Oral Surgery/sequestrectomy and osteomyelitis
QUESTION: I have a few questions about sequestrectomies and osteomyelitis.
1. Is osteomyelitis the only reason for performing a sequestrectomy of the mandible?
2. Would it ever be good practice not to take an x-ray before deciding to do a sequestrectomy of the mandible?
3. If one or more bone fragments and granulation tissue were removed during a sequestrectomy of the mandible, does that necessarily imply osteomyelitis?
4. Would there ever be any reason not to sew up the gums following a sequestrectomy of the mandible?
5. Would it ever be medically indicated to NOT give the patient antibiotics after a sequestrectomy?
Thank you for your attention.
ANSWER: Bpb - First of all all patients who have sequestrectomy should be placed on antibiotics. Sequestrum formation is due to blood decrease and the dying of bone. Sequestrectomy is also performed if pieces of bone are left without blood flow after surgery. An xray or CT scan is appropriate before a sequestrectomy is performed to localized it and see if there is any additional ones in the area. Like I said before, sequestrectomy alone does not say that it is osteomyelitis. After the removal it can be better defined. If after the sequestrectomy, there is evidence of infected tissue, not closing the wound is important to allow drainage of infection.
One thing about this situation, a procedure called hyperbaric oxygen can often regain normal blood flow and oxygen concentration to promote healing. I don't know if that was considered, but is can often resolve a great percentage of the problem.
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QUESTION: I really appreciate your prompt attention to my previous questions. I have a couple of more.
1. Would there ever be reason NOT to do a culture after removing granulation tissue and one or more bone fragments during a sequestrectomy? Shouldn't a culture be done as a matter of routine just to be safe?
2. If a debridement and/or curettage were also performed during a sequestrectomy, would adding some kind of bone filler be helpful to promote healing, even though the area was/is infected?
ANSWER: Bpb - In my experience, doing a culture is imperative. Before, during and after cultures are all important. Some of the wounds are not do to bacteria, but alleviating bacteria as a source of the problem is important.
Bone filler placed at the time of the debridgement or curettage is not appropriate. Decreased blood flow, one of the main causes of sequestrectomy prevents bone grafting. So waiting after the sequestrum removal until an assurance of normal blood flow and a lack of bacterial overgrowth is imperative before any graft is placed.
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QUESTION: Thanks again for all your insight. I think I'm making progress in my understanding, but I've got some more questions. First I'd like to give you more details about my specific case history.
Following a tooth extraction I complained of drainage around the extraction site for months. It apparently had at low discharge rate, and no doctor ever saw any pus or a fistula.
1. Is it possible for an infection of the gums or jaw to drain without a pronounced fistula (sort of like sweating).
In November, a sequestrectomy was performed on the site and at least one bone fragment and some granulation tissue was removed. However, my perceptions of drainage remained.
One doctor mentioned a technitium 99 bone scan as something more definitive that could be done, but I haven't had one yet. Another said that the scan wouldn't be useful. He said it would light up even without an infection present because of bone healing following the extraction and sequestrectomy.
2. Do you think a technitium bone scan could yield useful information even though the tooth was extracted only 9 months ago and a sequestrectomy was performed only 2.5 months ago?
3. Would the scan light up if the infection were mild or confined to the gums only? Or does it have to be in the bone?
4. Would you favor a technitium bone scan over gallium? Or is it six of one, half a dozen of the other?
Thank you again for your kind attention.
Bpb - Drainage for a infected area does not always come via a fistula. There can be a more diffuse drainage at a lower volume. Unfortunately, this type of drainage is indicative of significant dispersed infection vs a contained area.
I wish I cold advise you On the type of scan that is best, but I am not a radiologist and as such I can not give you a recommendation. You should see advice from a nuclear radiologist.
I wish you well and hope it all heals soon. Again, hyperbaric oxygen often contains this type of problem.