2014 self-study course three course

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ABOUT this FREQUENTLY asked COURSE… QUESTIONS… Q: Who can earn FREE CE credits? . READ the MATERIALS. Read and review the course materials. A: EVERYONE - All dental professionals in your office may earn free CE contact . COMPLETE the TEST. Answer the credits. Each person must read the eight question test. A total of 6/8 course materials and submit an questions must be answered correctly online answer form independently. for credit. us . SUBMIT the ANSWER FORM Q: What if I did not receive a ONLINE. You MUST submit your confirmation ID? answers ONLINE at: A: Once you have fully completed your p h o n e http://dent.osu.edu/sterilization/ce answer form and click “submit” you will be directed to a page with a 614-292-6737 . RECORD or PRINT THE unique confirmation ID. CONFIRMATION ID This unique ID is displayed upon successful submission Q: Where can I find my SMS number? of your answer form. t o l l f r e e A: Your SMS number can be found in the upper right hand corner of your

1-888-476-7678 monthly reports, or, imprinted on the back of your test envelopes. The SMS number is the account number for ABOUT your your office only, and is the same for f a x FREE CE… everyone in the office. 614-292-8752 Q: How often are these courses . TWO CREDIT HOURS are issued for available? successful completion of this self- A: FOUR TIMES PER YEAR (8 CE credits). e - m a i l study course for the OSDB 2014-2015 [email protected] biennium totals. . CERTIFICATE of COMPLETION is used to document your CE credit and is mailed to your office. w e b . ALLOW 2 WEEKS for processing and www.dent.osu.edu/ mailing of your certificate. sterilization Page 1 PANORAMIC AND 2014 RADIOLUCENCIES OF THE JAWS course The purpose of this study is to introduce health care professionals with some of the more common entities that are seen in the jaws. This study will focus three on preparing readers to formulate a reasonable differential diagnosis for radiolucencies of the jaws.

INTRODUCTION Panoramic radiography is an imaging technique that produces tomographic views for facial bones. The resulting images provide a broad overview of the teeth, jaw bones, and sinuses. The technique was first introduced in the armed forces to expedite oral exams for soldiers. While panoramic radiographs are limited in their able to differentiate between ability to determine dental caries, anatomy and . they are beneficial in locating the site of third molar impaction, To effectively interpret an image, temporomandibular joint problems, it is important to have good fractures, odontogenic and images and an appropriate setting tumors, and osseous pathology. The for evaluation. The sections below intensity of radiation exposure to will highlight ways in which such the patient during image an image can be achieved. determination is low and the images can be obtained in a relatively short QUALITY amount of time. The quality of the panoramic film Besides being limited in their ability is dependent on the appropriate to exhibit anatomic details required positioning of the patient, for assessing dental caries, minimal movement during the panoramic radiographs show a procedure, and the contrast written by significant degree of overlapping settings of the imaging machine. amber kiyani, dds structures in the incisor region. The An image of good quality will be superimposition of the cervical spine devoid of distortions and will in this region makes interpretation present a sharp image with a of any pathology in the anterior jaws good contrast. edited by difficult and creates a need for rachel a. flad, bs additional images. LIGHTING CONDITIONS karen k. daw, mba, cecm Panoramic radiographs are routinely evan miller Appropriate lighting conditions performed in dental practices. The are also important for assessing current recommendations advocate panoramic radiographs. Films and reimaging every five years. It is digital images can be best viewed important for us, as oral health care when the ambient lighting is professionals, to be able to read reduced. For panoramic films, these images effectively and to be Page 2

