Oral Path Test #4: Inflammatory Bone Disease

Front 1

Moth-eaten RL, irregular margins can represent (3):

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1. Inflammatory process **
2. Primary Malignancies
3. Metastatic neoplasms

Front 2

How do we get organisms into bone?

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1. Trauma
2. Pulp spread
3. PDL
4. Hematogenous (blood)

Front 3

"intense pain" primary feature

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Acute Osteomyelitis

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Usually infection à inflamed trabecular bone < one month duration, à pain (primary Sx), NOT evident radiographically until 60% bone demineralized; purulent exudate. Tx: antibiotic & drainage

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Acute Osteomyelitis

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Pus exudate from FACIAL PLANES that seperate MUSCLE BUNDLES --> stoft tissue swell, pain, "Ludwig's Angina"

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Cellulitis

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CELLULITIS with FASCIAL SPACE b/w muscles & structures of posterior floor of mouth that can COMPROMISE AIRWAY

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Ludwig's angina

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Nodule on gingiva mucosa where a draining sinus tract reaches the surface

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Parulis (gum boil)

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'gum boil'

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Parulis

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B. Can progress w/ or w/o acute stage low-grade inflam à mild-moderate pain; NO purulent exudate; “moth-eaten” radiographic appearance, mandibular molar MOST COMMON site, swelling common; may have sequestra (nonvital bone) in later stages.
C. Micro: resembles benign fibro-osseous process; scant inflammation.
D. Tx: Long term antibiotics, debridement, possible Hyperbaric Oxygen (HBO).

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Chronic Osteomyelitis

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AKA Garre’s osteomyelitis; prominent periosteal rxn associated w/ infected mandibular molar *ESP. in CHILDREN or as a post extraction complication; asymptomatic-mildly tender bony hard swelling w/ normal appearing overlying mucosa.
b. Radiographic: same as above but w/ “onion skinning” = proliferative periostitis (expanded cartex; occ view); trabeculae of bone perpendicular to long axis of bone; Tx: remove offending tooth, antibiotics.

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Chronic osteomyelitis w/ proliferative periostitis

Front 11

Low-grade infection, pulpitis, chronic perio dx is most common portal of entry, occasional pain, middle-aged black females, ill-defined diffuse radiolucent zone w/ sclerotic masses - like FCOD but NOT painful, (FCOD is an extensive form of periapical cemental dysplasia) à may have ant. lesions and simple bone cysts.
b. Histo: fibrous replacement of bone marrow; chonic inflame, osteoclastic activity; Tx: antibiotics, debridement of diseased tooth/area; HBO.

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Diffuse Sclerosing osteomyelitis

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BONE SCAR; ASYMPTOMATIC, YOUNG ADULTS; long standing pulpitis; Most at apex of tooth #19 & 30; physiologic bone rxn to low grade stim.; opaque mass @ apex; Tx: treat tooth if clinically indicated; Most can be diagnosed on basis of clinical & radiographic feat.
a. **Difference between Focal Sclerosing osteitis and Idiopathic sclerosis: In Condensing osteitis, the tooth has a “history” (ie large restoration, sometimes painful, etc.) In idiopathic, it is an asymptomatic tooth.

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Focal Sclerosing osteomyelitis
AKA: condensing osteitis

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Complex clinical = Synovitis, Acne, Pustulosis/psoriasis, hyperostosis sclerosis, osteitis; < 60 years old; Schronic Mulstifocal Osteomyelitis: no organisms, no response to antibiotics

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SAPHO Syndrome

Front 14

AKA 'DRY SOCKET'; failure to maintain clot; increased risk if: taking BCP, Alcohol, smoker, debilitated, frequent vomiting post op

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Alveolar Osteitis

Front 15

KID = Retrognathia, abnormal/absent crown & root development; 3 “H’s” =
1. HYPOVASCULAR
2. HYPOCELLULAR
3. HYPOXIC
harmful to endothelial cells, osteocytes, osteoblasts; radiated tissue heals slow or not at all; lifetime risk for osteoradionecrosis

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Radiation injury to bone

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BONE DEATH (avascular necrosis)secondarily infected; More COMMON in MANDIBLE, over 6500 cGy, and Smokers.
Types:
1. Early trauma induced: Teeth removed during radiation, don’t let teeth heal enough between extraction or surgery and start of radiation
2. Spontaneous: doses over 7400 cGy, one yr after radiation, Lingual Cortex=MOST COMMON site
3. Late Trauma induced: 5-10 yrs after radiation; cause= extraction or perio surgery w/ out HBO, failure to heal/exposed bone.
***Window of opportunity: immediate 3-4 mo. Period following radiation à deleterious effects haven’t yet fully developed; 21 days healing pre rad still PREFERRED method
G. Hyperbaric Oxygen (HBO) in tx or prev. of osteoradionecrosis
i. Increases vascularity of tissue (capillary angiogenesis); cannot revascularize dead bone (must remove); for surgical procedure in irradiated tissue: 20 dives (90 min. daily w/ 100% O2), then procedure, then 10 more dives. Use antibiotics.
ii. for osteoradionecrosis: 30 dives, debridement of area, 10 more dives; expensive, so prevention is best approach.
H. Post-radiation dental assessment
i. re-evaluate 1-2 months after last radiation tx; compliance, xerostomia; watch for recurrence; frequent recalls, prophys

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Osteoradionecrosis

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Early Trauma, Spotaneous, Later Trauma are types of:

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Osteoradionecrosis

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increases vascularity of tissue (capillary angiogenesis); cannot revascularize dead bone (must remove

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Hyperbaric Oxygen (HBO) in tx or prev. of osteoradionecrosis

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radiation up to lower mandible w/ 4000 cGy; causes xerostomia but NO SUBSTANTIAL RISK FOR OSTEORADIONECROSIS

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Radiation for Hodgkin’s Lymphomas

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Prevent/Treat BONE METASTASIS -breast & prostate; tx of Paget’s, avascular necrosis, osteoporosis.
DECREASE OSTEOCLAST activity, may cause poor healing, spontaneous oral ulceration, bone necrosis; Primarily the IV forms associated w/ osteonecrosis of jaw
L. Signs & Sx’s: Localized pain, Soft tissue swelling & inflamm.; loose teeth; exposed bone, drainage; numbness of jaw
M. Differences from osteoradionecrosis: Systemic effects—not localized; not associated w/ dec. vascularity; HBO not helpful; bisphosphonates persist in bone for 12 yrs or more; maxilla can be involved (mandible slightly more common)
N. Tx: no Biopsy unless suspect metastatic Dx. Systemic antibiotics; CHX rinse; Avoid surgery if poss. w/ symptomatic pts who show no response to antibiotics; close follow up—every 3-4 months
O. Prevention of Bisphosphonate associated osteonecrosis: exam before tx; Chx rinse; at least one month prior: necessary extractions, perio therapy, endo; After—avoid surgical procedures, implants, etc.

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Bisphosphonate associated osteonecrosis

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no risk of Osteoradionecrosis

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Radiation for Hodgkin's Lymphomas

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Which is systemic? Osteoradionecrosis of BIS-Phosphanate associated osteonecrosis

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Bisphosphonate assoc. osteonecrosis = systemic (Osteoradionecrosis = localized)