Inflammatory Lesions

„ Most common pathologic conditions of the jaws

„ Teeth create a direct pathway for inflammatory agents and pathogens to invade the bone when Inflammatory Lesions of the Jaws caries and periodontal Steven R. Singer, DDS disease are present

Inflammatory Lesions Bone Metabolism

„ Inflammation is the „ Balance of bone resorption by body’s response to chemical, physical, or osteoclasts and bone deposition by microbial injury osteoblasts

„ First, the inflammatory „ Osteoblasts mediate the resorptive response destroys the causative agent and activity of the osteoclasts walls off the injured „ Inflammatory conditions of bone exist area along a continuum, with varying clinical „ Second, it sets up an environment for repair features of the injured tissue

Inflammation of the Bone Inflammation of the Bone Periapical Inflammatory Lesions

Periodontal Osteomyelitis Lesions

Pericoronitis

1 The Cardinal Signs of Inflammation Acute v. Chronic Lesions Acute Lesions Chronic Lesions

„ Recent onset „ Long, insidious onset

„ Rapid „ Prolonged course

„ Pronounced pain „ Intermittent, low-

„ Often with fever and grade fever

„ Heat swelling „ Gradual swelling „ Redness „ Swelling „ Pain „ Loss of Function

Acute v. Chronic Lesions

„ Without a second radiograph, exposed at a different time, it is often impossible to determine if a lesion is chronic or acute.

„ Therefore, temporal descriptors are usually omitted from radiographic descriptions

Radiographic Features Location

Periapical Inflammatory Lesions

„ Epicenter of the lesion is usually at the apex

„ May also be along the lateral root surface due to accessory canals, root fractures, or iatrogenic perforations

Courtesy of USC School of Dentistry

2 Apical Rarefying Osteitis Location

Periodontal Lesions

„ Epicenter of the lesion is located at the alveolar crest

„ Inflammatory changes in bone may extend to the apex and into the furcation of posterior teeth

Periodontal Disease and Apical Rarefying Osteitis Location Osteomyelitis

„ Usually found in the posterior mandible

„ Involvement of the maxilla is rare, due to greater vascularity

Borders Apical Rarefying Osteitis

„ Generally poorly demarcated

„ Blending into normal trabeculation

3 Internal Architecture Effects on Adjacent Structures

„ Resorption will give a radiolucent „ Stimulation of surrounding bone, appearance to the lesion producing a sclerotic border „ Bone formation (osteosclerosis) will give „ Bone resorption, resulting in radiolucent trabeculation a denser and more areas numerous appearance „ Widening of the periodontal ligament „ Usually, lesion will present as a combination of altered density space. The greatest widening will be at the epicenter of the lesion „ Osteomyelitis will often yield sequestra of bone

Condensing Osteitis Osteomyelitis

Apical Rarefying Osteitis

4 Periapical Inflammatory Periapical Inflammatory Lesions Lesions Unacceptable Terminology Synonyms „ Acute apical „ Radicular cyst „ PAP or periapical

periodontitis „ Apical periodontitis* pathology

„ Chronic apical „ Apical rarefying „ Area periodontitis osteitis * „ Endo tooth

„ Periapical abscess „ Sclerosing osteitis * „ Perio-endo lesion

„ Periapical granuloma „ Condensing osteitis* „ Endo-perio lesion

Radiology *Preferred radiographic terminology! StationTM

Interrelationship of possible Apical Rarefying Osteitis and results of periapical inflammation Sclerosing Osteitis

Caries Periapical abscess Osteomyelitis Acute Necrotic pulp Apical periodontitis Chronic Trauma Periapical granuloma Periapical cyst

From White and Pharoah, 5th edition p.367

Apical Rarefying Osteitis and Periapical Inflammatory Sclerosing Osteitis Lesions

„ Local response of bone secondary to pulpal necrosis or severe periodontal disease

