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COURSE… FREQUENTLY asked

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

ABOUT your A: Your SMS number can be found in toll free the upper right hand corner of your FREE CE… monthly reports, or, imprinted on the 1-888-476-7678 back of your test envelopes. The SMS number is the account number for your office only, and is the same for . TWO CREDIT HOURS are issued for everyone in the office. fax successful completion of this self- study course for the OSDB 2015-2016 Q: How often are these courses 614-292-8752 biennium totals. available? . CERTIFICATE of COMPLETION is A: FOUR TIMES PER YEAR (8 CE credits). used to document your CE credit and e-mail is mailed to your office. [email protected] . ALLOW 2 WEEKS for processing and mailing of your certificate. . The Ohio State University College of web Dentistry is an American Dental dentistry.osu.edu/sms Association (ADA) Continuing Education Recognized Provider (CERP). Page 1 Pathology: A Guide to 2016 Differential Diagnosis

course Learning Objectives:

one 1. Be able to determine most likely diagnosis from clinical and radiographic information 2. Recognize radiographic pathology and be able to produce a reasonable differential 3. Recognize when radiographic findings warrant systemic work up 4. Use the radiographic and clinical features to determine when to treat or watch 5. Differentiate between lesions that are quickly and slowly progressing

This is a OSDB Category B – Supervised self-instruction course.

INTRODUCTION

This course serves as a review of bone lesions seen on panoramic radiographs and periapical films. The radiographic appearance of a lesion or condition provides features that help to narrow down the differential diagnosis of a lesion. Systemic disorders can present as abnormal changes in the jaw obligating dentists to recognize the written by presentation before other symptoms arise. Location and extent of Ashleigh Briody, DDS disease process can be helpful to guide a clinician to the correct differential diagnosis and necessary treatment (or negate the need for edited by further treatment). Lesions above the inferior alveolar canal on the mandible and in proximity to the teeth of both the mandible and maxilla Ross White, BS could be pathology of odontogenic origin (most likely) or other origin such Jon Strasbourg, BA as bone. Lesions within the alveolar canal are most likely neural (nerve tissue) or vascular (blood vessel) in origin. Changes below the inferior release date alveolar canal or not in close association with teeth on a panoramic radiograph could be bone pathology (more likely), odontogenic, or other May 2, 2016 (7:30 AM EST) entities such as salivary gland. It is prudent to note that depending on the angulation of the radiation source, lesions may appear more superior or last day to take the inferior on a two-dimensional image. Well-defined lesions are typically course at no charge benign, as the well-defined margin shows that the surrounding bone has June 6, 2016 (3:30 PM EST) had time to react to the process. Ill-defined margins suggest rapid processes such as infection and malignancy. This course focuses not on

odontogenic cysts and that occur in the bone but bone last day course is pathology itself. available for credit December 31, 2018

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CASE 1 CASE 2, continued..

A 52 year old male presents with chief concern of A 9 year old male was referred to OSU College bone pieces extruding from the gingiva since of Dentistry for evaluation of a 3 month history of extractions 3 months prior. One week prior to his a swelling in the area of teeth #6-8. Tooth #7 appointment he reports seeing a dentist who was displaced distally and #6 was unerupted and referred him to OSU College of Dentistry. The in a similar location to the contralateral canine. patient stated that he attempted to extract a Clinically, the lesion was expansile, firm and maxillary tooth on his own. He reports pain and tender to palpation. The differential diagnosis numbness of the chin. Clinical exam revealed poor included adenomatoid odontogenic tumor (AOT), dentition, left facial swelling and an area of central giant cell granuloma, and dentigerous exposed bone. Radiographically, the left mandible cyst. The panoramic radiograph showed a shows diffuse moth-eaten radiolucencies. The poorly circumscribed intrabony radiolucency. On remaining root tips from the maxillary and cone beam computed tomography (CBCT) mandibular teeth are noted many of which are images, a thin cortex of bone surrounded the associated with periapical radiolucencies. The expansile mass. The lesion showed a close patient denied history of bisphosphonate use and association with #6, so an odontogenic lesion radiation therapy. A biopsy was performed and a could not be ruled out. The patient underwent diagnosis of chronic was rendered. general anesthesia, the lesion was aspirated, The patient was prescribed systemic antibiotics, and an incisional biopsy was performed. The chlorhexidine and pain medications. Definitive pathologic diagnosis rendered was a central treatment in this case involves resection and giant cell granuloma. Intraoperatively, tooth #7 reconstruction of the jaw. was encased, had no bony support and was subsequently extracted. Tooth #8 expressed CASE 2 class II mobility but was spared along with the canine. Several weeks later the patient underwent excisional biopsy which showed a hybrid bone lesion showing central giant cell granuloma and ossifying fibroma.

