Acute and Chronic Suppurative Osteomyelitis of the Jaws: A 10-Year Review and Assessment of Treatment Outcome

Identifying Risk Factors Associated with Major Complications and Refractory Course in Patients with Osteomyelitis of the Jaw: A Retrospective Study

Despite improved knowledge regarding the diagnosis and treatment of osteomyelitis of the jaw (OMJ), it remains a clinical challenge for oral and maxillofacial surgeons. This study aimed to identify risk factors associated with severe forms of OMJ, i.e., related to the occurrence of major complications or the refractory course of the disease. A retrospective study was performed based on the medical records of all patients diagnosed with OMJ from the past 20 years. Collected data included demographic information, medical and dental history, clinical, radiological, and bacterial findings as well as treatment modalities. The main outcome variables were the onset of major complications and treatment results. Fifty-four patients were included. Our results showed that alcohol and smoking habits, as well as malnutrition, were significantly associated with the occurrence of major complications. We also established that dental implant-induced OMJ should be considered an aggressive subtype of OMJ. Finally, clinical bone exposure was significantly associated with unfavorable outcomes, whereas dental causes or radiological evidence of periosteal reaction were predictive of successful outcomes. Identifying such factors could be useful in preventing serious complications and informing patients about the refractory course of the disease based on the presence of these factors.

Recurrent chronic suppurative osteomyelitis in the maxilla of a patient with diabetes mellitus and glucose-6-phosphate dehydrogenase deficiency

AIMS

To report the case of chronic osteomyelitis of a maxilla in a woman with uncontrolled diabetes mellitus (DM), glucose-6-phosphate dehydrogenase (G6PD) deficiency and mental illness, in an attempt to clarify its pathogenesis and treatment.

METHODS AND RESULTS

A case of a woman with moderate G6PD deficiency (Class III) who developed bilateral and asynchronous chronic suppurative osteomyelitis (CSO) of her maxilla with extensive bone sequestra, fistulae and whose management was performed by local surgery for bony sequestra and fistulae removal; closure communication under 4 weeks antibiotic cover.

CONCLUSIONS

CSO of the jaw may be a complication of the G6PD deficiency and DM and its severity depends on patient's medical status.

Prophylactic Effects of NFκB Essential Modulator–Binding Domain Peptides on Bone Infection: An Experimental Study in a Rabbit Model

Introduction

Methods

Results

Conclusion

Monitoring jaw osteomyelitis therapy with single-photon emission computed tomography/computed tomography

OBJECTIVE

The aim of the study was to evaluate the value of single-photon emission computed tomography/computed tomography (SPECT/CT) for therapy response assessment of jaw osteomyelitis.

MATERIALS AND METHODS

Thirty-four baseline and 74 follow-up SPECT/CT examinations for therapy response assessment were performed in 34 patients with jaw osteomyelitis. SPECT/CT and planar late-phase bone scintigraphy images were assessed at baseline and follow-up, according to the following criteria: tracer uptake grade (0 = no uptake, 1 = low uptake, 2 = moderate uptake and 3 = high uptake); and morphologic signs (osteolysis, sequestration, sclerosis, periosteal reaction and pathologic fracture).

RESULTS

At baseline, SPECT/CT showed marked (grade 2 or 3) uptake in 91% (31/34) of the patients, osteolysis in 85% (29/34), sclerosis in 71% (24/34), periosteal reaction in 44% (15/34) and a sequestrum in 24% (8/34). In 24 patients with clinically complete remission during or after at least 12 months' therapy, bone scintigraphy showed grade 0 or 1 uptake in 100% (24/24) and SPECT/CT in 91% (22/24) of the patients. Sclerosis with the disappearance of osteolysis, sequestration and periosteal reactions was the predominant morphologic finding in complete responders (68%; 16/24). In 10 patients with symptoms of exacerbation of the osteomyelitis, 80% (8/10) showed increasing uptake, 90% (9/10) sclerosis, 80% osteolysis (8/10) and 40% (4/10) osteolysis and periosteal reactions.

CONCLUSION

SPECT/CT is a valuable tool to accurately assess therapy response, disease exacerbation and complications of jaw osteomyelitis. Low-grade (grade 1) residual tracer uptake is common in patients with clinically complete remission and is suggestive of ongoing bone remodeling and healing.