most dental offices have a view box that provides STEP 2 – MARGINS AND SHAPE the necessary lighting intensity. It is pertinent to ensure that the film is uniformly approximated to The margins can either be described as well- the light source. defined or ill-defined. Well-defined margins usually represent benign processes. They may STEPS TO ANALYZE PANORAMIC have corticated margins, a thin radio-opaque line around the periphery of the defect (sclerotic IMAGES margins), and a wider, non-uniform radio-opaque periphery. Ill-defined margins frequently There are two ways of coming up with a represent malignant processes. differential diagnosis when a radiographic anomaly is identified. The first one is called the The shape of the lesion can provide pertinent “Aunt Minnie” method and involves comparison of clues for diagnosis. A unilocular, well-demarcated the anomaly to the characteristic image database defect would be most consistent with a benign that you have in your memory. While this method cystic process. A multi-locular radiolucent process is frequently employed, it relies on human would be highly suggestive of either an memory and may fail to include numerous odontogenic or an ameloblastoma. possibilities in the list of differential diagnoses, which can be found on Page 11 of this study. STEP 3 – INTERNAL STRUCTURE Therefore, we advocate the use of the step-by- step technique outlined below. Radiographic defects are classified into three categories: radiolucent, mixed radiolucent, and STEP 1 - LOCATION radio-opaque. Radiolucent defects usually represent soft tissue growths within the jaws. Location of the radiographic defect is very Radio-opaque lesions would be most consistent important while formulating a differential with calcified masses, such as odontomas diagnosis. The initial step would include defining (collection of tooth-forming tissues) and whether the anomaly is localized, limited to a osteomas (benign bone tumors). Mixed defects specific area in the jaws, or exhibits a more diffuse represent bone forming processes that are involvement. A single periapical radiolucency of frequently referred to as fibro-osseous lesions. an anterior mandibular tooth would suggest a diagnosis of periapical inflammatory disease, STEP 4 – EFFECT ON SURROUNDING while multiple periapical radiolucencies would be STRUCTURES more consistent with cemento-osseous dysplasia. Similarly, unilateral defects are more suggestive of The effect of the lesion on surrounding structures a disease process while bilateral symmetrical is a good measure of the clinical behavior of the defects would most likely represent normal (or disease process. variations of normal) structures. Slow growing benign processes frequently result The relative position of the lesion can also be in tooth displacement, while odontomas would extremely helpful. Something in close association usually cause apical displacement of the tooth, with the tooth would most likely represent an thus impeding tooth eruption. Chronic odontogenic process, while those close to the inflammatory processes would result in tooth inferior alveolar canal would be suggestive of a resorption rather than displacement; uniform neural origin. widening of the periodontal ligament space is witnessed during tooth movement. Malignant Size is also critical for diagnostic purposes. A well- processes