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CASE 3 Periapical Radiopacities

Condensing :

Tooth #18 tested nonvital. The bone surrounding the apices exhibits increased density (radiopacity). Picture on the left was before root canal therapy. Picture on the right was 6 years post endodontic therapy. (Courtesy of Dr. Kitrina Cordell, LSUHSC School of Dentistry)

A 67 year old man presented with chief concern Condensing osteitis is an increased bone of pain in the right posterior mandible. He density in response to periapical disease. The reported that the day after the extraction of #28 radiograph of this lesion reveals a thickened and #29, he was admitted to the hospital for two periodontal ligament (PDL) in association with a weeks following a gastrointestinal biopsy uniform radiopacity adjacent to the apex of the procedure. After his hospital discharge, he diseased tooth. No expansion of the bone noticed that the pain was now intermittent and should be present. The treatment of this felt numbness along the right mandible and chin. condition involves eliminating the source of Clinically, there was significant expansion of the infection. In most cases, the radiopacity will right mandible, although the extraction sites return to normal radiodensity. Persistence of a appeared to be healing without incident. A radiopacity in the area after definitive resolution panoramic radiograph was taken and revealed of the source of infection is termed bone scar. an ill-defined radiolucency in the right mandible, The clinical significance of a bone scar is posterior to #27. The margins appeared ragged potential root resorption in an orthodontic patient and a biopsy was performed. The diagnosis if the scar is in the path of tooth movement. rendered was diffuse large B-cell Lymphoma. Follow up revealed that the pathology of the Idiopathic : mandibular lesion was consistent with that of the mass in the colon and the patient began chemotherapy treatment.

Radiopacity noted between the roots of #20 and #21. The lesion has blended borders with the surrounding bone. Both teeth are vital. (Courtesy of Dr. Kitrina Cordell, LSUHSC School of Dentistry)

Page 4 Idiopathic osteosclerosis, continued… Cemento-osseous dysplasia, continued…

Idiopathic osteosclerosis is an asymptomatic Cemento-osseous dysplasia (COD) is a benign benign process that results in increased bone fibro-osseous process that presents in several density. Age of onset ranges from 20 to 40 years ways. As the name suggests, there is a soft old and is more common in the posterior tissue “fibro” component (radiolucent) and a hard mandible. Radiographically, this presents as a tissue “cemento-osseous” component singular or multiple well-defined radiopacities. (radiopaque). In the first stage, the lesion will As the name implies, this process is idiopathic; appear radiolucent, clinically mimicking therefore, teeth in the area should be vital unlike periapical pathosis. Vitality testing would result in condensing osteitis. Over time, the lesion may in a normal response and this is essential in remain unchanged or enlarge, although lesions preventing unnecessary over treatment such as usually stabilize once a patient reaches root canal therapy or extraction. As time adulthood. In contrast to condensing osteitis, progresses, COD will become progressively idiopathic osteosclerosis can be separate from more radiopaque while retaining a radiolucent the apices and teeth in the area will respond rim. The radiolucent rim is helpful in normally to vitality testing. This can be helpful in differentiating this process from condensing differentiating these two lesions and prevent the osteitis and idiopathic osteosclerosis as those need for a biopsy. No treatment is required for entities typically lack this feature. Three forms of this process; however, periodic radiographic this lesion have been described: focal cemento evaluation may be helpful in monitoring the osseous dysplasia, periapical cemento-osseous progression. Root resorption of adjacent teeth dysplasia, and florid cemento-osseous dysplasia. can occur. Radiographically, central Focal cemento-osseous dysplasia occurs in a can mimic idiopathic osteosclerosis. In the case single site, most commonly in the posterior of multiple areas of idiopathic osteosclerosis, mandible. Periapical cemento-osseous further evaluation may be warranted to rule out dysplasia occurs in the anterior mandible area Gardner’s syndrome, a syndrome characterized near the apices of the incisors and canines. by several features, including multiple osteomas. Florid COD shows multifocal involvement, and in some cases all four quadrants are affected. Cemento-osseous dysplasia: Periapical COD and florid COD both have a marked predilection for black females. A significant predilection for females is seen in all types of COD. There is no treatment necessary for this entity and it is prudent to note that due to the abnormal bone in this area, a biopsy procedure can increase the risk for osteomyelitis. In the proper clinical setting, if COD is suspected, periodic radiographic follow up could be useful.

