Sales Training 2014 - Dentistry

Infections, Injury to Bone and Maxillary Sinus Disorders

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or infection characterised by a localised, hard, non- tender, unilateral bony swelling. The disease occurs primarily in children and young adults and occa- sionally in older individuals. The swelling of several weeks duration is situated on the lateral and inferior aspects of the mandibular molar and bicuspid regions. The skin overlying the lesion is normal. Lymphadenopathy, fever and leu- kocytosis usually do not occur. Proliferative periostitis is commonly associated with a carious lower first molar tooth and a past history of toothache. Occasionally, no dental cause is detectable (Table 15.1). RADIOGRAPHIC FEATURES Radiograph shows a focal, well-calcified area of the bone without radio- lucent border. Radiolucency may be associated with the apices of the teeth. In occlusal radiograph, the lesion appears as an area of radiopacity with thin layers of new bone for- mation giving an onion-skin appearance (Table 15.1). DIFFERENTIAL DIAGNOSIS The condition has to be differentiated from syphilis (gumma of the bone in tertiary syphilis), congenital syphilis (irregular thickening of the sternal head of the clavicle in 30% of cases and sabre skin in 4% cases), leukaemia, hypervitaminosis A (fragmentation of the distal fib- ular epiphysis and marked periosteal thickening), fracture (callus) and infantile cortical hyperostosis (asymmetric and multifocal periosteal new bone). HISTOPATHOLOGIC FEATURES The tissue is com- posed of new bone, osteoid with many trabeculae bordered by osteoblasts. Most trabeculae are arranged parallel to each other and at right angle to the cortex separated by fibrous connective tissue. TREATMENT The lesion does not require treat- ment generally.When required, treatment is directed towards the eradication of identifiable sources of inflammation. When the affected tooth is not restor- able, extraction is indicated. Chronic Sclerosing Osteomyelitis The two distinct types are chronic diffuse sclerosing osteomyelitis which affects only the mandible and

Figure 15.3 A panoramic radiograph mottled radiopacity indicating chronic suppurative osteomyelitis of the right body of the mandible with pathological fracture (arrow).

Box 15.1 Antibiotic regimen for osteomyelitis of jaws

Regimen I: For hospitalised/medically com- promised patient or when IV therapy is indicated • Aqueous penicillin, 2 million IV every 4 hours, plus metronidazole 500mg every 6 hours • On improvement, for 48–72 hours switch over to – Penicillin V 500mg PO every 4 hours, plus metronidazole 500mg PO every 6 hours, for an additional 4–6 weeks or – Ampicillin/sublactam (unasyn), 1.5–3.0g IV every 6 hours • On further improvement, for 48–72 hours switch over to – Amoxicillin clavulanate (augmentin), 875/125mg two times a day, 4–6 weeks or more Regimen II: For outpatient treatment • Penicillin V 2 g plus metronidazole 0.5 PO every 8 hours, for 2–4 weeks after last sequestrum has been removed and the patient is without symptoms or • Clindamycin 600–900mg IV every 6 hours, then clindamycin 300–450mg PO every 6 hours or • Cefoxitin (mefoxin) 1g IV every 8 hours or 2g IMor IV every 4 hours until no symptoms present, then switch over to cephalexin 500mg PO every 6 hours, for 2–4 weeks.

is also known as Garre’s chronic non-suppurative sclerosing osteomyelitis or periostitis ossificans . CLINICAL FEATURES Chronic osteomyelitis with proliferative periostitis is a response to mild irritation

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