BDS12030 Radiographic Interpretation of Inflammatory Jaw Lesions PDF

BDS12030 Radiographic Interpretation of Inflammatory lesions of the jaws Aim: The aim of this tutorial is to orient the student with the clinical and radiographic features of various inflammatory lesions of the jaws. Subject Title Goes Here Objectives: By the end of the tutorial, the student shou...

BDS12030 Radiographic Interpretation of Inflammatory lesions of the jaws Aim: The aim of this tutorial is to orient the student with the clinical and radiographic features of various inflammatory lesions of the jaws. Subject Title Goes Here Objectives: By the end of the tutorial, the student should be able to: - Describe the clinical and radiographic features of the various inflammatory lesions of the jaws. - Differentiate between the various inflammatory lesions of the jaws. Inflammatory lesions of the jaws • The most common pathologic condition of the jaws. • Presence of teeth in the jaws creates a direct pathway for infectious and inflammatory agents to invade bone by means of caries and periodontal disease. • The body responds to any injury with an inflammatory response, that walls off the injurious stimulus and sets up an environment for repair of the damaged tissue. • Response depends on: virulence of the micro-organism & tissue (host) resistance Inflammatory Lesions Periapical diseases (inflammation around the apex) Periodontal diseases or pericoronitis (Infection extends to overlying S.T.) Osteomyelitis (infection extends to the bone marrow) General features of inflammation Clinically • The four cardinal signs of inflammation: redness, hotness, swelling and pain • Acute lesions → rapid onset, usually more painful • Chronic lesions → prolonged course with a longer insidious onset and pain is less intense. General features of inflammation Radiographically Location: Periapical (at the apex) or Periodontal at alveolar crest (may be more apical in cases of more bone loss) Periphery: -Usually ill-defined -Normal trabecular pattern gradually changes into an internal RO or RL region Internal structure RL or sclerotic (RO) or Mixed Effect on surrounding structures Bone: formation or resorption PLS: Apical widening (periapical lesions) Cervical widening (PD lesions) Root: Resorption (chronic lesions) Periosteum: May form new bone parallel to the surface Sources of Infection • • • • • Inflammatory diseases of the dental pulp Extraction wounds Infection from periodontal diseases infection from compound fractures Rarely, hematogenous infection Sequalae of pulpitis • • • • • • • Acute apical periodontitis Chronic apical periodontitis Acute dentoalveolar abscess Chronic dentoalveolar abscess Granuloma Radicular cyst Osteomyelitis Acute Apical Periodontitis ▪ ▪ ▪ ▪ Toxins from the necrotic pulp pass through the root apex Inflammatory reaction confined to periodontal ligament space (PDL)only Clinically: tender on palpation, tooth as if extruded from socket and pain on biting Radiographically: Widening of the PDL space at root apex Acute dentoalveolar abscess • The inflammatory exudate continues to pass to the periapical periodontal ligament → more tissue destruction → pus formation (confined to the apical periodontal ligament) ▪ Clinically: more intense features than apical periodontitis ▪ Radiographically: Widening of the PDL space and loss of lamina dura at root apex Chronic apical periodontitis • May be as a sequela of acute apical periodontitis. • Or starts as chronic due to low virulence of micro-organism and high body defense. • Recurrent dull aching pain • Mild tenderness on percussion • Radiographically: widening of PMS & intact lamina dura. Chronic dentoalveolar Abscess • Clinically: An inflammatory reaction to pulpal infection and necrosis characterized by gradual onset, little or no discomfort and an intermittent discharge of pus through an associated sinus tract. • Radiographically: Periapical RL area, with ill defined boarders Periapical Granuloma • Pulp death or necrosis → localized mass of chronically inflamed granulation tissues at the root apex • Clinically: no tenderness on percussion and tooth is non vital • Radiographically: Circumscribed RL. Usually not more than 1.5-2cm in diameter (usually smaller in size than a radiculr cyst). Periapical granuloma Periapical (radicular) cyst - Long standing periapical granuloma, may undergo cystic degeneration - The cyst may also result from pulp death and necrosis • Clinically: - Asymptomatic non-vital tooth, unless infected. - Rounded swelling with a bluish color. On palpation: hard, egg shell crackling, or fluctuant • Radiographically: - Round or ovoid RL with well defined border, may be corticated - If the cyst becomes infected: ill-defined border and loss of cortication Osteomyelitis • It is an inflammatory disease of bone that extends to the bone marrow and secondarily affects the calcified portion of the bone (cancellous and cortex) and the periosteum. • Some bony parts become ischemic and necrotic → forming Sequestrae Causes of Osteomyelitis 1- Odontogenic : toxins from root canal → PDL space --> extraction wound 2- Predisposing factors: Paget’s disease of bone and osteopetrosis 3- Diseases that lower defensive mechanism as malnutrition, diabetes, anemia. 4- Radiation (Osteoradionecrosis) 5- Medication (MRONJ) leukemia and Clinically • Site: - Adult: posterior Mandible > maxilla . - In infants: more in the maxilla • Gender: Male > while diffuse sclerosing is more in females. • Age: Incidence increase by age. • Mandible >Maxilla, because: - Dense cortical bone takes longer time for the pus to be released, so it spreads within the bone rather than to open in the soft tissue. - Extraction of lower teeth may be difficult → trauma and infection. - The mandible has less blood supply. Classification (types) of osteomyelitis • Acute: - Suppurative - Subperiosteal • Chronic: - Suppurative - Sclerosing : Focal or diffuse • Chronic with proliferative periostitis (Garre’s) • Osteoradionecrosis • MRONJ 1- Acute suppurative Osteomyelitis Clinically: • Rapid onset with severe pain • Generalized symptoms as fever, malaise, leukocytosis, lymphadenopathy and paresthesia (if the lesion affects the mandibular canal) Radiographically • No radiographic changes within the first 10 days after the infection. • Diffuse lytic changes in the bone begin to appear 2- Acute subperiosteal Osteomyelitis As the infection approaches the cortex →Spread into the subperiosteal space →Periosteum is elevated and the pus is pooled, stripping the periosteum off the bone →local necrosis and resorption of the cortex (reduced blood supply and pressure from the pus) →Finally, pus will find its way out and drain intra, or extra orally. • - Clinically Severe pain (due to stripping the periosteum and pooling of pus). Tenderness of the involved teeth. Sinuses discharging pus. Intra, or extraoral swelling. Regional lymphadenopathy. • Radiographically: • Erosion of the cortex giving a moth-eaten appearance. Chronic Osteomyelitis • May occur as a sequlae of the acute phase • Or due to reduced virulence of the micro-organism and an elevated body resistance. • Considered as a persistent abscess of bone with suppuration, necrosis, resorption, sclerosis and hyperplasia. 3- Chronic suppurative Osteomyelitis • Occurs after acute osteomyelitis, or from dental infection. • Clinically: - Mild tenderness. - Low grade fever. - Regional lymphadenopathy. - Intra, or extra-oral sinuses draining pus. - Leukocytosis is slightly higher. • Radiographically: - Single or multiple RL. - Irregular with poorly defined borders → Moth-eaten appearance. - Separation of the diseased bone by RO. - Sequestrum formation (more RO.). - Fistulae appears as RL. hallo over the bone penetrating the cortex. 4- Chronic sclerosing Osteomyelitis A- Focal sclerosing osteomyelitis (FSO) (Condensing osteitis) It’s a focal reaction due to long standing infection and high tissue resistance. B- Diffuse sclerosing osteomyelitis : a condition represents a proliferative reaction of bone to low grade infection. A- Focal sclerosing osteomyelitis (FSO) (Condensing osteitis) A physiologic reaction of bone to inflammation or a long-standing infection • Clinically • • • • • Younger age group. Usually related to lower first molar. Usually associated with deep cavity or deep caries (prolonged irritation). Associated with vital or non-vital tooth. Mild tenderness on percussion. • Radiographically: • Diffuse or well-defined sclerotic (RO) area around the apex of the affected tooth. • Not attached to the tooth, and may be variable in size B- Diffuse sclerosing osteomyelitis (DSO) • Chronic