Cementoblastoma:

Cementoblastoma is a benign of cementoblast origin. Radiographically, this lesion presents as a radiopacity attached to the root surface. Because the lesion is of Multiple areas of mixed density noted in lower right and anterior cementoblast origin, it will be fused to the root mandible. (Courtesy of Dr. Kitrina Cordell, LSUHSC School of Dentistry) surface and the PDL space will not be present between the lesion and the tooth. Most commonly, the lesion occurs in association with the distal root of a mandibular first molar. Pain and swelling has been reported in two-thirds of the cases and typically the tooth affected responds normally to vitality testing. Page 5

. Treatment usually consists of surgical removal Hypercementosis, continued… of the tooth and mass. hypercementosis from cementoblastoma. Foreign bodies: Radiographically, this lesion presents as an enlarged root with a PDL space visible between the enlarged root and bone. Causes of localized hypercementosis include , adjacent , unopposed teeth, and repair of vital root fracture. Generalized hypercementosis has been reported to have a weak association with and pituitary , , calcinosis, rheumatic fever, thyroid goiter, Garner syndrome, and a significantly stronger association with Paget Disease(discussed later). If Paget disease is suspected, the patient should be referred to his physician for evaluation of serum alkaline 67 year old female with history of orthognathic surgery many phosphatase level. years prior. Also note the tonsillar calcifications superimposed on the ramus/angle of the mandible bilarterally. In review, radiopacities near the apices of teeth Body modification, trauma, aesthetic surgery, can present in similar ways. Important clues orthognathic surgery and cultural traditions can include presence of a radiolucent rim (as seen in also appear in unsuspecting ways on a COD), absence of a radiolucent rim(as in radiograph. While not discussed in detail in this condensing osteitis and idiopathic course, it is important to consider this entity in osteosclerosis), visible PDL space (widened in the right clinic setting. condensing osteitis, present in hypercementosis and cementoblastoma around the root Hypercementosis: expansion). Vitality testing prior to further treatment is imperative and can also help narrow the differential, making it an effective first step in the diagnosis. Another helpful feature is proximity to the root. Condensing osteitis occurs in close association with apices of teeth, whereas idiopathic osteosclerosis can present near the apices or in other areas.

Tooth #19 shows an enlarged root surround by an intact PDL.

In contrast to cementoblastoma, hypercementosis is not neoplastic and results from hyperplasia of the layer on the surface of the root. Cemental and dentinal radiodensity is similar and often precludes evaluation of the extent of hypercementosis. In early stages, it can be difficult to distinguish

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The lack of radiographic changes on the root surface of the teeth in the area excludes hypercementosis. The most likely diagnosis is cemento-osseous dysplasia. Other factors that support this diagnosis include the age, race, and sex of the patient.

Quiz: A 23 year old female presents with the asymptomatic isolated lesion shown below. The tooth in the area tests vital and has no previous restoration. The most likely diagnosis of this lesion is:

a. Condensing osteitis b. Idiopathic osteosclerosis (Images courtesy of Dr. Kitrina Cordell, LSUHSC School of Dentistry) c. Cemento-osseous dysplasia d. Cementoblastoma e. Hypercementosis QUIZZES AND DISCUSSIONS

