and bone dysplasias cause alteration in bone architecture. Florid cemento-osseous dysplasia (FCOD) and chronic diffuse osteomyelitis (CDO) are two independent disease processes that may have overlapping clinical and radiographic characteristics. Differential diagnosis can be crucial, as the course of each process and its clinical management varies.

CASE DESCRIPTION

A patient reported to the oral and maxillofacial radiology clinic at the University of Medicine and Dentistry of New Jersey's New Jersey Dental School with a complaint of chronic pain in the mandible. One of the authors (S.R.S.) obtained a panoramic radiograph. Later, the patient underwent computerized tomographic examination and biopsy. On the basis of the clinical, radiographic and histopathologic examinations, the authors made diagnoses of CDO and FCOD. The bilateral presentation of CDO along with the simultaneous presence of FCOD and these conditions' vivid radiographic appearances make this case highly unusual.

CLINICAL IMPLICATIONS

Multiple, simultaneous processes can yield an atypical radiographic appearance seen on routine radiographic examinations. Characteristics unique to each process are used to make the differential diagnoses. FCOD can make the mandible more susceptible to osteomyelitis.

Use of antibiotic impregnated polymethylmethacrylate beads for the treatment of chronic mandibular osteomyelitis in a Bennett's wallaby (Macropus rufo-griseus rufogriseus)

Antibiotic impregnated polymethylmethacrylate beads were surgically implanted into the mandible of an adult Bennett's wallaby (Macropus rufogriseus rufogriseus) suffering from chronic mandibular osteomyelitis that had proven refractory to systemic antibiotic treatment. Although a discrete inflammatory mass remained, clinical signs of inappetance and a discharging sinus were alleviated following implantation of the beads. This procedure resulted in a more satisfactory outcome than other methods of treatment used previously for this condition and avoided the problems associated with regular handling and prolonged medication.

Use of an orthopaedic fixator for external fixation of the mandible

A patient presented with a chronically infected, non-united fracture of the mandible, with considerable bone loss. He was treated with a metacarpal fixator, the miniPennig external fixator. The fixator is stable and smaller than conventional mandibular fixators. It can be applied and removed under local anaesthesia, if necessary, requires little maintenance and produces minimal scarring. The successful outcome in this patient is encouraging and we commend the use of the fixator in similar difficult cases.

Acne with chronic recurrent multifocal osteomyelitis involving the mandible as part of the SAPHO syndrome: case report

For 12 years, a 26-year-old man had acne conglobata and a non-suppurative diffuse sclerosing osteomyelitis of the mandible as part of a chronic recurrent multifocal osteomyelitis of the sternum, the pelvic bones, and the femoral head, and aseptic arthritis of the knee, the fibulotalar, and the sternoclavicular joints. This fulfills the formal criteria of the SAPHO syndrome. Repeated surgical and antibiotic treatment combined with hyperbaric oxygen caused partial improvement. Complete relief and partial disappearance of the scintigraphic lesions was achieved with long-term corticosteroids, non-steroidal anti-inflammatory drugs, minocycline, and isotretinoin.

Diffuse sclerosing osteomyelitis and florid osseous dysplasia

The literature on diffuse sclerosing osteomyelitis of the mandible has included at least two groups of lesions: (1) those from which bacterial infectious agents are rarely isolated (chronic-tendoperiostitis); and (2) those from which bacteria are readily isolated (true diffuse sclerosing osteomyelitis). The latter should be distinguished from secondarily infected florid osseous dysplasia. In this article the features of 16 patients with sclerotic jawbone lesions associated with symptoms of infection are analyzed. Eleven patients showed a large area of sclerosis of the mandible that was not restricted to the alveolar process and was surrounding an infectious focus. The histologic pattern revealed a deposition of reactive bone. These lesions are considered to represent true diffuse sclerosing osteomyelitis. The remaining five patients showed sclerotic lesions restricted to the alveolar process in one or more quadrants of the jaws. Apart from inflammation and reactive changes, histologic pattern revealed a fibroblastic stroma with bone and cementum-like structures that are formed by metaplasia. These lesions are considered to represent secondarily infected florid osseous dysplasia.

Chronic sclerosing osteomyelitis of the mandible in monozygotic twins

Identical female twins with chronic sclerosing osteomyelitis of the mandible are presented. The diagnoses of both at the age of 12 years were based on typical history, and on clinical, radiographic, and histologic findings. High concentrations of IgA and IgG were detected in the serum of both patients, but deviations were not observed in other immunologic variables. The normally commensal organism, Propionibacterium acnes grew from a bone biopsy specimen from the mandible of one twin. No oral focus of the disease was confirmed in either case. We suggest that hereditary factors must have played a role in the pathogenesis of these cases of chronic osteomyelitis.

Decortication in the treatment of diffuse sclerosing osteomyelitis of the mandible. Retrospective analysis of 41 cases between 1969 and 1990

Thirty-four patients with mandibular diffuse sclerosing osteomyelitis who had been treated by means of 61 decortications were evaluated retrospectively. Eighteen patients (53%) were free from symptoms on an average of 5.4 years after surgery. Of these, 12 had improved after their first operation. In the other six patients, decortication was performed two to four times before healing was clinically observable. Symptoms recurred in 75% of the cases within 12 months after surgery. Neither sex, location, extent, and chronicity of the disease nor the precise surgical technique used seemed to affect the outcome. The patients who exhibited improvement, however, were significantly older and more often edentulous than the patients in whom the symptoms recurred. Possible causes of failure were an insufficiently radical surgical procedure and retention of devitalized teeth in the decorticated area.

Gingivitis/stomatitis in cats

Any alteration in the balance of bacterial challenge versus the host's ability to resist and repair will result in oral lesions that are similar in appearance. The bacterial cause of gingivitis and periodontitis in humans and in all other animals in which it has been studied is firmly established, and specific species of predominantly gram-negative anaerobes have been implicated. Naturally occurring or acquired immunopathologies are likely to result in premature dental disease. When oral disease is associated with the accumulation of plaque, a positive response can be achieved by reducing the bacterial challenge to the host through the maintenance of oral hygiene by timely professional dental prophylaxis and home care. Disease that is the result of atypical immune responses, however, can be much more difficult to manage. Such oral disease can occur with either immune deficiencies or exaggerated immune responses, and it is likely that multiple mechanisms are active concurrently. In any case, gram-negative anaerobes present in plaque are likely to be a major contributing factor. Therefore patients with chronic refractory gingivitis-stomatitis must be considered to be plaque intolerant. Only with a frequent regimen of aggressive and thorough professional dental treatment plus meticulous oral home care on a daily basis can one expect to keep these cases in remission. Because this is often unrealistic, the only other way to keep these patients free of disease is by total dental extraction. The tissues that are colonized by the causative organisms must be eliminated. All root tips and bony sequestra must be removed and healing with intact epithelium accomplished before these cases will go into remission. Edentulous feline patients that continue to have signs of gingivostomatitis have been found to have an area of nonhealed bony sequestrum and chronic osteomyelitis. Once effective debridement has been accomplished and epithelial healing completed, nonresponsive cases can be expected to go into remission (Color Plate 2, Figure 7). It is hoped that as more is learned about this frustrating problem, the many factors influencing feline oral disease will be scientifically documented. In the future, actual diagnoses can be systematically made early on in disease, and treatment will be more than just symptomatic.