would result in a more irregular defined radiolucency in the anterior maxilla, widening of the membrane space. between the central incisors, would represent a nasopalatine duct when it is larger than 6 Corticated and sclerotic margins are seen in mm. Anything smaller would be put into the association with lesions that are benign and slow category of an enlarged incisive canal. growing. Page 3 Dislocation of the inferior alveolar canal would may be barely perceptible, while others can span indicate a fibro-osseous process. Uniform an entire quadrant. The lamina dura along the widening of the canal would suggest a benign apex of the tooth is lost, and local or generalized neural process while a more irregular widening widening of the periodontal ligament space may would be indicative of a malignancy extending be identified. down the canal. In rare instances, periapical cysts may be located Periosteal bone growth is seen in association with more laterally due to an infected accessory canal. both benign and malignant intra-osseous Except for location, the radiographic presentation processes, including osteomyelitis and Ewing’s of lateral radicular cysts is similar to their sarcoma. counterparts at the apex. A persistent radiolucent defect following extraction of the tooth is called a STEP 5 – FORMING AN INTERPRETATION residual cyst. These present as round to oval radiolucencies that may undergo calcifications Once the lesion has been assessed according to over a period of time. the above parameters, you begin by placing it in the category of either normal or abnormal. If the Periapical abscesses have a more alarming lesion is abnormal, then it is either developmental presentation radiographically; however, or acquired. This step is followed by adding a symptoms and vitality testing can help in descriptor to the disease process, such as benign, establishing a diagnosis. Abscesses present as ill- malignant, slow-growing, inflammatory, or fibro- defined radiolucencies. The non-vital tooth may osseous. Once the lesion has been assessed, the exhibit widening of the periodontal ligament best way to establish a definitive diagnosis is to space. perform a biopsy. Diagnosis and Management PERIAPICAL RADIOLUCENCIES Diagnosis can be established through vitality PERIAPICAL INFLAMMATORY DISEASE: testing. Electric testing is much superior to cold testing. Endodontic therapy or extractions of Periapical inflammatory disease is a broad term the offending tooth are the treatments of choice. that encompasses periapical cysts, , and abscesses. All three apical processes are MENTAL FORAMEN caused by non-vital teeth. The origin of periapical cysts is linked to epithelial rest cells of Malassez The mental foramen is an anatomic structure that proliferates secondary to microbial located in close proximity to the apex of the of the root canals. Periapical granulomas are second . The foramen serves as an exit areas of granulation tissue produced in response site for the mental nerve as it separates from the to the non-vital tooth in attempts to wall off the inferior alveolar nerve in the mandibular canal. infection. Abscesses are either seen at the onset of periapical inflammatory disease or following acute exacerbation of a previous cyst or . Pain is usually a frequent symptom and may be occasionally accompanied by tooth mobility.

