2. Inflammatory Jaw Diseases Flashcards
- Chronic apical periodontitis
- Radicular cyst
- Condensing osteitis
- Osteomyelitis
- Medication-related osteonecrosis
- Proliferative periostitis
◦ Flow chart illustrates what happens to the pulp as it becomes infected and inflamed
Inflammatory jaw diseases are inflammatory in nature
They can be: acute and/or chronic, local or diffuse, infectious in origin
◦
Pathology: reactive to infection, not directly result of infection itself
In FS2, Ali discussed acute inflammation and chronic inflammation using acute pulpitis as the model
Acute inflammation is often the result of ____
‣ mediated by ____ or ____
‣ Chronic inflammation is result of persistent ____, leading to chronic inflammation
mediated by ____ and ____ cells
bacteria
neutrophil
polymorphonucleocytes
irritants
lymphocytes
plasma
◦
‣
‣
____ plays a role in both chronic and acute inflammation
Clean up debris in abscess
And macrophages can play a role as histiocytes in chronic inflammatory type process
google: a stationary phagocytic cell in CT
As pulp is dying, because both acute and chronic pulpitis, will cause continual cell death in pulp space
It goes from reversible–> ____ pulpitis
◦ In January- we will begin endo course - pulp inflammation and how to restore and repair inflammatory pulpal disease, this will serve as good backdrop for that class
macrophages
irreversible
As the pulp evolves from normal to reversible pulpitis:
As the term implies, its reversible. If you eliminate the insult, the pulp should go back to normal
People who have sensitivity to cold, most likely experiencing ____ pulpitis. As the tooth comes into contact with cold it is tender/ sensitivity. As you swallow a cold item, and
the cold no longer in contact with tooth, pulp goes back to normal- this is transient pulpitis/reversible pulpitis
Characterized mechanistically by ____
Hyperemia means blood vessels engorge and are congested with blood cells As you eliminate insult, the pulp goes back to normal, blood flow goes back to normal
How do you protect this from happening? If the dentin is exposed or if you have mild cervical gingival resorption/recession and root dentin is exposed, you can apply ____ to surface. This may help close tubules and help mitigate sensitivity
‣ This is quick and easy approach to limit tooth sensitivity to ice cream and candy
reversible
hyperemia
fluoride varnish
If however, that pulp becomes more progressively inflamed, usually through caries or through fracture that now gives open area for bacteria to enter into tooth, that will evoke a true inflammatory response
as that inflammatory response progresses, that tooth will go from reversible to irreversible pulpitis. In this case, acute pulpitis
As pulpitis further evolves, it will go from preliminary early inflammatory response to one that has progressed to abscess. As ____ accumulate you get abscess
formation
As abscess forms, the only place the abscess can move is through ____ of tooth
Recall that the tooth is a closed organ, essentially one way in and one way out. Primarily through apex, where blood supply and nerve fibers comes from If you’re developing abscess within tooth (he draws tooth on board- caries on top of tooth, bacteria goes into pulp), as you accumulate inflammatory cells, they’ll keep accumulating as long as infection is still there, and you’ll form an abscess
An abscess wants to grow and evolve, it need to grow and create space for itself-
only way for this to happen is it to move ____ through tooth- and as it does it kills
more and more tissue
Now you’ve developed full fledged acute pulpitis- irreversible pulpitis. That tooth warrants treatment- either ____ treatment (to remove infected tissue) or ____ if you cant afford endo
neurtrophils apex down endo extraction
In some cases the acute inflammatory response may settle on its own spontaneously but the bacteria ____/ toxins- remain persistent. Therefore in some pt- may go from acute to chronic pulpitis
Abscess has resolved spontaneously through whatever mechanism. But bacteria still producing junk, so irritants persisting within the canal– that has now evolved to chronic
pulpitis
Its still ____ and warrants a treatment, but its now chronic condition rather than acute condition
In either instance- you have partial or complete pulpal ____
In either instance pulp warrants intervention. Intervention could be root canal or ____
irritants
irreversible
necrosis
extraction
Chronic apical periodontitis Periapical granuloma
• Most common ____ inflammatory jaw disease
• Non-responsive to ____ tests
• Well-____, corticated, ____ radiolucency
radiolucent: lesion is ____, no color to lesion- different from surrounding tissue
osteolytic lesion: implies you’ve lysed the bone- what is there is not full bone/complete bone, its mixed with fibrous and ____ tissue
radiopaque: lesion is ____. Implies calcification in some nature (bone or other structure)
unilocular lesion: circular/egg/ovoid lesion
multilocular: ____ bubbles
These are radiolucent lesions seen at apex of teeth, or lateral side of the tooth
You may have lateral canals on some teeth
By definition this is ____ pulpitis (chronically inflamed tooth) that has progressed to periapical pathology
