Oral Pathology Non-neoplastic Diseases Chapter 8 & 9

What is a benign fibro-osseous lesion?

Benign bone lesion composed of cellular fibrous connective tissue mixed with irregular bone trabeculae or cementum-like material.

What are the nonneoplastic benign fibro-osseous lesions?

Periapical cemento-osseous dysplasia, focal cemento-osseous dysplasia, florid cemento-osseous dysplasia, fibrous dysplasia, and ossifying fibroma.

What is periapical cemento-osseous dysplasia?

Common fibro-osseous disease of unknown cause affecting periapical bone around vital teeth.

Where is periapical cemento-osseous dysplasia most commonly located?

Anterior mandible.

Clinical presentation of periapical cemento-osseous dysplasia

Asymptomatic and localized.

Composition of periapical cemento-osseous dysplasia

Fibrous tissue with calcifications.

Radiographic appearance of early periapical cemento-osseous dysplasia

Well-circumscribed radiolucency that may mimic periapical inflammatory disease.

Radiographic appearance of late periapical cemento-osseous dysplasia

Dense radiopaque lesion with a thin radiolucent rim.

What is florid cemento-osseous dysplasia?

Disordered deposition of cementum and bone affecting multiple quadrants.

Location of florid cemento-osseous dysplasia

Posterior maxilla and mandible involving multiple quadrants.

Cause of florid cemento-osseous dysplasia

Unknown.

What disease can florid cemento-osseous dysplasia resemble radiographically?

Paget disease.

Does florid cemento-osseous dysplasia usually cause bone expansion?

No.

How is florid cemento-osseous dysplasia diagnosed?

Clinical and radiographic appearance.

Major complication of florid cemento-osseous dysplasia

Osteomyelitis.

Dental hygiene recommendation for florid cemento-osseous dysplasia

Maintain excellent oral hygiene to preserve dentition.

What is focal cemento-osseous dysplasia?

Asymptomatic fibro-osseous lesion similar microscopically to other cemento-osseous dysplasias.

Location of focal cemento-osseous dysplasia

Posterior mandible.

Typical size of focal cemento-osseous dysplasia

Less than 1.5 cm.

Diagnosis of focal cemento-osseous dysplasia

Microscopic examination and biopsy.

Prognosis of focal cemento-osseous dysplasia

Excellent.

What is fibrous dysplasia?

Developmental disorder where normal bone is replaced by fibrous connective tissue and calcified material.

Cause of fibrous dysplasia

Usually associated with GNAS gene mutation.

What determines the severity of fibrous dysplasia?

Timing of the genetic mutation during embryologic development.

Microscopic appearance of fibrous dysplasia

Cellular vascular fibrous tissue with irregular bone trabeculae.

Dental effects of fibrous dysplasia

Malocclusion, tooth displacement, tipping; teeth rarely mobile.

Most common type of fibrous dysplasia

Monostotic fibrous dysplasia.

What bone is most commonly affected in monostotic fibrous dysplasia?

Maxilla.

What is craniofacial fibrous dysplasia?

Fibrous dysplasia involving the maxilla and adjacent craniofacial bones.

What is polyostotic fibrous dysplasia?

Fibrous dysplasia involving multiple bones.

Skin finding associated with polyostotic fibrous dysplasia

Café-au-lait macules.

What is McCune-Albright syndrome?

Polyostotic fibrous dysplasia with endocrine abnormalities and café-au-lait spots.

Endocrine abnormalities seen in McCune-Albright syndrome

Precocious puberty, hyperthyroidism, type 2 diabetes, skeletal deformities.

What is Jaffe syndrome?

Polyostotic fibrous dysplasia with café-au-lait skin macules.

What does MRONJ stand for?

Medication-Related Osteonecrosis of the Jaw.

Diseases commonly treated with antiresorptive medications

Osteoporosis, metastatic bone cancer, and Paget disease.

Goal of antiresorptive medications

Reduce bone resorption by decreasing osteoclast activity.

Common antiresorptive medications

Bisphosphonates and denosumab.

Mechanism of bisphosphonates

Alter osteoclast function and inhibit bone resorption.

Mechanism of denosumab

Blocks RANK-L, preventing osteoclast activation.