Radiographic Presentation

Periapical cysts and granulomas usually present as well-defined, unilocular radiolucencies that can be identified on panoramic films or periapical films. Acute exacerbation of either of these processes can make the radiolucency appear ill-defined. The size of the lesions can be variable; some lesions Page 4 This structure is a rare finding on radiographs, and previous extraction site. A fine trabecular pattern can appear as a round, oval, or an irregularly can be noted in the radiolucent defect. shaped defect, located between the alveolar ridge and the border of the mandible. Infrequently, the Diagnosis and Management mental foramen may appear in the periapical region of the second premolar, mimicking Biopsy is usually necessary to rule out other periapical inflammatory disease. If no overt significant pathology. Once the diagnosis is evidence of caries is identified, vitality testing or established, no treatment is warranted. obtaining periapical radiographs may help in sorting out this confusion. CEMENTO-OSSEOUS DYSPLASIA

SURGICAL CILIATED CYST Cemento-osseous dysplasia is a benign fibro- osseous process of the jaw. While this should Developing a surgical ciliated cyst, or primarily fit into the category of mixed radiolucent postoperative maxillary cyst, is a consequence of and radio-opaque lesions of the jaws, the process sinus . During the procedure, sinus initiates as a radiolucent defect that becomes mucosa is separated from the sinus lining. This radio-opaque over a period of time. During this detached epithelium then proliferates to form a radiolucent phase, this process can be confused cyst in close association to the maxillary molars. with several other entities discussed in the study The lesions are asymptomatic and identified and so deserves a discussion here. during routine imaging. Cemento-osseous dysplasia can be classified into Radiographic Presentation three types: focal, periapical, and florid. Focal presents as a single lesion, periapical involves the Surgical ciliated cysts present as a well-defined periapical region of the mandibular anterior teeth, radiolucent defects with corticated margins. They and florid involves more than two distinct areas in one or both jaws. Since the only difference are usually located between apices of maxillary molar teeth. between these three is the extent of involvement of the jaws, we will discuss all three collectively. Diagnosis and Management The exact etiology of cemento-osseous dysplasia is not known. It is suspected that it results due to History of a sinus procedure and electric pulp changes in bone metabolism. testing should help rule out periapical inflammatory disease. Biopsy is necessary to Cemento-osseous dysplasia occurs more establish a diagnosis. The cyst is treated by simple commonly in women. Periapical and florid types enucleation. tend to favor African-American women. Most women are between their 30s and 50s at the time FOCAL OSTEOPOROTIC BONE MARROW of diagnosis. The lesions are asymptomatic unless DEFECT secondarily infected and are identified during routine imaging. Rarely, expansion of the jaws A focal osteoporotic bone marrow defect is a focal may be seen in association with this process. collection of hematopoietic bone marrow that appears as a radiolucent defect. It is seen more Radiographic Presentation commonly in females and edentulous areas of the posterior mandible appear to be a preferred site The process initiates as an irregularly shaped, well- for occurrence. The condition is asymptomatic defined radiolucency. Occasionally sclerotic and is usually identified on routine radiography. margins can be identified at the periphery of the lesion. In the periapical variant, the radiolucencies Radiographic Presentation are usually mistaken for periapical inflammatory disease. Most patients have endodontically Radiographically, the lesion appears as either a treated teeth in the area. As the lesion matures, well-circumscribed or ill-defined radiolucency in a r a d i o - o p a q u e f o c i c a n be i d e n t i f i e d Page 5 in the internal structure. Fully mature lesions Management appear completely radio-opaque. Loss of lamina dura may be seen in some instances. Extraction along with complete enucleation is the choice of treatment. Occasionally the affected Diagnosis and Management tooth can be forced to erupt through orthodontic intervention. The diagnosis can usually be made clinically. However, if it is difficult to render a diagnosis INTER-RADICULAR clinically, a biopsy should be performed. Once the diagnosis is confirmed, no treatment is necessary. RADIOLUCENCIES It is important to educate the patient about the necessity of retaining dentition. Foci of cemento- LATERAL PERIODONTAL CYST osseous dysplasia do not resorb like the normal bone. Once the teeth are extracted, these foci can A lateral periodontal cyst is an be exposed to the oral environment and that forms along the lateral surfaces of the root. predisposed to infection. This infection is nearly The cyst is developmental in nature and believed impossible to control and would result in to arise from remnants of dental lamina. It occurs osteomyelitis involving the entire jaw. more commonly in older patients. The mandibular canine-premolar region, followed by the maxillary PERICORONAL RADIOLUCENCIES lateral incisor-canine-premolar region are the most frequent sites of occurrence.

