 Hello everyone, welcome back to OMFS lecture series. In this lecture we shall discuss the management of jaw osteomyelitis. So there are a certain goals that we need to achieve while managing a case of osteomyelitis. Those goals are to attenuate and eradicate proliferating pathological organisms to promote healing and to re-establish the vascular permeability. You know that the vascular supply to the infected bone is compromised, so it is important to re-establish the blood supply to the bone. The Marx protocol for treatment of osteomyelitis include the following to disrupt the infectious foci, debridement, culture and identification of specific pathogens, drainage and irrigation of the region, adjunctive treatments like profanation and decortication in order to enable microvascular reperfusion and reconstruction. These are the treatment guidelines given by Marx in the year 1992. Therefore for a successful treatment following principles are considered. Early diagnosis, a bacterial culture and sensitivity testing, adequate antibiotic therapy and pain control, proper surgical intervention followed by reconstruction. Management of osteomyelitis can be divided into conservative and surgical management. Complete bed rest is advised to the patient followed by supportive therapy which includes nutritional support in the form of high protein and high caloric diet and also adequate multivitamins has to be supplemented. The patient has to be kept rehydrated orally or through administration of IV fluids. Blood transfusion is performed in case the RBCs and hemoglobin count is low. Pain is controlled with analgesics sedation may be also employed for keeping the patient comfortable and to allow to sleep. Here is the recommended antibiotic regimens for osteomyelitis of jaws. Antibiotic of first choice or regimen 1 is penicillin which is considered as an empirical therapy. So you may administer aqueous penicillin 2 million units intravenously every 4 Re or oxacillin 1 gram IV every 4 Re. Once the patient has been asymptomatic for 48 to 72 hours then you may switch to penicillin V orally 500 mg which is given every 4 Re. Also, Dytaloxacillin 250 mg orally every 4 Re for 2 to 4 weeks may be administered. Regimen 2 is based on the culture and sensitivity results. Penicillin is resistant to penicillins like oxacillin, loxacillin, Dytaloxacillin or Fluoxoxacillin may be given. Glendamycin is the second choice antibiotics which is effective against penicillinase producing stephalococcal, streptococcal and anaerobic bacteria including bacteroids. This is used because of its ability to diffuse widely in the bone. It is not recommended as first choice because it is bacterial static and can cause diarrhea due to pseudomembraneous colitis. Cifazolin or Cifalexin is the third choice of antibiotics in osteomyelitis. It is effective against most cocci including penicillinase producing stephalococci and gram negative aerobic bacillae. For example, E. coli, Klebsilla and Proteus. Cifalosporins are not recommended as first choice because they are moderately effective against anaerobes and also because of broad spectrum coverage. This increases the antibiotic complications like bacterial resistance and super infection. Therefore, Cifalosporins are third choice of antibiotics and not considered as a first choice antibiotic. The fourth choice is erythromycin. Again these drugs cannot be used as first choice because they are bactero static and rapidly develop resistance strains. So, this is regarding the antibiotic regimen used for osteomyelitis of jaw. In a non-healing case of osteomyelitis where it does not respond to antibiotics you may consider hyperbaric oxygen therapy. We know that the tissues are hypoxic as a blood supply has been cut off due to vascular collapse. So, basically HPO is supplying oxygen to the tissues devoid of it. How is HPO given? Hyperbaric oxygen therapy involves the intermittent usually daily inhalation of 100% humidified oxygen under pressure which is greater than one atmospheric absolute pressure. The patient is placed in a chamber and oxygen is given by mask. Each dive or exposure is 90 minutes in length. The treatment is given 5 days per week for 30 to 60 or more dives in a mono place chamber. So, understand that hyperbaric oxygen therapy is administering 100% oxygen at 2.488 for 90 minutes twice daily for 5 days per week. So, over the last several decades, HPO therapy has emerged as a potential alternative to surgical reperfuration. What are the beneficial aspects of hyperbaric oxygen therapy? HPO therapy enhances the lysosomal degradation by the defense mechanism of the body like the leukocytes and oxygen radical. The free radicals of oxygen which are supplied during the HPO therapy are toxic to many pathogenic anaerobes that means it is bactericidal. The exotoxins liberated by these organisms are also made inert by exposure to a high partial pressure of oxygen. The tissue hypoxia which is present at the site is intermittently reversed by HPO therapy. This will enhance the wound healing. And the positive enhancement of neo angiogenesis is another beneficial aspect of HPO therapy. Neo angiogenesis is nothing but the formation of new blood vessels. Therefore, the tissue hypoxic condition within the wound can be reversed and thus the wound healing is promoted. So, this is regarding the hyperbaric oxygen therapy. Moving on to the surgical management of jaw osteomyelitis. Surgical intervention is done under antibiotic coverage started at least one to two days prior to the procedure. The first step is incision and drainage. Incision and drainage should be done as soon as possible. It relieves the pressure and pain caused by the pus accumulation. Incision of abscess can be carried out intra-orally or extraordinarily depending upon the location. Evacuation of pus by drainage, lessens absorption of toxic products and prevents further spread of infection in the bone, thus helping in its localization. The second step is to extract the offending teeth. Sometimes