osteomyelitis with more bone formation → sclerotic radiographic appearance • • • • Clinically Old females. Mild pain and fever Acute exacerbation may occur with multiple draining sinuses. Radiographically: Early: Osteolytic (RL) + sclerotic (RO) Late: More sclerosis (cotton wool appearance) 5- Chronic with proliferative periostitis (Garre’s osteomyelitis) • The inflammatory exudate reaches the subperiosteum →elevation of the periosteum →formation of new bone • Clinically - Mostly in the mandibular posterior area. - Young age, as the periosteum is loosely attached to the bone and has an increased osteogenic potential • Radiographically - New bone formation is seen on the occlusal view: Thin RO line parallel to bone surface (Double cortex) - As more layers of new bone are formed: Onion skin appearance 6- Osteoradionecrosis (ORN) • An inflammatory condition (osteomyelitis) that occurs after the bone has been exposed to therapeutic doses of radiation for head and neck cancer treatment. • The irradiated bone is hypocellular and hypovascular. • It is characterized by exposed bone, bone necrosis and failure to heal for at least 3 months. It usually progresses, to become more extensive and painful, leading to infection and pathological fracture. • Clinically - More in the posterior mandibular area (primary tumors and metastatic lesions in lymph nodes being irradiated are commonly adjacent to this part of the mandible) - Loss of mucosal covering → exposure of bone → becomes necrotic (due to loss of vascularity from the periosteum) → sequestrates - Pathologic fracture - Pain may or may not be present. - Intermittent swelling and drainage extraorally. • Radiographically (similar to chronic osteomyelitis) • Location: posterior mandible • Periphery: ill defined. If the lesion reaches the inferior border of the mandible: irregular resorption of the bony cortex. • Internal Structure: Scattered regions of radiolucency, with and without central sequestra (RO). 7- MRONJ • Medication related osteonecrosis of the jaw (MRONJ) is an adverse drug reaction consisting of progressive bone destruction in the maxillofacial region of patients under current or previous treatment with antiresorptive and antiangiogenic medications. • Antiresorptive medications (such as Bisphosphonates) are used for treatment of osteoporosis and cancer. • In 2014, the American Association of Oral and Maxillofacial Surgeons: BRONJ (Bisphosphonate related osteonecrosis of the jaw) → MRONJ • Clinically • An area of exposed bone after an invasive dental surgical procedure. • The most common areas affected are the posterior mandible (60%) and the maxilla (40%) and both (9%). • The areas may be asymptomatic or present with pain and swelling. • Radiographically • Radiographic changes are similar to those in osteoradionecrosis or chronic osteomyelitis with the presence of sequestra. Axial CT scans of the same patient, before bisphosphonate therapy, and one year later. Pericoronitis It is inflammation of the tissues surrounding a partially erupted tooth →Food or microbial debris trapped under the soft tissues →Gingival inflammation →Inflammation may extend to the underlying bone Clinically • Pain and swelling • Trismus • Ulcerated operculum. • • • - Radiographically If confined in the soft tissue, then no bony or radiographic changes If extends to underlying bone: Localized rarefaction or sclerosis Osteomyelitis - RL adjacent to crown with ill-defined sclerotic border enlarging the follicular space - In extensive cases: new bone at inferior cortex and posterior border of ramus Inflammatory Lesions Periapical diseases (inflammation around the apex) Periodontal diseases or pericoronitis (Infection extends to overlying S.T.) Osteomyelitis (infection extends to the bone marrow) Reading material: • Oral Radiology: Principles and Interpretation (7th Ed.) by White, S. C. and Pharoah, M. J, published by Mosby Elseiver. Aim: The aim of this tutorial is to orient the student with the clinical and radiographic features of various inflammatory lesions of the jaws. Subject Title Goes Here Objectives: By the end of the tutorial, the student should be able to: - Describe the clinical and radiographic features of the various inflammatory lesions of the jaws. - Differentiate between the various inflammatory lesions of the jaws.