Quiz: A 53 year old Black female presents with multiple radiographic lesions. The patient is asymptomatic and clinical evaluation reveals no expansion. Lower anteriors responded normally to vitality testing. The most likely diagnosis would be: a. Idiopathic osteosclerosis b. Condensing osteitis c. Cemento-osseous dysplasia In this case, the patient has a radiopacity in d. Hypercementosis association with the distal root of #31. The lesion has blended borders (most easily seen on the mesial) with no expansion. Absence of a radiolucent rim leads away from a diagnosis of cemento-osseous dysplasia. The lack of a large restoration and a normal response to vitality testing excludes condensing osteitis. While the location is good for cementoblastoma, the lesion is not fused to the root therefore hypercementosis and cementoblastoma can be excluded. The most likely diagnosis is idiopathic osteosclerosis. Remember, resorption can occur in idiopathic osteosclerosis. Discussion: The panoramic radiograph above reveals multiple radiopacities of varying degrees Quiz: A 61 year old female presents for routine that are well circumscribed by a radiolucent rim. dental care. Panoramic x-ray is shown below. The teeth in the lower anterior area were all vital Tooth #31 tested vital. The radiopacities which rules out condensing osteitis, a condition associated with tooth #31 would most likely seen surrounding nonvital teeth. The well- represent: defined radiolucency surrounding the radiopacity a. Condensing osteitis excludes idiopathic osteosclerosis, an entity that b. Idiopathic osteosclerosis typically exhibits a radiopaque lesion that blends c. Cemento-osseous dysplasia with the surrounding bone. d. Cementoblastoma

e. Hypercementosis Page 7

palatal aspect of the maxillary tuberosity. Large exostoses can become ulcerated and painful which may warrant removal and/or biopsy if a definitive diagnosis is needed. Radiographically, these lesions present as well circumscribed radiopacities. Depending on the location, the differential could include a sialolith, , or other bony pathosis.

Discussion: In this case, the lesion in question is Osteoma: radiopaque with a radiolucent rim. The vitality of #31, in conjunction with the presence of a Osteomas present as bony hard masses less radiolucent rim, excludes condensing osteitis. than 2 cm in diameter. The most common Because there is no radiolucency separating the location is the body of the mandible and condyle. radiodense lesion and the tooth, cemento- This entity can occur on the bone surface, within osseous dysplasia can most likely be excluded. the bone, or in extraosseous locations. The lesion is closely associated with the root of Radiographically, osteomas are well defined #31, which is not seen in idiopathic round to ovoid radiopacities. No treatment is osteosclerosis. This leaves two entities, necessary for a majority of these lesions; cementoblastoma and hypercementosis. however, if present in the condyle and Cementoblastomas typically arise in the 3rd symptomatic, removal may be warranted. If decade of life and can behave aggressively multiple osteomas are noted, a patient should be causing expansion, erosion of the bone, tooth evaluated for Gardner’s syndrome. Gardner’s displacement, and local destruction. The most syndrome is characterized by precancerous common location for a cementoblastoma is the intestinal polyps, multiple osteomas, and other distal root of the first mandibular molar. tissue abnormalities. The clinical significance is Hypercementosis can present radiographically paramount due to an almost 100% malignant similar to cementoblastoma, as seen in this case. transformation rate of the intestinal polyps by age Considering the age of the patient as well as the 30. Treatment for Gardner’s syndrome includes lack of expansion and pain, the most likely prophylactic colectomy and close clinical follow diagnosis is hypercementosis. up for other cancers.

Osteoblastoma: LOCALIZED RADIOPACITIES NOT IN ASSOCIATION WITH Osteoblastomas are rare benign neoplasms of TEETH origin. Osteoblastomas are commonly associated with dull pain and tenderness not relieved by non-steriodal anti-inflammatory drugs Exostoses: (NSAIDs). Radiographically, these lesions can Exostoses are benign bony hard growths that be radiolucent to radiopaque with variable arise from the cortical plate of the maxilla and quantities of mineralization within. The size can mandible. While the etiology is controversial, vary from 2-4 cm; however, rarely, they can be up genetic and environmental influences(such as to 10 cm. An aggressive variant of this lesion clenching and grinding) have been suggested. exists and can cause more significant local Most authors agree that both factors play a role in destruction. the development of exostoses. While most professionals in the dental field can easily Ossifying fibroma (Cemento-ossifying recognize a palatal tori, lingual tori, and fibroma, central ossifying fibroma): exostoses, the less commonly occurring unilateral palatal presentation can sometimes raise alarm. Ossifying fibroma is a benign neoplasm of fibrous In this entity, a bony protuberance arises from the origin containing variable amounts of calcified tissue such as cementum and bone. Page 8