drainage is achieved by extraction of the offending teeth. The third step is debridement. Followed by incision and drainage, thorough debridement of affected area should be carried out. The area may be irrigated with hydrogen peroxide and normal saline. Any foreign body, necrotic tissue or small sequestrum also should be removed at this stage. The next step you may consider is a decortigation, which is removal of chronically infected lateral and inferior cortical plates of bone one to two centimeter beyond the area of involvement. Thus you gain access to the bone medulla. Once the cortical plate is removed, you gain access to the medullary bone. So what are the steps in decortication? You first create a buckle flap by placing a crystal incision along the necks of the teeth. A mucoperiostal flap is reflected up till the inferior border of the mandible. The teeth in the involved area are removed, followed by removal of cortical plates, lateral and inferior to the involved area, preferably with a chisel. The bony bed is then thoroughly debrided and the flap is closed primarily. Any dead space can be eliminated by applying pressure bandage and also by placing irrigation tubes. So this is how decortication is performed. After decortication, two small tubes are placed against the bony bed through separate skin incisions and secured with sutures. One tube is connected to the low pressure suction to allow drainage of pus and the other is kept patent to provide a route through which locally antibiotics may be installed. So daily first saline irrigation has to be performed followed by antibiotic insulation and this is repeated until negative cultures are obtained. Systemic antibiotics are also continued for at least two to three months following cessation of clinical evidence of disease. The next step is sequestromy which is the removal of sequestra or the necrosis bone. This is an integral part of definitive therapy. This method helps in establishing a local micro vascular proliferation. This is undertaken through an intraoral or extraoral approach depending upon the site of sequestrum. So sequestra are usually cortical and may be cancerless or corpico-canceless. These are avascular and therefore poorly penetrated by antibiotics. Pathological fractures can also occur in the region of sequestra due to bone loss. So once a proper access has been gained through an intraoral or extraoral approach the contents are carefully cuted from this site until healthy bone is exposed to the view. So this is the method of sequestromy. Saucerization is the excision of margins of necrotic bone overlying a focus of osteomyelitis. This is useful in chronic form because it permits removal of the sequestra and enables a better visualization. It is performed with a large round bar and the buccal cortex is reduced to the level of unattached mucosa. Thus producing a saucer-like defect. So here the defect formed is a saucer-like and not a deep hollow cavity. Both sequestromy and saucerization are to be carried out after the acute phase has subsided. This enables a better defense mechanism of host and the host can overcome the virulence of organisms. Refination or fenestration is the creation of bony holes or windows in the overlying cortical bone adjacent to the infectious process. This is performed for the decompression of the medullary compartment. Drilling of holes into the cortex and thus reaching the medulla allow vascular communication between the pediosteum and the medullary cavity. When extensive portion of the bone is involved in the disease process then resection of the jaw bone is advocated. Following resection reconstruction is performed to maintain the continuity of the fragments to prevent pathological fracture, to prevent facial deformity and to provide attachment of the soft tissues. So this is regarding the surgical management of osteomyelitis. Following all the surgical steps post-operative care has to be considered. This includes continued use of antibiotics, analgesics and warm saline mouth rinses, adequate hydration, complete rest, removal of sequestra in case there are any in the alveolar part of the bone. The wound is then closed preferably primarily with a drain. So this is all about the surgical management of jaw osteomyelitis. Here is an extra oral clinical picture of a patient with uncontrolled diabetes mellitus. There are multiple draining sinuses with pus discharge for two years. This is the close up view of one of the draining sinuses. Incraoral picture showing the exposed sequestrum in the oral cavity. So after controlling the disease, surgical resection was planned. Hemimandibletomy was planned. And this is the surgical picture of resection of the hemimandibletomy. And this is the resected specimen. Several complications can occur as a result of osteomyelitis of jaw. With chronic osteomyelitis, neoplastic conversion of inflammatory metiaplasia to squamous cell carcinoma is noted. Therefore, neoplastic transformation is one of the complications of osteomyelitis. Another one is the discontinuity defect. The defects can be spontaneous or surgically induced. So this will necessitate jaw reconstruction once the infection is resolved. A third complication is the progressive diffused sclerosis. This condition involves the cortical and medullary portion of the maxillofacial skeleton over a period of time. So these are the complications associated with jaw osteomyelitis. Considering the prognosis of the condition, if proper, aggressive and comprehensive therapy is instituted on time, then the recovery of acute and chronic osteomyelitis is always good. But in cases of certain chronic osteomyelitis, which is associated with regional or systemic disease like microvascular or immunosuppressive disorders, then the treatment itself may be worse than the disease. So in these cases, attempt should be done to provide a long-term conservative therapy than any major surgical debrigment. So that's all regarding the management of osteomyelitis of jaw. Thank you.