4. pulpal and periapical pathology and inflammatory lesions of the jaw part 2

what is inflammation of bone, specifically extension of inflammation from/beyond periapical region to the marrow space, cortex, cancellus portion of bone and periosteum?

osteomyelitis

pyogenic organisms can reach bone marrow through what four mechanisms?

• abscessed teeth

• post-surgical infection

• trauma ie untreated tooth fracture 

• hematogenous spread

what are some predisposing conditions of osteomyelitis?

• malnutrition

• diabetes

• leukemia

• anemia

• alcoholism

• HIV

• diabetes w reduced bone vascularity

  • Pagets

  • florid osseous dysplasia

  • fluorosis 

what are some relevant terms and synonyms of osteomyelitis?

• acute osteomyelitis

• acute suppurative osteomyelitis

• acute pyogenic osteomyelitis

• proliferative periostitis 

• periostitis ossificans 

is osteomyelitis synonymous with Garre’s osteomyelitis?

NO

which osteomyelitis?

• mandible, PM area

acute osteomyelitis

which osteomyelitis?

characteristic clinical features:

• pain, swelling, redness, fever, purulent discharge, mobility in involved teeth 

acute osteomyelitis 

Dental sequelae

long-term or secondary dental problems that result from a previous dental disease or trauma

islands of necrotic bone, may vary in size

which osteomyelitis?

• sequela of inadequately treated acute phase

• may arise de novo

• CRMO

• SAPHO syndrome 

• clinical features: intermittent recurrent pain and swelling

chronic osteomyelitis

CRMO of chronic osteomyelitis

• Chronic Recurrent Multifocal Osteomyelitis 

• also occurs in long bones of children, pain, swelling

SAPHO syndrome of chronic osteomyelitis

Synovitis (inflammatory arthritis), Acne (pustulosa), Pustulosis (psoriasis), Hyperostosis (acquired), Osteitis (osteomyelitis)

which osteomyelitis?

• no radiographic features bc no manifestation in early stages; may vary in stage

acute osteomyelitis 

which osteomyelitis phase? 

periphery:

• poorly defined

• non-corticated

• gradual transition to normal trabeculae

acute

which osteomyelitis phase? 

internal structure:

• decrease in bone density, loss of sharpness of trabeculae 

• localized or scattered regions of radiolucency, ill defined periphery 

• mixed radiolucent-radiopaque areas

  • “moth-eaten”

  • irregular outline

help: mandibular trabeculae looks like lasagna but here more granular and indistinct 

acute

moth bitten acute osteomyelitis

which osteomyelitis phase? 

internal structure:

• sequestration, sinus tract or fracture 

acute

white and black arrow

which imaging is method of choice for seeing internal structure (sequestrea) of acute osteomyelitis?

CT/CBCT

which osteomyelitis phase?

some effects on surrounding structures:

• bone formation, periosteal stimulation = onion skin

• bone resorption

acute

periosteal reaction

new bone formation parallel to the cortex (almost looks like periosteum lifted and bone under)

proliferative periostitis and the onion skin periosteal reaction have the same radiographic appearance 

true

which osteomyelitis phase?

some effects on surrounding structures:

• fistulous/sinus tract 

acute

what’s going on here?

what is going on here?

pathological fracture, facture on a compromised boone

which type of chronic osteomyelitis?

• primary response: proliferation reaction

• sclerotic appearance of involved bone 

• subperiosteal bone deposition

• slight jaw enlargement

• involves large segment of jaw

diffuse sclerosing osteomyelitis

diffuse sclerosing osteomyelitis, young pt

• diffuse sclerosing of left angle-ramus of mandible = L more radiopaque than R

which chronic osteomyelitis?

diffuse sclerotic bone 

case of SAPHO syndrome bc wrist and mandible involved 

what is ORN?

osteoradionecrosis: radiation induced damage to bone resulting from exposure to therapeutic doses of radiation, clinically exposed necrotic bone and radiologic changes similar to osetomyelitis

what minimum dose for hypocellularity and hypovascularity in head and neck region of ORN?

50 Gy

ORN

ORN at third molar extraction site

BRONJ stands for

bisphosphonate related osteonecrosis of the jaws (chemotherapy and osteoporosis drugs)

• bone exposure in pts w history of iv/oral bisphosphonates

• following invasive dental surgical procedure 

• radiographic features indistinguishable from osteoradionecrosis and osteomyelitis 

BRONJ

BRONJ and ORN are the same radiographically but different pathologically

true

BRONJ

BRONJ

which is osteomyelitis?

L picture: osteomyelitis: ill-defined, mixed density lesions above and below IAN canal, moth eaten VS R: not osteomyelitis, well defined radiopaque lesions in maxilla and mandible above IAN canal

pericoronitis

soft tissue inflammation surrounding the crown of partially erupted tooth

pericoronitis, sometimes does not have radiographic features since it’s soft tissue 

• late: localized rarefaction and sclerosing

• osteomyelitis: periosteal reaction

enlarged follicle is a sign of pericoronitis

false

what is mucositis?

localized thickening of mucosa

sinusitis 

generalized thickening of mucosa

what is going on here?

severe sinusitis and sclerotic changes in bony walls (osteogenic reaction)

• not a true cyst 

• obstruction or dilatation of the duct of seromucous glands in sinus resulting in submucosal accumulation of secretions 

• non-corticated margins, soft tissue dome shaped radiopacity in maxillary sinus 

mucous retention pseudocyst

mucous retention pseudocyst

radiographic features:

• relative radiopacity on the floor of sinus

• well-defined, not corticated

• dome-shaped

mucous retention pseudocyst