Some recent authorities suggest that this process osteosarcoma, chondrosarcoma, and other is of odontogenic origin, due to its histopathologic cancers. Biopsy is required for definitive similarity to cemento-osseous dysplasia. An x- diagnosis; however, 6 month radiographic follow- ray of this lesion would reveal a central up in an asymptomatic setting of a well radiopacity with a radiolucent rim usually not in circumscribed, unchanging, radiopaque lesion is association with teeth. While radiographically often employed to reduce morbidity and similar to focal cemento-osseous dysplasia, this unnecessary surgery of benign processes. Any entity has the propensity to cause much more ill-defined and/or progressive lesion should be local destruction and disfigurement. These biopsied to rule out a malignancy or destructive lesions are typically solitary although they can benign process. present multifocally. Multiple ossifying fibromas could warrant evaluation for hyperparathyroidism- Quiz: A 53 year old female presents with jaw tumor syndrome. The treatment for ossifying radiopaque mass near the inferior border of the fibroma is surgical excision and, classically, it left mandible(Also present: an area of radiopacity shells out of the surrounding bone easily. This surrounded by a radiolucent rim in the left differs from focal COD which falls apart in many posterior edentulous area, radiopaque areas near gritty pieces. A more aggressive variant, juvenile the apices of #30 and #31 and others). She ossifying fibroma, typically occurs in a younger reports that it has been there since she was a kid population and can cause significant expansion and it is asymptomatic. Clinically, there is left and swelling. The juvenile variant is more facial asymmetry and upon palpation of the common in the maxilla, whereas traditional external body of the mandible, the mass is bony central ossifying fibroma usually occurs in the hard. The most likely diagnosis of this lesion is: mandibular molar and premolar area. a. Malignancy - Osteosarcoma and b. Osteoma chondrosarcoma: c. Osteoblastoma d. Ossifying fibroma Osteosarcoma is a cancer which produces bone. e. Sialolith Osteosarcoma of the jaw typically arises in the 3rd to 5th decade of life with a mean age in the 30s. The most common symptoms include pain and swelling although other signs of malignancy such as paresthesia and tooth mobility may present. The radiologic findings vary from case to case and may be completely radiopaque, mixed radiolucent/radiopaque, or completely radiolucent. Sunburst pattern can be seen in a quarter of the cases and external root resorption causing a spiked root appearance may be suggestive, though not specific to this malignancy. Discussion: In this case, the radiograph revealed an ovoid calcified mass on or near the left In review, location of radiopacities within or mandible. The lesion appears to be peripherally around the jaws can help narrow the differential. located (not within the mandible) due to its The differential for radiopaque lesions that do not visibility below the inferior border. Clinical exam necessarily occur in association with apices of revealed that the mass was on the facial surface teeth include exostoses, osteoma, of the mandible, excluding exostosis and sialolith. osteoblastoma, central ossifying fibroma, The lack of a radiolucent rim surrounding the odontogenic lesions (such as AOT, CEOT, COC, lesion suggests that is not an ossifying fibroma. odontomas) and osseous malignancies such as While osteoblastoma can rarely occur on the surface of the bone, it more commonly occurs within the medullary space. Page 9

This entity was ruled out due to history of RADIOLUCENT LESIONS OF unchanged lesion for more than 50 years and lack of pain. In addition, osteoblastoma typically BONE (SINGLE) appears as a radiolucency with areas of radiopacity within, whereas this lesion appears as Central giant cell granuloma (CGCG) (see a uniform radiopacity. The most likely diagnosis case 2): of this lesion is osteoma. The lesion superior to the osteoma in the left posterior mandible Central giant cell granuloma is a benign lesion of exhibiting a radiolucent rim with varying degrees unknown cause. It usually arises before age 30 of radiopacity is suggestive of a benign fibro- and is more common in the mandible. osseous process. In conjunction with the Radiographically, the lesions may be unilocular or radiographic changes in the periapical area and multilocular radiolucencies and are often seen posterior right mandible, the multifocal crossing the midline. This entity can mimic the presentation is most consistent with cemento- radiographic presentation of periapical disease if osseous dysplasia. The radiopacity surrounding small, or any of the other multilocular lesions the roots of #30 suggests condensing osteitis, (ameloblastoma, odontogenic keracyst (OKC), characterized by bony changes in response to a hemangioma) if large. A diagnosis of central nonvital tooth. This case was included in this giant cell granuloma warrants further work up to course to remind the dental health team that a rule out hyperparathyroidism. Multiple CGCGs patient can present with one lesion or multiple could represent cherubism or other inherited unrelated lesions. conditions, therefore, patients should be referred for further evaluation. Quiz: A 67 year old female presents with this radiopaque mass near the area of the apices of Simple (): #20-23. #21 and #22 tested vital. Which of the following would NOT be considered in the differential? a. Exostosis b. Osteoma c. Sialolith d. Idiopathic osteosclerosis