DENTIGENEROUS CYST Radiographic Presentation

A is a developmental A lateral periodontal cyst presents as a well- odontogenic cyst that forms due to the collection defined radiolucency on the lateral surface of the of fluid between the tooth and the follicle. The root. Smaller cysts tend to be unilocular, while cyst primarily surrounds the crown of the tooth. larger cysts may be multilocular. While no root While most cysts are asymptomatic, and noted on resorption is noted in association with this cyst, routine radiographs, some can result in significant divergence of roots may be occasionally noted. swelling and pain if they are secondarily infected.

Dentigerous cysts can occur over a wide age Diagnosis and Management spectrum and the third molars are a common site of occurrence. Inclusions in the differential diagnosis may include

a lateral radicular cyst or an odontogenic Radiographic Presentation keratocyst. The former can be ruled out by

performing an electric pulp test. Biopsy is usually Dentigerous cysts present as a unilocular necessary to establish diagnosis and enucleation is radiolucent defect around the crown of a tooth. the treatment of choice. The radiolucency is well-demarcated and frequently exhibits a corticated margin. The size TRAUMATIC of the cyst can vary remarkably from a few millimeters to several centimeters. Displacement Traumatic bone cysts are known by a whole range of teeth may be noted in larger cysts. Examples of of synonyms, including simple bone cyst, lateral variants are usually associated with a unicameral bone cyst, extravasation cyst, solitary mesioangular impaction. Circumferential bone cyst, and progressive bone cavity. Despite dentigerous cysts surround the crown and root of being classified as a type of cyst, it is not a “true the teeth. In rare instances, teeth can erupt cyst” due to the absence of an epithelial lining. through the dentigerous cyst and the cyst may The etiology and pathogenesis of this traumatic appear as a radiolucency surrounding the root(s) bone cyst is currently unknown. It may rarely be of the tooth. To clinically suspect a diagnosis of a seen in association with fibro-osseous processes. dentigerous cyst, the radiolucency around the tooth should be larger than 5 mm – anything smaller would be considered an enlarged follicle. Page 6 Traumatic bone cysts mostly occur in younger SOLITARY CYST-LIKE individuals, usually in their 20s. Males tend to be more commonly affected. The mandible is the RADIOLUCENCIES preferred jaw of involvement. The lesion is primarily asymptomatic and detected during STAFNE’S BONE DEFECT routine radiography. However, there have been reports of pain and swelling in association with this A Stafne’s bone defect is a concavity created by process. Aspiration of the lesion produces a straw- the submandibular salivary gland on the lingual colored liquid. side of the mandible. Occasionally, similar defects may be noted in the anterior part of the mandible Radiographic Presentation due to sublingual and parotid glands of the ramus. While the anomaly is considered developmental in The lesion appears as a radiolucent defect, most nature, it is not seen in children, and the majority commonly involving the ramus of the mandible. of the cases are noted in older adults. Unilateral The boundary of the lesion is well-defined in involvement with this process is more frequent. proximity to the alveolar process, but blurs out The lesions are completely asymptomatic and close to the border of the mandible. Scalloping is noted only in routine radiographic studies. almost always noted between the roots of teeth. Radiographically, a Stafne’s bone defect appears as a well-demarcated radiolucency with corticated Management margins in close proximity to the angle of the mandible. In the absence of symptoms, the Curetting the lining of to diagnosis should be easy to make clinically. For induce bleeding usually allows the defect to heal lesions in the anterior mandible and the ramus, over time. magnetic resonance imaging, computed tomography, or a biopsy may be necessary. Once NASOPALATINE DUCT CYST the diagnosis is confirmed, no further intervention is necessary. A nasopalatine duct cyst, also known as incisive canal cyst, is a non-odontogenic cyst arising from BUCCAL BIFURCATION CYST the remnants of the nasopalatine duct. It commonly occurs in individuals between the ages A buccal bifurcation cyst arises from epithelial rests of 40 and 60 and men tend to be more frequently in the periodontal ligament space. The cyst is affected. Most lesions are asymptomatic and believed to be inflammatory in origin. It is seen noted on routine radiographs. In symptomatic most frequently in association with the mandibular lesions, swelling of the anterior palate immediately first and second molars that exhibit enamel adjacent to the central incisors may be identified. extensions. Children appear to be more Pain and drainage may accompany the swelling commonly affected and may cause the eruption of occasionally. the involved teeth to be delayed. In some instances, the involved tooth manages to erupt Radiographic Presentation partially. Swelling accompanied by slight pain may be reported in association with this entity. A nasopalatine duct cyst presents as an oval or heart-shaped radiolucency between the central Radiographic Presentation incisors. The radiolucency is well-defined with sclerotic borders. The size of the cyst can be quite The cyst may present as a subtle radiolucent defect variable, ranging between 6 mm to 6 cm. A or a well-demarcated circular radiolucency distal to radiolucency of less than 6 mm would be more the furcation of the involved tooth. The cyst may consistent with an enlarged incisive canal. occasionally be seen with corticated margins and may result in tipping of the tooth roots. Diagnosis and Management

A biopsy is necessary to rule out other . Enucleation is believed to have a good prognosis. Page 7 Management

The cyst is enucleated, and the enamel extension defect is removed.