„ At least 60% demineralization must occur before the lesion can be seen on a radiograph. Therefore, it is inappropriate to use a radiograph as a vitality test

5 Periapical Inflammatory Periapical Inflammatory Lesions Lesions

„ Histologically, the lesion is apical periodontitis, which is defined as a periapical abscess or periapical granuloma

„ The reaction is initiated by toxic metabolites from the necrotic pulp

„ Clinically, the symptoms may include pain, swelling, fever, lymphadenopathy, or may be asymptomatic

Periapical Inflammatory Periapical Inflammatory Lesions Lesions

„ Acute lesions may evolve into chronic Location ones „ At the apex of a tooth „ Therefore, it is important to note that „ May be along the root surface if the clinical presentation may not associated with a lateral canal or correspond with the histopathological or perforation from root canal treatment radiographic findings

Periapical Inflammatory Apical Rarefying Osteitis Lesions Borders

„ Ill-defined, gradually blending with normal trabeculation

„ Can occasionally have a well- demarcated border

6 Periapical Inflammatory Periapical Inflammatory Lesions Lesions Internal Architecture Internal Architecture „ Earliest change is loss of bone density „ The region of the lesion closest to the resulting in widening of periodontal apex is generally lucent, while the ligament space periphery tends to be exhibit sclerotic „ As the lesion progresses, loss of density changes involves a larger area „ When the lesion is mostly lucent, the „ As the lesion progresses, a mixed term Apical Rarefying Osteitis is used rarefying and sclerotic appearance may „ When the lesion is mostly sclerotic, the be seen. term Apical Condensing Osteitis is used

Periapical Inflammatory Periapical Inflammatory Lesions Lesions Internal Architecture Effects on adjacent structures

„ When closely examined, the sclerotic „ Lesions may stimulate resorption or areas exhibit both increased number deposition of surrounding bone. and thickness of trabeculae „ The sclerotic lesion may be localized or may extend over a wider area „ The lesion may destroy cortical borders, such as the floor of the maxillary sinus or cause displacement or remodeling. This remodeling is called halo effect

Periapical Inflammatory Halo Effect Lesions Effects on adjacent structures

„ Chronic lesions may result in root resorption

„ If the cortical border of the maxillary sinus is perforated, there may be a localized thickening of the schneiderian membrane. This is called mucositis

7 Root Resorption Halo Effect and Mucositis

Mucositis Mucositis

Periapical Inflammatory Lesions Internal Resorption Effects on adjacent structures

„ Internal or external resorption of the root, calcification of the pulp chamber, and wide appearance of the pulp chamber may be evident

8 Internal Resorption Internal Resorption

Periapical Inflammatory Periapical Inflammatory Lesions Lesions Differential Diagnosis

„ Early lesions of Periapical Cemental Dysplasia (PCD) often have an appearance similar to that of a periapical inflammatory lesion. Pulp vitality testing must be performed to differentiate the two lesions. „ Idiopathic osteosclerosis 8/06 3/07

Differential Diagnosis Periapical Cemental Dysplasia

9 Periapical Cemental Dysplasia Periapical Cemental Dysplasia

Idiopathic Osteosclerosis Idiopathic Osteosclerosis

Case courtesy of Ohio State Case courtesy of Ohio State University College of Dentistry University College of Dentistry

Idiopathic Osteosclerosis Bone Marrow Defect

10 Pericoronitis

„ Inflammation of the tissues surrounding a partially erupted tooth. rd „ Usually occurs around 3 molars

„ Starts in soft tissue surrounding erupting tooth

„ May extend into the bone surrounding the tooth

„ Often associated with trismus

Radiographic Features of Pericoronitis Pericoronitis Location

„ Early lesions may show no radiographic features

„ Follicular space may be expanded around the crown. >3mm should be monitored

Radiographic Features of Radiographic Features of Pericoronitis Pericoronitis Borders Internal Architecture