Acronym PAP– defined as PeriApical pathology lesions are well defined: sometimes are ____ or sclerotic (synonymous terms), corticated border implies a well defined, usually white, boarder that stands out from adjacent tissue
chronic endo defined unilocular black inflammatory white soap
chronic
corticated
Chronic apical periodontitis Periapical granuloma
If the lesion persists as acute phenomenon, in this case as an abscess that has left the apex- as you know abscesses they need space to grow and evolve, they will follow path of least ____
In the oral cavity the path of least resistance is dictated by the position of ____ in bone
Muscular attachments, density of bone, where roots are in relation to the bone
Max central incisors roots are more in the ____ of bone
Max lateral incisor roots- more ____ and ____ positioned
If lateral incisor becomes infected acutely and forms abscess- abscess goes to ____ more
likely, rather than buccal (opposite for central incisor)
Max 2nd molar- has 3 roots
Palatal root with abscess– will go to ____ most likely
◦ Buccal root- more likely to ____
◦ Canine infections
canines have ____ roots, and muscles are far south in mouth
if it progress as abscess it will goes to brain as a ____ which is a life threatening condition
◦
◦ Mandibular infections can go to ____ spaces (Ludwigs angina) life threatening also
All Dictated by path of least resistance/and local anatomy
resistance
root
middle
distal
palatally
palate
palate
buccal
longest
cavernous sinus thrombosis
neck spaces
Chronic apical periodontitis
These are both examples of periapical granulomas
Radiolucency on radiograph
◦ Can see outline that stands out from adjacent tissue. It has well corticated border/ sclerotic border ◦ ◦
You cannot distinguish acute pulpitis versus ____ pulpitis on histology, it is all part of the same spectrum
Acute: ____
chronic: ____, plasma cells, with fibrosis
Term “granuloma” is a misnomer. This is not granulomatous inflammation, but ____ inflammation. Alawi even prefers the term “chronic apical periodontitis”. Apical because the apex of the tooth, periodontitis because its inflammation of the bone
Odontogenic, inflammatory pathology: Typically see acute and chronic cells with macrophages and fibrosis
Hard to make distinction and this acute chronic distinction is NOT made by the histology (non-specific histopathology), but by ____
If you see radiographic lesion that is inflammatory in nature, the implication of the radiographic presentation is that it was at some point a chronic lesion
Acute lesion does not manifest with ____ changes of this nature
◦
◦
At most you might see widened ____ with acute lesions ‣
chronic
neutrophils
lymphocytes
chronic
symptomology
radiographic
PDL
Phoenix abscess
____ abscess arising within ____
Presents with ____
Phoenix abscess– acute exacerbation (re-symptomatic) of a previously ____ state
radiographic appearance implies chronic at some point, and this chronic lesion became reinfected / re-symptomatic through whatever mechanism ◦ ◦
‣ Acute sign and symptoms / acute exacerbation of previously chronic lesion
example: Bugs became ____
◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦
Patient with small fistula on mucosa (blue arrow)
Fistula: is abscess that is ____ (through whatever mechanism) ◦ ◦
◦
If this abscess is on gum/soft tissue it results in a lot of pain
If you see a fistula- you can stick ____ point and take radiograph, to see where gutta percha is
tracking to to see which tooth is source of abscess
picture example: Radiograph shows that incisor is source of abscess
Because radiographically a periapical granuloma may look no different from radicular cyst (aka periapical
cyst), you need ____
acute
periapical granuloma
chronic
reinfected
open
gutta percha
histology
Radicular cyst • Most common \_\_\_\_ cyst • \_\_\_\_ cyst • Tooth is always\_\_\_\_ • Well-defined, \_\_\_\_ – Can’t tell by radiograph if it’s \_\_\_\_ or cyst
He prefers the term radicular cyst, because periapical may imply its at tip of apex, while radicular implies wherever around tooth it is
(If its lateral canal, apical canal- may still see a cystic lining and hence radicular cyst)
◦ This is single most common odontogenic cyst, inflammatory in nature Radiographically can not be differentiated from periapical granuloma
Always go hand in hand if you think one, have to include the other in ____
Like periapical granuloma, tooth associated with radicular cyst is always ____ (tooth is completely dead)
The only way you can get lesion in the bone is if the tooth is dead. If the tooth isn’t dead, you won’t get periapical lesion
odontogenic
inflammatory
non-vital
granuloma
DD
non-vital
Pictures to illustrate radicular cyst. If its characterized as a cyst: it means it’s a cavity lined by ____
That is how you distinguish cyst microscopically from ____ and that is why biopsy important
Its semantic because you can treat the same way. Treat radicular and periapical granuloma with ____ or extraction
‣
(we’ll talk about evolution next lecture)
Both can recur if not treated properly. Radicular cyst can evolve further if left untreated
epithelium
apical periodontitis
root canal