ODONTOGENIC KERATOCYST

Odontogenic are developmental, odontogenic cysts that are believed to arise from remnants of dental lamina. These cysts follow a relatively aggressive clinical course and a high recurrence rate. The presence of more than one has been linked to Gorlin syndrome, a condition characterized by skeletal abnormalities and basal cell carcinomas. While the Central giant cell granulomas are more commonly cysts can occur at any age, most people are found in the mandible, rather than the maxilla. A diagnosed before they reach 50 years old. Despite female predilection is noted and most patients are attaining large sizes, odontogenic keratocysts in their 30s and 40s. Pain and swelling are rarely exhibit clinical expansion. The posterior frequent complaints. The overlying mucosa may mandible is a common site of occurrence. appear dusky-pink in some instances. Most lesions are slow-growing, but locally aggressive. Radiographic Presentation Radiographic Presentation Smaller odontogenic keratocysts may present as unilocular radiolucencies with well-defined Lesions in the mandible are seen as well-defined borders, while larger cysts present as multilocular radiolucencies lacking corticated or sclerotic radiolucencies. Occasionally, corticated margins margins. Lesions in the maxilla may appear more may be noted. It is not uncommon to see ill-defined in comparison. Displacement of teeth odontogenic keratocysts in association with and resorption of roots is a common phenomenon impacted teeth. In older individuals, the cyst would seen in association with this process. The lamina most likely occur in the anterior maxilla. dura of teeth in the vicinity of the lesion is no longer visible. If the lesions grow large enough, Diagnosis and Management they may cause displacement of the mandibular canal. A biopsy is necessary to establish a diagnosis. Enucleation followed by aggressive curettage and Diagnosis and Management close clinical follow-up is recommended. A biopsy is needed to confirm diagnosis. Once the SOLITARY RADIOLUCENCIES diagnosis is made, hyperparathyroidism should be ruled out by blood testing. Surgical resection WITH WELL-DEFINED BORDERS remains the choice of treatment. More conservative methods, such as corticosteroid and CENTRAL GIANT CELL GRANULOMA interferon injections into the lesion, have been attempted with limited success. A central giant cell granuloma is currently believed to be a reactive process that exclusively affects the BENIGN ODONTOGENIC TUMORS jaws. The lesions bear a striking clinical and histopathologic resemblance to intra-osseous Although some tumors exhibiting characteristic tumors seen in patients with hyperparathyroidism. features are discussed separately in this study, this The only way to distinguish the two processes is to section will just outline some radiographic features rule out hyperparathyroidism in the affected common to most odontogenic tumors. individual. Page 8

Odontogenic tumors are relatively rare and can suspected, it may be necessary to embolize the involve either of the jaws. Most tumors initially vessels to minimize bleeding during surgery. present themselves as unilocular radiolucencies Recurrences are rare. that are well-defined and may have corticated or sclerotic margins. Over a period of time, these MULTILOCULAR tumors develop small radiolucencies that may continue to grow over a period of time. The RADIOLUCENCIES degree of calcification will vary according to the type of tumor. Surgical resection is the preferred AMELOBLASTOMA choice of treatment. Ameloblastoma is a benign odontogenic BENIGN SOFT TISSUE TUMORS OF THE JAWS neoplasm that arises from the remnants of dental lamina and odontogenic epithelium. It is a locally Soft tissue tumors can arise from neural and invasive, slow growing tumor that has a high rate vascular structures within the jaws. Neural lesions of recurrence. are usually found in close association of the mandibular canal, while the intra-osseous Ameloblastomas are seen more commonly in hemangiomas tend to favor the posterior patients between the ages of 20 and 50. No sex mandible. predilection is noted. Most lesions are identified in the posterior mandible. They present themselves Neural tumors are seen over a wide age range. No as slow growing, painless swellings and expansion specific sex predilection is noted. Certain tumors of the jaw may be seen occasionally. Larger may have significant pain and swelling, and jaw lesions may result in tooth displacement, mobility, expansion appears to be a consistent feature. Most and loss. processes present as radiolucent defects that are well -defined and occasionally exhibit corticated PROLIFERATIVE VERRUCOUS : margins. While the shape may vary, these tumors primarily maintain a unilocular outline. In some Proliferative verrucous leukoplakia is a condition instances, expansion of the mandibular canal is characterized by development of multiple also seen. leukoplakic lesions in the oral cavity. Women tend to be more frequently affected and the gingiva is a Vascular processes are relatively rare in the jaws. common site of involvement. The leukoplakias The mandibular ramus is the preferred site of may evolve to or squamous occurrence and a female predilection is noted. The cell carcinoma over a period of years. lesion is primarily asymptomatic. Compression of the inferior alveolar nerve may result in Radiographic Presentation paresthesia. In most cases the hemangiomas are well-demarcated radiolucencies with corticated Ameloblastomas present themselves as well- margins. However, reports of tumors exhibiting ill- defined radiolucent lesions that may occasionally defined margins are also present. The demonstrate a corticated margin. Smaller lesions arrangement of the residual bone trabeculae gives are usually round to oval and bear a strong the lesion its characteristic multilocular radiologic resemblance to cystic processes. Larger appearance. An increase in the dimension of the lesions usually appear multilocular due to the mandibular canal is noted in tumors arising in the compartments created by bony septa. The terms canal. Resorption of the tooth roots and occasional “soap bubble” or “honey-comb” are commonly displacement of the teeth may be seen in used to refer to this pattern. Ameloblastomas may association with this process. result in root resorption and tooth displacement.