Treatment and Clinical Outcomes of Osteoarticular Infections Among Pediatrics Admitted to Jimma University Medical Center, Ethiopia: A Prospective Observational Study

BACKGROUND

Despite the high burden of osteoarticular infections in sub-Saharan Africa, there is a paucity of data regarding the osteoarticular infections management approach and clinical outcomes in the region. Hence, this study aimed to evaluate a management protocol, clinical outcomes, and its determinants among pediatric patients with osteoarticular infections.

METHODS

A pediatric patient admitted to Jimma University Medical Center (JUMC), Ethiopia, with a diagnosis of osteoarticular infections was enrolled prospectively from April 30 to October 30, 2019. Clinical characteristics, management modality, and in-hospital complications were recorded from admission to discharge. Data were analyzed by using SPSS v.23 and the p-value <0.05 was considered statistically significant.

RESULTS

Among a total of 150 pediatric patients enrolled in this study, osteomyelitis was diagnosed in 111 (74%), while the rest 39 (26%) had septic arthritis. The majority 105 (70%) of the study participants were male with a mean age of 8.79 ± 4.2 years. The culture was performed for only 3.6% of the patients. Almost all (98.7%) of the patients received intravenous (IV) antibiotics, and ceftriaxone was the most common IV antibiotic used as a monotherapy 66 (44.6%) or in combination with metronidazole 47 (31.8%) or gentamicin (12.8%). Almost half (45.3%) of the patients had poor treatment outcomes. Factors associated with poor treatment outcome were comorbidity [AOR=3.3, 95% CI (1.08-10.16)] and use of combination antibiotics [AOR=2.9, 95% CI (1.16-7.3)]. Rural residence [AOR=0.39, 95% CI (0.168-0.92)] and surgical interventions [AOR=0.29, 95% CI (0.006-0.144)] were associated with good treatment outcomes.

CONCLUSION

Almost half of pediatric patients with osteoarticular infections had poor treatment outcome. Health providers should increase the accessibility of microbiological tests and diagnostic imaging, which can guide treatment decisions and improve outcomes of patients with osteoarticular infections.

[Imaging features of osteomyelitis of the jaws with different diagnostic methods. A review]

Osteomyelitis of the jaws (OM) is an infectious pathology involving the bone marrow. It is due to various etiologies, the main one being odontogenic. The diagnosis of OM is a challenge for dentists, who must rely on clinical and imaging examinations. Panoramic radiography is the most frequently used imaging test, but it has some limitations that have improved with the incorporation of new imaging methods such as computed tomography, cone beam computed tomography, magnetic resonance imaging, and bone scintigraphy with radionuclides. The purpose of this review was to describe the imaging characteristics of OM of the jaws according to the radiological diagnostic methods available in the literature in order to provide radiologisst with greater knowledge and improve reporting in daily practice.

Decompressive effects of draining tube on suppurative and sclerosing osteomyelitis in the jaw

Background

Osteomyelitis (OM) in the jaw is an inflammatory disease of osseous tissue that begins in the medullary space and progressively expands to the cortical portion of the bone, the Haversian system, the periosteum and the overlying soft tissue. Despite advances in dental and medical care, OM persists and is of important concern in modern medicine. Active negative pressure is known to prevent post-operative hematoma; decrease the number of bacterial pathogens, accumulation of toxins, and necrotic tissue; and promote osteogenesis and angiogenesis with the use of a draining tube such as the Jackson-Pratt (JP) or Hemovac. The purpose of this study was to assess the effectiveness of decompression for the treatment of OM in the jaw.

Methods

This retrospective study included a total of 130 patients, 55 patients with sclerosing OM and 75 patients with suppurative OM were included. The radiographic bone densities expressed as a grayscale values (GSVs), were measured using an easy digitalized panoramic analysis (EDPA) method, processed on the conditional inference tree, generated by the R program® 3.2.3 with a probability of 96.8%. Rectangle annotation analysis of INFINITT PACS® (INFINITT Healthcare, Seoul, Korea) of 50 mm² was determined as the region of interest (ROI). Student’s t-test and ANOVA were used to determine significance (p < 0.05).