Discussion: This is a trick question. All of these could be considered in the differential. When looking at a panoramic x-ray, its necessary to determine if the lesion is within bone(such as Simple bone cyst shown with corresponding CBCT images idiopathic osteosclerosis), on the bony surface (Courtesy of Dr. David Barnett and Dr. Kitrina Cordell, LSUHSC (such as an osteoma or exostosis), or School of Dentistry) superimposed on bone (such as a sialolith in Wharton’s duct). After some questioning, the patient reported that her sialolith was present for 15 years. Page 10

Simple bone cyst is a lesion that results from expansion, blood studies may be prudent. Blood trauma to the jaw. Patients may not remember tests showing elevated serum alkaline the traumatic event so a lack of trauma would not phosphatase with normal blood calcium and preclude this entity from the differential. phosphorus levels could be suggestive of Paget Radiographically, this lesion is radiolucent and disease; however, other conditions should be often scallops between the roots of the teeth. ruled out first. The final diagnosis results from a Upon biopsy, a surgeon is met with an empty combination of clinical, radiographic, and blood cavity. Though it is called a cyst, this lesion lacks tests. The clinical significance of a patient with an epithelial lining. Treatment includes curettage Paget disease in the dental office must not be of the walls of the cyst to promote bleeding which overlooked, as complications can occur. in turn will promote bone remodeling. Complications include difficult extractions due to hypercementosis, potentially significant bleeding Central hemangioma: episodes if surgery is performed during the lytic phase of abnormal remodeling, infection and slow Hemangioma is a neoplasm of vascular origin. wound healing in the sclerotic phase, and This lesion typically occurs in the 2nd to 3rd possible development of medication-related decade of life and has a female predilection. The osteonecrosis of the jaws (MRONJ) from radiographic appearance exhibits a unilocular or bisphosphonate therapy. multilocular radiolucency and the margins vary from well to ill defined. Expansion has been : reported in larger lesions. The treatment often consists of “watch and wait” because in many instances, the lesions involute on their own. If biopsy is warranted, it is absolutely imperative that a surgeon aspirates prior to removal to prevent significant blood loss.

Generalized/diffuse radiopacities:

When bony changes appear diffuse or generalized, other differential diagnoses should be considered. Abnormal can suggest conditions such as Paget Disease, osteopetrosis, osteomyelitis, fibrous dysplasia, malignancy, and other systemic disorders.

Paget disease: Paget disease is a metabolic bone disorder that results in abnormal bone remodeling. It occurs in the 5th decade and presents as a diffuse radiolucent (lytic phase) to radiopaque(sclerotic phase) abnormality of the jaw(s) affected. Classically, the radiograph of Paget disease will reveal a cotton wool pattern. It most commonly affects the posterior maxilla and causes (Courtesy of Dr. Molly Rosebush, LSUHSC School of Dentistry) expansion. Intraorally, a patient may experience tooth movement or report that his/her denture is Osteopetrosis is a rare disorder characterized by too tight. Generalized hypercementosis has been increased bone density due to abnormal associated with Paget Disease, and if noted, may osteoclast function. The increased bone density warrant blood studies to be ruled out. Florid results in lack of bone marrow, thus patients have cemento-osseous dysplasia can also mimic this hematologic problems and brittle . The process and in the clinical setting of significant more severe types are usually diagnosed at birth Page 11

or in the first decade of life. The most common radiographically and clinically resemble Paget type, autosomal dominant adult type, has the best disease, fibrous dysplasia is typically seen in a prognosis. Bone pain is present in less than half younger population whereas Paget disease of affected patients. A radiograph of an affected presents over age 40. jaw would reveal diffuse and generalized increase in radiodensity of the bone. While the bone is more dense, it is also brittle and can be REFERENCES AND susceptible to fracture or infection. RESOURCES Osteomyelitis (See case 1): 1. Neville B., Damm D., Allen C., & Chi, A. Osteomyelitis is an acute or chronic infection of (2016). Oral and Maxillofacial Pathology (4th ed.). bone. Radiographically, it can be radiolucent to Elsevier. mixed radiolucent/radiopaque and has been described as having a “ratty” appearance. 2. Mortazavi H, Baharvand M, Rahmani D, Jafari Osteomyelitis more commonly affects the S, Parvaei P. Radiolucent rim as a possible mandible due to the increased bone density and diagnostic aid for differentiating jaw lesions. decreased vascular supply compared to the Imaging Sci Dent. 2015 Dec; 45(4): 253–261. maxilla. It can be localized or diffuse and can resemble malignancy in some cases. Treatment 3. Woo SB, Central cement-ossifying fibroma: of this condition involves biopsy for definitive primary odontogenic or osseous neoplasm? J diagnosis followed by removal of all diseased Oral Maxillofac Surg. 2015 Dec;73(12 tissue, including the source. Suppl):S87-93