Biopsy is mandatory to confirm a diagnosis. Soft Diagnosis and Management tissue tumors of the jaws are treated by surgical resection. While resecting neural tumors, special Diagnosis is established following biopsy. Surgical care should be taken to preserve the inferior resection is the preferred choice of treatment. The alveolar nerve. When vascular lesions are Page 9 margins of the resection are defined by advanced Radiographic Presentation imaging techniques. The patient should be closely followed to monitor for recurrences. Osteomyelitis presents as an expansive, ragged, ill-defined radiolucency that bears a close GLANDULAR ODONTOGENIC CYST radiographic resemblance to intra-osseous malignancies. Bone surrounding the radiolucent

defect may appear radiolucent. Periosteal A glandular odontogenic cyst is a developmental thickening may be noted occasionally. cyst that arises from the remnants of the Sequestrated bone may present as a central odontogenic epithelium. The cyst has unique radio-opacity. histopathologic features that distinguish it from other developmental cysts. It shows a female Management predilection and is seen more commonly in individuals in their 40s and 50s. It follows an Long-term antibiotics with local debridement are aggressive course and exhibits a high rate of the treatment of choice. recurrence. MALIGNANCIES OF THE JAWS Radiographic Presentation Malignant processes involving the jaws may be Glandular odontogenic cysts show a predilection primary or metastatic. Carcinomas, sarcomas, and for anterior region of the jaws. The mandible is hematopoietic malignancies may arise from involved more frequently than the maxilla. The various elements in the jaws. Metastatic deposits lesion presents as a well-defined unilocular or from the lung, kidney, breast, or prostate may multilocular radiolucency with a corticated margin. also be seen in this region. Except for leukemia, Displacement of teeth may be noted to dentate lymphoma, and Ewing’s sarcoma, most patients. malignancies affect older individuals. Sex predilection will vary according to each individual Diagnosis and Management tumor type. Pain and numbness are common symptoms. Occasionally, fracture of the jaws in Biopsy is performed to establish diagnosis. the affected area may also be seen. Excision with rigorous curettage or partial resection may be employed to prevent recurrence. Malignant neoplasms are shown with ill-defined margins that exhibit no cortication. They usually lack a definitive shape and may be observed as SOLITARY RADIOLUCENCIES clusters of osseous destruction, rather than one WITH POORLY DEFINED uniform lesion. While most lesions are radiolucent, reactive bone formation may give it a BORDERS mixed radiolucent or radio-opaque appearance. Teeth are displaced, loosened, and easily OSTEOMYELITIS exfoliated. The lamina dura of the teeth in the vicinity of the lesion may be lost with periodontal Osteomyelitis is the presence of inflammatory cells ligament space, exhibiting irregular increases in in intertrabecular areas of vital bone. It is mostly a its width. consequence of periapical inflammatory disease or trauma. It can be classified into acute and chronic Biopsy is important to establish a definitive forms depending on the duration of the disease. diagnosis. For primary malignancies, wide Acute osteomyelitis is accompanied by systemic surgical resection with partial maxillectomy or signs and symptoms, including fever mandibulectomy (with or without chemotherapy and occasionally soft tissue and radiation) is the choice of treatment. For swelling and paresthesia. Chronic osteomyelitis metastatic disease, the prognosis is poor and may present itself with local swelling, pain, and palliative care is usually the only option. sinus tracts. Page 10 Multilocular Radiolucencies DIFFERENTIAL DIAGNOSIS OF • Odontogenic keratocyst RADIOLUCENCIES • Ameloblastoma • Glandular odontogenic cyst