Results

Significant changes was observed between radiographic bone density in the sclerosing type with drain and without drain at the six-month and one-year follow-up (p < 0.05). Significant difference was demonstrated between the suppurative OM with drain and without drain groups at the one-year follow-up (p < 0.05).

Conclusion

The OM groups with drain exhibited more enhanced bone density compared to the groups without drain at the six-month and one-year follow-ups. The drain insertion for decompression is effective for the management of sclerosing and suppurative OM. It is recommended to implement it for the management of OM.

Degloving Approach for the Management of Extensive Mandibular Osteomyelitis

ABSTRACT

Extensive osteomyelitis of the mandible is usually managed using elaborate procedures including resection and reconstruction of the affected part of the mandible. This brief clinical report, the authors present a case of 75-year old male with extensive osteomyelitis of the mandible, incidentally diagnosed with anemia of chronic disease and Type I diabetes mellitus and managed using an intraoral degloving approach exclusively. This has proved to be a procedure ensuring better blood supply, decreased morbidity, precluding an elaborate reconstruction procedure and an overall reduction in cost. The advantages, scientific basis, rationale and pitfalls have been discussed briefly.

Are Oral Antibiotics an Effective Alternative to Intravenous Antibiotics in Treatment of Osteomyelitis of the Jaw?

PURPOSE

To review treatment of osteomyelitis of the jaw (OMJ) and determine whether antibiotic route and/or length of administration impacts resolution of infection postsurgically.

METHODS

The investigators designed a retrospective cohort study enrolling a sample of patients treated at Harborview Medical Center from January 1, 2009 to December 31, 2019. The primary predictor variable was antibiotic administration route: oral (PO) only, intravenous (IV) only, IV transitioned to PO (IV + PO), or none. The secondary predictor was duration of antibiotic therapy (≤6 weeks or >6 weeks). The primary outcome variable was resolution of infection at 2 months follow-up posttreatment completion. The secondary outcome variable was number of surgeries to resolution of infection. Descriptive, bivariate, and multiple linear regression statistics were computed, with statistical significance set at P < .05.

RESULTS

Sixty-seven individuals met inclusion criteria (38 male), mean age 51 years (18 to 88). Forty-nine (73%) received PO antibiotics, 12 (18%) IV + PO, 3 (4%) IV, and 3 (4%) none. Both PO and IV antibiotics were associated with clinical resolution (P = .022, .005, respectively) compared with debridement alone. Antibiotic duration of ≤6 weeks compared with >6 weeks was not significant. Seventy-six percent (51 of 67) required only 1 surgery. In the multivariate logistic regression, PO was associated with clinical resolution (P = .025, OR = 5.05). Penicillin allergy (P = 0.049, OR = 0.223) and diabetes (P = .008, OR = 0.104) were adversely associated with outcome.

CONCLUSIONS

OMJ was successfully treated with oral antibiotics and surgery. Prescribing 6 weeks of IV antibiotics may be antiquated. Clinicians should consider oral penicillins as first line whenever possible. Further studies are recommended.

Development of osteomyelitis following dental abscesses-influence of therapy and comorbidities

OBJECTIVES

Bacterial osteomyelitis of the jaw is a severe disease potentially requiring extensive surgical treatment. We have evaluated the incidence rates of bacterial osteomyelitis following dental abscessation associated with primary or secondary tooth extraction.

MATERIALS AND METHODS

A retrospective cohort study was designed and included patients with dental abscesses and surgical treatment including the extraction of focus teeth. Patients were either treated with primary removal during acute infection or secondary delayed extraction within an infection-free interval. The primary outcome variable was the occurrence of bacterial osteomyelitis following the abscess. Secondary outcomes were the influence of general disease, antibiotic therapy, and surgical technique.

RESULTS

One hundred nine patients were enrolled in the study; 4 patients (3.7%) developed osteomyelitis. Primary tooth extraction was performed on all these patients (p = 0.017). Significant associations of diabetes (p = 0.001), the use of clindamycin (p = 0.025), and transcutaneous incision (p = 0.017) with the incidence of osteomyelitis were detected.

CONCLUSIONS

More severe infections may be associated with a higher risk for the development of osteomyelitis following dental abscesses. A history of diabetes and clindamycin therapy might form further predisposing risk factors. Because of the low incidence and the small case number, our data need to be interpreted carefully.