Fibrous dysplasia: 4. Delai D, Bernardi A, Felippe GS, da Silveira Teixeira C, Felippe WT, Santos Felippe MC. Fibrous dysplasia is a diffuse, benign, fibro- Florid cement-osseous dysplasia: a case of osseous process that can result in painless misdiagnosis. J Endod. 2015 Nov;41(11):1923-6 swelling, asymmetry, or less commonly severe disfigurement. The majority of fibrous dysplasia 5. Mufeed A, Mangalath U, George A, Hafiz A. patients have the monostotic type (one affected Infected florid osseous dysplasia: clinical imaging bone). In the jaws, a predilection for the maxilla and follow-up. BMJ Case Rep. 2015 Mar 9;2015 is seen. Radiographically, this lesion is described as having a “ground glass” or “orange peel” appearance with poorly defined margins. In most EDUCATIONAL LINKS cases, treatment does not extend beyond periodic follow up and conservative management. 1. http://www.oooojournal.net/ In cases that result in functional deficits or 2. http://www.joomr.org/ cosmetic problems, surgery may be warranted. ABOUT THE AUTHOR

In review, generalized radiographic changes may ASHLEIGH BRIODY, DDS suggest an underlying systemic problem. In ASHLEIGH BRIODY GRADUATED FROM LOUISIANA STATE general, ill-defined localized changes suggest UNIVERSITY SCHOOL OF DENTISTRY IN NEW ORLEANS, LOUISIANA. SHE IS CURRENTLY A SECOND YEAR RESIDENT IN infectious etiology or malignancy whereas well- THE ORAL AND MAXILLOFACIAL PATHOLOGY PROGRAM AT THE defined localized changes suggest a benign OHIO STATE UNIVERSITY COLLEGE OF DENTISTRY. HER FUTURE process. When generalized changes are noted, CAREER PLANS INCLUDE SUPPORTING A BIOPSY SERVICE AS WELL AS TREATING AND MANAGING PATIENTS WITH ORAL age of patient and location can be helpful in DISEASE. reaching diagnosis. Fibrous dysplasia and Paget disease are more common in the maxilla, and DR. BRIODY CAN BE REACHED AT [email protected] florid cement-osseous dysplasia, osteomyelitis, NEITHER I NOR MY IMMEDIATE FAMILY HAVE ANY FINANCIAL INTERESTS THAT WOULD and metastasis to the jaws are more common in CREATE A CONFLICT OF INTEREST OR RESTRICT MY JUDGEMENT WITH REGARD TO THE the mandible. While fibrous dysplasia can CONTENT OF THIS COURSE Page 12

post-test instructions - answer each question ONLINE - press “submit” - record your confirmation id - deadline is June 6, 2016 (3:30 PM EST)

Paget disease is more common in young 1 T F patients whereas fibrous dysplasia is more common in older patients.

You take a perioapical radiograph (PA) and 2 notice a periapical radiolucency associated with T F a lower incisor. The next step would be to start endodontic therapy.

Condensing osteitis occurs in association with 3 T F nonvital teeth whereas cemento-osseous dysplasia occurs in association with vital teeth

4 In early stages, cementoblastoma can appear T F radiographically similar to hypercementosis.

d i r e c t o r 5 Generalized hypercementosis can be seen in john r. kalmar, dmd, phd T F patients with fibrous dysplasia [email protected]

program manager Malignancy will typically appear ill-defined on a ross white, bs 6 T F radiograph whereas osteomyelitis will be well- [email protected]

defined channel coordinator Patients with fibrous dysplasia can have blood jon strasbourg, ba 7 T F disorders as a result of the increased density in strasbourg,[email protected] the affected bone.

The clinical significance of recognizing a patient 8 T F with Gardner's syndrome is risk for colon

cancer. Page 13