From the Guidelines
Differential diagnoses and management of osteomyelitis, periodontal disease, purulent abscess, and chronic fibrous periostitis require targeted approaches based on the specific condition, with a focus on early diagnosis and intervention to prevent complications. The management of these conditions involves various strategies, including:
- Osteomyelitis: surgical debridement and drainage of associated soft-tissue abscesses is the mainstay of therapy 1, along with 4-6 weeks of antibiotics, such as vancomycin or ceftriaxone, and possibly hyperbaric oxygen therapy.
- Periodontal disease: management involves professional dental cleaning, scaling and root planing, daily oral hygiene with brushing and flossing, chlorhexidine mouthwash, and in severe cases, antibiotics like amoxicillin 1.
- Purulent abscesses: require incision and drainage as primary treatment, followed by culture-guided antibiotics, such as trimethoprim-sulfamethoxazole or clindamycin, for 5-10 days if systemic symptoms are present 1.
- Chronic fibrous periostitis: management focuses on treating the underlying cause, anti-inflammatory medications like ibuprofen, and in some cases, surgical intervention to remove fibrous tissue 1. It is essential to note that MRI with contrast is the examination of choice for the evaluation of suspected osteomyelitis 1, and imaging modalities like CT or labeled leukocyte scan and sulfur colloid marrow scan combination can be useful alternatives if MRI is contraindicated or extensive artifact from metal is present 1. In terms of diagnosis, a definite diagnosis of bone infection usually requires positive results on both histological and microbiological examinations of an aseptically obtained bone sample 1, and a probable diagnosis of bone infection is reasonable if there are positive results on a combination of diagnostic tests, such as probe-to-bone, serum inflammatory markers, plain X-ray, MRI or radionuclide scanning 1. Overall, the management of these conditions requires a multidisciplinary approach, with a focus on early diagnosis and intervention to prevent complications and improve patient outcomes.
From the Research
Differential Diagnoses
- Osteomyelitis: an inflammatory condition of bone secondary to an infectious process 2
- Periodontal disease: a localized, acute suppurative infection of the periodontium, which may not require antibiotics for resolution 3
- Purulent abscess: a localized collection of pus in the tissue, which can be a complication of periodontal disease or osteomyelitis
- Chronic fibrous periostitis: a condition characterized by inflammation of the periosteum, which can be a complication of osteomyelitis
Management Strategies
- Osteomyelitis: treatment should be based on clinical examination, radiographic interpretation, and experience, and may include antibiotics, surgical bony debridement, and further surgical intervention 3, 4, 2
- Periodontal disease: treatment may include antibiotics, surgical intervention, and supportive care 3
- Purulent abscess: treatment may include drainage of the abscess, antibiotics, and supportive care
- Chronic fibrous periostitis: treatment may include antibiotics, surgical intervention, and supportive care
Risk Factors
- Diabetes mellitus: increases the overall risk of acute and chronic osteomyelitis 5, 2
- Cardiovascular disease: increases the overall risk of acute and chronic osteomyelitis 2
- Clindamycin therapy: may be a predisposing risk factor for the development of osteomyelitis following dental abscesses 5
- Transcutaneous incision: may be a predisposing risk factor for the development of osteomyelitis following dental abscesses 5
Diagnostic Tools
- Bone biopsy and microbial cultures: offer definitive diagnosis of osteomyelitis 2
- Magnetic resonance imaging with and without contrast media: has a higher sensitivity for identifying areas of bone necrosis in later stages of osteomyelitis 2
- Plain film radiography: should be performed as initial imaging, but sensitivity is low in the early stages of disease 2