CLINICAL RELEVANCE

Osteomyelitis of the jaw is a rare but severe disease that may require extensive therapy and that impairs the quality of life of affected patients. The evaluation of risk factors to enable further reduction of incidence is therefore urgently required.

Coagulase-negative staphylococci (CoNS) as a significant etiological factor of laryngological infections: a review

This review article shows that coagulase-negative staphylococci (CoNS) are widely responsible for laryngological diseases. General characteristics of CoNS infections are shown in the introduction, and the pathogenicity in terms of virulence determinants, biofilm formation and genetic regulation mechanisms of these bacteria is presented in the first part of the paper to better display the virulence potential of staphylococci. The PubMed search keywords were as follows: CoNS and: nares infections, nasal polyps, rhinosinusitis, necrosing sinusitis, periprosthetic joint infection, pharyngitis, osteomyelitis of skull and neck bones, tonsillitis and recurrent tonsillitis. A list of laryngological infections and those related to skull and neck bones was presented with descriptions of the following diseases: rhinosinusitis, necrotizing sinusitis, nasal polyps, nares and nasal skin infections, periprosthetic joint infections, osteomyelitis, pharyngitis, and tonsillitis. Species identification and diagnostic problems challenging for diagnosticians are presented. Concluding remarks regarding the presence of CoNS in humans and their distribution, particularly under the effect of facilitating factors, are mentioned.

Extirpative Cultures Reveal Infectious Pubic Bone Osteomyelitis in Prostate Cancer Survivors With Urinary-Pubic Symphysis Fistulae (UPF)

OBJECTIVE

To examine the infectious features of patients with urinary pubic symphysis fistula (UPF) and their association with osteomyelitis.

METHODS

We conducted a review of our quality improvement database for 36 patients with UPF undergoing bone resection and extirpative surgery from October 2012 to January 2019. An assessment of bone and urine cultures was carried out along with surgical, radiologic, and demographic data. We analyzed descriptive statistics and used Fisher Exact Tests and unpaired Welch t tests to assess for associations with positive bone cultures.

RESULTS

In our cohort, 33 patients (91.7%) had positive bone cultures with the 3 most common organisms being candida (22.0%), enterococcus (18.0%), and pseudomonas (10.0%). There was a correlation between positive preoperative urine culture and positive bone culture (P <.01), with 63.0% of those with positive urine cultures growing the same organism on bone culture.

CONCLUSION

In this series, 91.7% of patients undergoing extirpative surgery for UPF at our institution have positive bone cultures at time of pubic bone debridement. Additionally, we demonstrate a statistically significant correlation between positive urine cultures and positive bone cultures in these patients. This supports the need for a multidisciplinary approach including infectious disease, orthopedic surgery and reconstructive urology in order to address this complex clinical condition.

Diagnostic Performance of CT-Guided Bone Biopsies in Patients with Suspected Osteomyelitis of the Appendicular and Axial Skeleton with a Focus on Clinical and Technical Factors Associated with Positive Microbiology Culture Results

PURPOSE

To assess diagnostic performance of CT-guided percutaneous needle bone biopsy (CTNBB) in patients with suspected osteomyelitis and analyze whether certain clinical or technical factors were associated with positive microbiology results.

MATERIALS AND METHODS

All CTNBBs performed in a single center for suspected osteomyelitis of the appendicular and axial skeleton during 2003-2018 were retrospectively reviewed. Specific inclusion criteria were clinical and radiologic suspicion of osteomyelitis. Standard of reference was defined using outcome of surgical histopathology and microbiology culture and clinical and imaging follow-up. Technical and clinical data (needle size, comorbidities, clinical factors, laboratory values, blood cultures) were collected. Logistic regression was performed to assess associations between technical and clinical data and microbiology biopsy outcome.

RESULTS

A total of 142 CTNBBs were included (46.5% female patients; age ± SD 46.10 y ± 22.8), 72 (50.7%) from the appendicular skeleton and 70 (49.3%) from the axial skeleton. CTNBB showed a sensitivity of 42.5% (95% confidence interval [CI], 32.0%-53.6%) in isolating the causative pathogen. A higher rate of positive microbiology results was found in patients with intravenous drug use (odds ratio [OR] = 5.15; 95% CI, 1.2-21.0; P = .022) and elevated white blood cell count ≥ 10 × 10⁹/L (OR = 3.9; 95% CI, 1.62-9.53; P = .002). Fever (≥ 38°C) was another clinical factor associated with positive microbiology results (OR = 3.6; 95% CI, 1.3-9.6; P = .011).