• Large odontogenic cysts Periapical Radiolucencies • Odontogenic myxoma • Mental Foramen • Central hemangioma • Incisive foramen • Central giant cell granuloma • /granuloma/abscess • Brown tumor of hyperparathyroidism • Surgical ciliated cyst • Benign odontogenic neoplasm • Osteomyelitis • Benign intraosseous neoplasm • Periapical cemento-osseous dysplasia • Malignant odontogenic neoplasm • Traumatic bone cyst • Malignant intraosseous neoplasm • Benign intraosseous neoplasm

• Malignant intraosseous neoplasm

• Metastatic disease

Pericoronal Radiolucencies • Dental follicle • Dentigerous cyst • Odontogenic keratocyst • Cystic ameloblastoma • Adenomatoid odontogenic tumor • Ameloblastic fibroma

Interradicular Radiolucencies • Periodontal cyst/abscess • Lateral radicular cyst • Lateral periodontal cyst References available upon request. • Traumatic bone cyst • Incisive canal cyst • Squamous odontogenic tumor • Benign odontogenic tumor • Benign intraosseous neoplasm • Malignant odontogenic neoplasm • Malignant intraosseous neoplasm

Unilocular Radiolucencies • Focal osteoporotic bone marrow defect ORIGINATING FROM PAKISTAN, DR. KIYANI WENT TO RIPHAH • Residual cyst UNIVERSITY FOR THEIR 5-YEAR DENTAL SCHOOL PROGRAM. GRADUATING WITH A 4.0 GPA, SHE CAME TO THE OHIO STATE • Odontogenic keratocyst UNIVERSITY IN ORDER TO FURTHER HER STUDIES FOCUSING ON ORAL • Traumatic bone cyst AND MAXILLOFACIAL PATHOLOGY. SHE PLANS TO TAKE THE • Stafne’s defect INFORMATION SHE LEARNS BACK TO PAKISTAN FOR BOTH • Central giant cell granuloma DIAGNOSTIC AND TEACHING PURPOSES. • Incisive canal cyst HER CURRENT RESEARCH STUDIES AS A FELLOW AT OSU • Surgical ciliated cyst INVOLVE EVALUATING THE ORAL CHANGES ASSOCIATED WITH • Early phases of cemento-osseous dysplasia GASTROINTESTINAL DISEASES.

• Benign odontogenic neoplasm DR. AMBER KIYANI CAN BE CONTACTED • Benign intraosseous neoplasm AT: [email protected] • Malignant intraosseous neoplasm • Metastatic disease

Page 11 post-test instructions - answer each question ONLINE - press “submit” - record your confirmation id - deadline is September 21, 2014

Cemento-osseous dysplasia initiates as a radio- 1 T F opaque defect that becomes radiolucent over time.

A Stafne’s bone defect is asymptomatic and can 2 T F only be detected through a routine radiographic SUBMITstudy.

Malignant neoplasms usually lack a definitive 3 T F shape.

4 T F Defects smaller than 6 mm between the maxillary ONLINEcentral incisors are called nasopalatine duct cysts .

Dentigerous cysts are caused by the collection of 5 T F fluid between the tooth and the follicle. d i r e c t o r john r. kalmar, dmd, phd [email protected]

6 Ameloblastomas always present as unilocular SUBMITT F radiolucencies with central opacifications. a s s i s t a n t d i r e c t o r karen k. daw, mba, cecm [email protected] The mental foramen is an anatomic structure 7 T F located in close proximity to the apex of the first channel coordinator premolar. rachel a. flad, bs [email protected]

ONLINEOdontogenic keratocysts are most commonly 8 T F found in the anterior maxilla of older patients.

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