Inflammation

What are the 4 cardinal signs of inflamamtion?

Redness

Swelling

Heat

Pain

What are the causes of inflammation and infection?

Inflammation: can be triggered by infection, trauma, autoimmune disease, allergies, radiation, surgery

Infection: always microbial in origin

What are the features of infection?

Inflammation (cardinal signs) + Pus + fever + spreading cullulitis

Can acute inflammation be acute? What about the other way around?

Acute can become chronic and vice versa

Where can periapical inflammation be found?

Mostly at apex 

CAN be anywhere along root

What does the term periodontal/pericoronal mean? Where at the toth?

At the alveolar crest

Where do you find osteomyelitis?

Why?

Most frequently in the posterior mandible

• Due to less circulation of blood here

What are the radiographic signs of acute inflammation? (2 major ones probs on exam)

Inadequate time for changes in calcified content in the early stages

• Radiographic signs of acute inflammation begin to show as infection progresses

Widening of PDL space

Increased radiolucency and proliferative osteitis at times

What are the radiographic signs of chronic inflammation? (5)

Some combination of the following

• Increased radiolucency

• Increased radiopacity

• Mixture of increased radiolucency and radiopacity

• Periosteal bone deposition

• Sequestration fistula and pathological fracture

** make sure to rule out malignancy

What are the 5 inflammatory conditions?

1. Periapical inflammatory disease

2. Pericoronitis

3. Osteomyelitis

4. Osteoradionecrosis

5. Medication-Related Osteonecrosis of the Jaws

What do you see radiographically of periapical inflammatory lesions?

• What are the 3 types

• What is the severity of each?

• Which is radiolucent which is radiopaque

Apical periodontitis (only mild PDL widening)

• Early S&S

• Only at apex

Apical Rarefying Osteitis (periapical radiolucent lesion)

• Periapical abscess, granuloma, cyst

Apical Sclerosing Osteitis (periapical radiopacity)

** You can have a mixture of rarifying and sclerosing osteitis

What happens in Apical Periodontitis?

What happens first?

1. Widening of the PDL

2. Loss or thickening of lamina dura

What is apical rarefying/sclerosing osteitis?

What causes it?

How does it present clinically?

• Local response of the bone around the apex of a tooth resulting from necrosis of the pulp

• Pulp necrosis comes from bacterial invasion via caries or trauma

• Entrapped epithelium can be stimulated to form radicular cysts

• Typically presents as a toothache but can be asymptomatic or can have severe facial swelling/pain

How does apical rarefying/sclerosing osteitis present radiographically?

Where does it normally present on the tooth?

How large is the zone of transition?

• Presents as periapical abscess or granuloma

• Epicenter of a lesion at the apex of a tooth or at least on the root

• Wide zone of transition to normal looking bone

What are the radiographic features of rarefying/sclerosing osteitis?

• Radiolucent/Radiopaque

• Lamina dura present? PDL present?

• Margins?

• Size?

• Can it be both?

Radiolucent lesion

• Lesion may entirely appear radiopaque

Loss of the lamina dura and PDL space

Margins: ill-defined or well-defined

Size varies

Often a combination of sclerosing and rareficaiton takes place

What is a dense bone island? 

How does it present radiographically?

• Margin definitions

• Margins

• Radiolucent/opaque

• How is the PDL?

Well circumscribed and no radiolucency

Irregular Margins

PDL maintains uniform width

Is the pulp vital/non-vital in Apical Sclerosing Osteitis vs Dense Bone Island?

Apical Sclerosing Osteitis: Non-vital

Dense Bone Island: Normal vital pulp

How to test for Dense Bone Island?

Confirm if it’s a dense bone island via vitality test

What is a consequence of dense bone islands?

Resorb Roots

Is the first stage of PCOD radiolucent/radiopaque?

What happens when it matures?

First: Radiolucent

Later: Becomes mixed to radiopaque

Where on a radiograph is the mental foramen?

Mandibular 2nd premolar

What happens to healed lesions of Periapical infections (4)?

Heal as Fibrous Scars —> Radial trabecular bone pattern

Root resorption

Odontogenic sinusitis

Hypercementosis

What does it look like when apical rarefying osteitis is adjacent to the maxillary sinus?

Halo sign

How do you manage Periapical Inflammatory Lesions

• What happens if it’s untreated?

RCT or Extraction

Untreated = Osteomyelitis

What is Pericoronitis?

What are the 3 S&S?

What tooth is it associated with?

Inflammation of the soft tissue (operculum = covering tooth) surrounding a partially erupted tooth crown due to microbial irritation/entrapment

• S&S include: pain, swelling, trismus

Associated with 3rd molars

What are the radiographic findings of Pericoronitis?

No change

Flame-shaped or semilunar rarefaction around the tooth crown and sclerosis of the adjacent bone surface

How do you manage Pericoronitis?

Extraction

What is Osteomyelitis?

What causes it?

Acute or chronic?

Max or mand prevalence?

Widespread response of the bone to inflammation

• Due to pyogenic organisms introduced via abscessed teeth, surgery, or hematogenous spread

• Can be acute or chronic

Mand > Max due to decreased blood supply

What is a hallmark feature of Osteomyelitis? What does this look like radiographically?

Hallmark feature: presence of sequestrum (fragments of necrotic bone)

• Radiographically looks like dense bone island with radiolucency around it

In Acute Osteomyelitis, what are the radiographic changes?

What can it mimic?

How soon is the onset?

No radiographic changes may appear at first unless there is slight and poorly-defined decrease in bone density and then sclerosis later

10 days later: decrease in density of trabeculae and blurred outline

Mimics malignancy with ill-defined borders

Disease develops 2 weeks after disease onset

How strong are the symptoms of Chronic Osteomyelitis?

Less severe symptoms and symptom history may involve a greater period of time than acute form

What are the radiographic features of Chronic Osteomyelitis?

Increased and decreased density regions (favoring sclerosis)

Very wide zone of transition (poor defined borders) and moth eaten

Sclerotic periosteal reactions possible

Sequestra present as islands of necrotic bone, due to ischemic injury

What does it mean to have sequestration?

What do large vs small sequestra look like?

Large

• Segments of necrotic bone

• More dense

• Better defined border

Small

• Radiopaque islands of bone in radiolucent regions

How to manage acute Osteomyelitis?

Removal of infection source + antibiotics

How to manage Chronic Osteomyelitis?

What if it isn’t treated?

Difficult to eradicate: employ long term antibiotics, surgery, and Steroids

If left unchecked, can spread to condyle and lead to septic arthritis

How does Osteoradionecrosis occur? What does it cause?

How much radiation?

Presence of exposed bone after the delivery of radiation to head/neck in the therapeutic doses

• 60-70 Gray (this is a ton)

Causes: hypovascularity and hypocellularity = hypoxia = compromised healing

What can happen to exposed bone in Osteoradionecrosis?

How is it different from Chronic Osteomyelitis?

Can become secondarily infected

Appears similar to chronic osteomyelitis but the necrosis is not inflammatory

Is Osteoradionecrosis more common or less common in maxilla compared to Chronic Osteomyelitis?

What is the Characterization of the PDL space in Osteoradionecrosis?

More common in maxilla than Chronic Osteomyelitis

PDL space is irregular but uniform widening

In Medication-related osteonecrosis of the Jaw, what drugs cause it?

What do these drugs do?

What is the hallmark characterization of MRONJ?

Due to bisphosphonates

• Drugs are used to reduce bone metabolism

• Characterized by exposed bone in oral cavity

What is more destructive, malignancies or inflammation?

Malignancies