„ May be ill defined „ Radiolucent, with thin, sparse

„ A sclerotic border is not unusual trabeculae „ Increased trabeculation toward periphery

11 Radiographic Features of Radiographic Features of Pericoronitis Pericoronitis Effects on adjacent structures Differential diagnoses

„ Sclerotic border „ Enostoses and osteosclerosis

„ In larger lesions, periosteal new bone „ Fibrous dysplasia

formation may be evident „ Malignancies such as osteosarcoma and squamous cell carcinoma

Pericoronitis

Osteomyelitis Osteomyelitis

„ Inflammation of the bone „ Bacteria and by-products stimulate an „ May spread to involve: inflammatory reaction in bone

„ Marrow „ In young patients, the periosteum is

„ Cortex Periosteum lifted by inflammatory exudates. New

„ Cancellous portion bone is laid down. This is called Garre’s Osteomyelitis „ Caused by pyogenic organisms from abscessed teeth, trauma, or surgery „ Presence of sequestra is a hallmark of osteomyelitis. These can be seen in „ Source of infection can not always be identified both plain films and CT

12 Radiographic features of Osteomyelitis Osteomyelitis

„ Acute and chronic forms exist Location

„ Acute form demonstrates purulent „ The most common location of drainage osteomyelitis of the jaws is the „ Paresthesia of the lip may be present, posterior body of the mandible suggesting a malignancy „ Involvement of the maxilla is rare, perhaps due to its excellent vascularity

Radiographic features of Radiographic features of Osteomyelitis Osteomyelitis Borders Internal architecture

„ The borders of these lesions are ill- „ Initially, there is a slight decrease in the defined, gradually blending into the radiodensity of the bone, with the normal trabecular pattern trabeculae becoming less well defined „ There may be scattered areas of lucency in the area „ Later, areas of sclerotic bone are seen „ Sequestra are most apparent in the chronic forms

Radiographic features of Radiographic features of Osteomyelitis Osteomyelitis Internal architecture Effects on adjacent structures „ Chronic osteomyelitis may arise from the „ Surrounding bone may be resorbed or acute form or de novo laid down „ In the chronic form, the balance tips in favor of osteoclastic activity „ May cause resorption of the cortex „ Trabeculae may be completely obscured, „ In Garre’s osteomyelitis, the cortex is yielding a uniformly opaque appearance to expanded through deposition of new the bone bone. The radiographic appearance of „ Sequestra are generally larger in the chronic these new layers of bone is termed form onion skin or proliferative periostitis

13 Osteomyelitis Osteomyelitis in a 12 yo male

Case courtesy of Dr. Grace Petrikowski

Osteomyelitis in a 12 yo male Osteomyelitis in a 12 yo male

Case courtesy of Dr. Grace Case courtesy of Dr. Grace Petrikowski Petrikowski

Osteomyelitis in a 12 yo male Osteomyelitis and FCOD

Case courtesy of Dr. Grace Petrikowski

14 Sequestrum of Osteomyelitis Garre’s Osteitis

Garre’s Osteitis

Photo credit: Betty Huang ‘09

Osteonecrosis of the Jaw ONJ Case 1 (ONJ) ONJ – Case #1

„ Found in patients using Bisphosphonates for chemotherapy

„ May also be found in patients using Phosamax for osteoporosis

„ Radiographic appearance resembles chronic sclerosing osteomyelitis

15 ONJ Case 1 ONJ Case 1 ONJ – Case #1 ONJ – Case #1

ONJ Case 2 ONJ Case 2 ONJ – Case #2 ONJ – Case #2

Radiographic features of Did I just sleep through the Osteomyelitis entire lecture? Differential diagnosis

„ Fibrous dysplasia

„ Pagets disease of bone

„ Osteosarcoma

„ Osteonecrosis of the Jaw (ONJ) The patient’s age and clinical presentation may help in the diagnosis

16 Thanks!

17