What happens to exposed bone in MRONJ?

It becomes necrotic and heals slowly.

Why does infection persist in MRONJ?

Dead bone is removed slowly, allowing bacterial biofilm formation.

Which cancer has the greatest MRONJ risk?

Multiple myeloma.

MRONJ Stage 1

Exposed necrotic bone, asymptomatic, no infection.

MRONJ Stage 2

Exposed necrotic bone with pain and clinical infection.

MRONJ Stage 3

Exposed necrotic bone beyond alveolar bone with pain, infection, and complications.

Complications seen in MRONJ Stage 3

Pathologic fracture, fistula, inferior border osteolysis, sinus or zygoma involvement.

What is Paget disease?

Chronic metabolic bone disease with abnormal bone remodeling.

Other name for Paget disease

Osteitis deformans.

Bone changes in Paget disease

Excessive resorption followed by disorganized repair producing large weak bone.

Laboratory findings in Paget disease

Elevated serum alkaline phosphatase and urinary hydroxyproline.

Cause of Paget disease

Unknown; viral, genetic, and environmental theories.

Who is most commonly affected by Paget disease?

Men over age 50.

Bones commonly affected by Paget disease

Pelvis, femur, spine, tibia, skull, and jaws.

Which jaw is more commonly affected by Paget disease?

Maxilla.

Characteristic facial appearance in Paget disease

Leontiasis ossea (lion-like face).

Common treatment for Paget disease

Bisphosphonates.

Major complications of Paget disease

Fractures and osteosarcoma.

What is a central giant cell granuloma?

Nonneoplastic intraosseous lesion composed of fibrous tissue with multinucleated giant cells.

Histology of central giant cell granuloma

Multinucleated giant cells, fibrous tissue, red blood cells, inflammatory cells, hemosiderin.

Most common jaw affected by central giant cell granuloma

Mandible.

Pain associated with central giant cell granuloma

Usually absent or mild discomfort.

Radiographic appearance of central giant cell granuloma

Radiolucency with sclerotic or ill-defined borders.

Common dental finding with central giant cell granuloma

Root divergence.

Features of nonaggressive central giant cell granuloma

Small, asymptomatic, no root resorption or cortical perforation.

Features of aggressive central giant cell granuloma

Large, painful, destructive, root resorption, cortical perforation.

Systemic disease associated with giant cell granuloma

Hyperparathyroidism.

What is a brown tumor?

Giant cell lesion associated with hyperparathyroidism.

Treatment of a brown tumor

Treat the underlying hyperparathyroidism.

What is an aneurysmal bone cyst?

Pseudocyst containing blood-filled spaces surrounded by giant cells and fibrous tissue.

Most common location of aneurysmal bone cyst

Long bones.

Jaw occurrence of aneurysmal bone cyst

Rare.

Radiographic appearance of aneurysmal bone cyst

Unilocular or multilocular radiolucency with honeycomb or soap-bubble appearance.

Clinical swelling of aneurysmal bone cyst

Rapid ballooning or blowout expansion.

Lesions associated with aneurysmal bone cyst

Fibrous dysplasia, giant cell granuloma, chondroblastoma.

What is osteomalacia?

Disease caused by deficient mineralization of bone due to calcium deficiency.

What is rickets?

Osteomalacia occurring in children due to vitamin D deficiency.

Causes of osteomalacia

Vitamin D deficiency, malabsorption, liver disease, kidney disease, medications, chronic antacid use, tumors.

Oral findings of osteomalacia

Delayed tooth eruption and periodontal disease.

Key radiographic difference between early and late periapical cemento-osseous dysplasia

Early lesions are radiolucent; late lesions are radiopaque with a radiolucent rim.

Best management for asymptomatic cemento-osseous dysplasia

Observation and routine dental care.

Which fibro-osseous lesion most closely resembles Paget disease radiographically?

Florid cemento-osseous dysplasia.

Which fibro-osseous lesion is linked to the GNAS mutation?

Fibrous dysplasia.

Which antiresorptive medication blocks RANK-L?

Denosumab.

Which antiresorptive medication directly alters osteoclast function?

Bisphosphonates.