This is cavity lined by epithelium. Any type of ____! Just like soft tissue cyst, any type of epithelium can line the cyst. In this case, the lining is stratified squamous epithelium. When Alawi diagnoses cyst microscopically: “Unless I know how cyst was in relation to tooth anatomically- I can’t give distinctive diagnosis- can just say it is a cyst”
If he was told it was around apex of tooth - this is now ____
◦ This is by definition clinical pathologic correlation. Correlate pathology with the radiology to make appropriate diagnosis
◦ On its own ____ alone- not radicular cyst (on differential yes, but not a cyst until you know it’s a cyst)
Two top choices for this on differential: ____ cyst, ____ apical periodontitis
Microscopically after biopsy- cystic structure - now diagnosed as radicular cyst
◦
If microscopically it just showed ____ inflammation, it would be chronic apical periodontitis
This example doesn’t have corticated border. This is not an absolute requirement, but more often the lesion is well defined with a border
epitheilum
radicular cyst
radiograph
radicular
chronic
chronic
The origin of both chronic apical periodontitis and radicular cyst is ____ of tooth through whatever mechanism: caries, fracture line where bacteria entered
tooth becomes infected, tooth went through acute stage or ____ to chronic stage
◦
If chronic stage: bacteria are still present, but not ____ and not overtly causing infection within the tooth but they are releasing irritant, toxins, metabolic byproducts that aren’t good for tissue structure
This was caused by bacteria but what precipitated lesion specifically- isn’t ____ directly but the garbage that bacteria is producing and the response of the body over time
Body tried to wall off inflammation- by producing cystic structure of just chronic inflammation
This is no longer direct consequence of bacteria itself
While in acute pulpitis, an abscess is direct consequence of ____ and the ____ response that goes with it Someone’s q: You would still see bacteria in this scenario, but not growing as you would see in an abscess. Where as in a phenox abcess- you would see the ____ changes plus acute ____ process and bacteria to go along with it In this context, bacteria reactivated themselves and growing to cause another abscess in chronic background
What we have discussed (radicular cyst, chronicle apical periodontitis, and pheonix access were the three radiolucent pathologies. Next - radiopaque
infection
straight
aggressive bacteria bacteria inflammatory chronic inflammatory
Condensing osteitis
• More common in ____ and young adults
• Usually ____
• Induced by same types of ____ irritants
Also chronic inflammatory nature, but pathology is not directly caused by ____. Pathology is a result of bone trying to protect itself from irritants coming from tooth
Rather than forming chronic inflammatory tissue, bone has become ____ meaning there is more Condensing osteitis is a chronic inflammatory condition but its reactive to chronic inflammation
◦ In this case the bone is reactive
What you see is radiopaque lesion - meaning dark white lesion- to imply calcification
◦
Circles areas in yellow are condensing osteitis
Looking at the lesion on the bottom right. If you follow the PDL, even area where it is more white (radiopaque are) PDL is ____. This is a very important distinction. you can follow this line around the tooth, the PDL is
intact
(different pathology) May see pathology with radiopacity at apex of tooth, but in that context PDL is surrounding the radiopacity- ____, when the PDL follows outline of radiopacity. This is different pathology that
what is seen here as condensing osteitis
kids
lower first molar
chronic
inflammation
hyperplastic
intact
Condensing osteitis is a ____ phenomenon to chronic inflammatory changes within tooth The root is ____, not vital, instead of showing lucency, bone is responding by making more bone to protect itself Most common location for this pathology: lower first molar, often times the ____ root The ____ itself is vital but the root is not.
This tooth is more likely to be ____ to endo test - electropulp test
Pulp not completely normal but there is some response to test because part of tooth is still alive
Even though some of tooth is alive, half of root is dead or dying so it requires root canal to ensure long term
survival
◦ To treat this pathology because it’s a chronic inflamed condition, the tooth will warrant ____
◦
◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦
Normal root canal therapy: Gutta percha is root canal filling material. Once you seal apices- if done properly- it
should be enough to clean tooth of debris and ensure no further leakage into adjacent bone
If this was inflammatory, that should help resolve lesion over time ◦
◦
When patient comes back for follow up – you take a radiograph to ensure area is resolving. If was
inflammatory in nature- it should resolve effectively
In contrast, for the condensing osteoma, still same therapy- root canal therapy but the hyperdense bone may take more ____ to resolve on its own
As long as it doesn’t get bigger or change, then have the patient come back for routine follow up to ensure
◦
therapy worked
reactive dead mesial tooth hyper-responsive
root canal therapy
time