CONCLUSIONS

CTNBB had a low sensitivity of 42.5% for isolating the causative pathogen. Rate of positive microbiology samples was significantly higher in patients with IV drug use, elevated white blood cell count, and fever.

Evaluation of the bactericidal effect of cold atmospheric pressure plasma on contaminated human bone: an in vitro study

The use of cold atmospheric pressure plasma (CAPP) as a bacterial decontaminant for chronic wounds has shown good results. The purpose of this in vitro study was to evaluate the bactericidal effects of CAPP on the cancellous area of the bone. Sterile glass slides and processed sterile human bone allografts 1, 2, 3, and 4mm thick were used for initial contamination and further CAPP treatment. Each block was contaminated with Staphylococcus aureus suspension on one side. Each slide was turned 180° and treated on the reverse side. The bacterial count in colony-forming units (CFU) was then measured and compared with that of a control group, and the bactericidal effects of CAPP in relation to bone density evaluated. A significant reduction in count was measured between treated and untreated groups (groups A-D: p<0.01 and group E: p=0.04). A strong positive linear relation was found between bone density and the S aureus count (r=0.844, p=0.156). Treatment with CAPP had a bactericidal effect on bone structures with a penetration depth of up to 4mm. It might be used for all diseases involving infected bone, and so extends the existing range of treatments.

Differential Diagnosis of Periapical Radiopacities and Radiolucencies

Periapical pathoses represent changes noted at the apices of teeth within the alveolar process that are suspected on examination, visualized via imaging, and confirmed via histopathology. They can be bone forming or destructive. There are pathologic entities that show both types of changes at the apical regions. These lesions must be identified if they are odontogenic in origin because treatment modalities differ. This article discusses identification of radiopaque and radiolucent lesions noted on radiographs. The common opacities and lucencies are described. When required, advanced imaging is used to depict changes within the bone near the periapical regions of mandibular and maxillary teeth.

Septic arthritis of the temporomandibular joint: Case series and literature review

Background: Septic arthritis of the temporomandibular joint (SATMJ) is a relatively uncommon condition in the adult population and can result in significant morbidity. This study reviewed seven cases of SATMJ, including their management and complications.Clinical Presentation: A retrospective study was performed on seven cases that developed SATMJ documented from 2011 to 2017. Seven cases demonstrated SATMJ that resulted in joint destruction and complications, such as mandibular osteomyelitis, vertebral osteomyelitis, bone erosion, ankylosis, and death. The management of these seven cases was presented, as well as the treatment outcomes.Clinical Relevance: SATMJ should be treated aggressively, as it may cause severe damage to the TMJs and adjacent tissues, which could lead to loss of function, malocclusion, and potentially fatal complications.

Infected Cemento-Osseous Dysplasia: Analysis of 66 Cases and Literature Review

The aim of this study was to describe a series with 66 cases of infected cemento-osseous dysplasia (COD) and to discuss the demographic distribution, clinicoradiographic features and treatment of this condition. A study looking back on the diagnoses made at a single Brazilian centre within a 28-year timeframe was performed. A literature review with searches across five databases was also conducted to identify reports on osteomyelitis/infected COD. Descriptive and statistical analyses were performed. The case series study showed a female/male ratio of 21:1. Affected individuals' mean age was 57.4 years. Mandible was the most affected site (95.5%) and florid subtype was the most frequent infected COD (62.1%). Tooth extraction was the main factor associated with the development of infection associated within a COD lesion. The literature review retrieved 30 studies reporting 46 cases of this condition. Asian women in their 40 s and 50 s were more affected. Surgery for removal/curettage of necrotic bone was acknowledged as an appropriate approach to the treatment of this infection. The clinicodemographic data of the study were similar to data collected across the literature. Clinicians, maxillofacial surgeons and oral rehabilitation providers should be alert to the diagnosis of COD, since infection is a frequent complication whose management is challenging.