Bone pathology I - inflammatory disease of bone - osteitis

Question 1

name types of inflammatory diseases of bone?

Answer 1

alveolar osteitis (dry socket)

focal sclerosing (condensing) osteitis

osteomyelitis

radiation injury and osteoradionecrosis

medication related osteonecrosis of the jaw

Question 2

types of osteomyelitis?

Answer 2

• Suppurative osteomyelitis.
• Sclerosing osteomyelitis.
• Chronic osteomyelitis with proliferative periostitis
  (Garre’s osteomyelitis, periostitis ossificans).

Question 3

osteitis?

Answer 3

localised inflammation of the bone with no progression through medullary cavity

Question 4

osteomyelitis?

Answer 4

inflammation of the interior of the bone usually involving the medullary cavity; may progress to erode or even perforate the cortex

Question 5

periostitis?

Answer 5

inflammation of the periosteal surface of the bone; may cause superficial erosion of the cortex

Question 6

osteonecrosis?

Answer 6

death of one tissue; areas of non-vital bone are separated by osteoclasts and form sequestra;

occurs in osteomyelitis, after radiotherapy, bone infarction, and in relation to drugs

(bisphosphonates and denosumab) and chemicals (phosphorus exposure)

Question 7

bisphosphonates?

Answer 7

reduce osteoclast activity by decreasing osteoclast progenitor development and recruitment and by promoting osteoclast apoptosis

Medication related osteonecrosis of the jaw (MRONJ)

Question 9

MRONJ?

Answer 9

medication-related osteonecrosis of the jaw

Question 10

osteonecrosis vs osteomyelitis?

Answer 10

Both ONJ and osteomyelitis cause painful bone loss.

But bacteria or fungi cause osteomyelitis, which is a type of bone infection.

When the infection affects your jawbone, you may have symptoms similar to ONJ.

Question 11

Healing of extraction sockets?

Answer 11

• After tooth extraction, the
  socket fills with blood which
  forms a clot.
• The clot is organized to form
  granulation tissue.
• Resorption of the crestal bone
  and other bony fragments.
• Gingival migration and
  proliferation over the gap.
• Replacement of granulation
  tissue with woven bone.
• Remodelling of the woven
  bone.

after 4 weeks, trabecular bone formed in socket and gingival migration = seal and keratinised

Question 12

dry socket aka?

Answer 12

alveolar osteitis

Question 13

is alveolar osteitis a complication of extraction?

Answer 13

yes 1-3%

Question 14

what teeth have a higher risk of alveolar osteitis?

Answer 14

lower molars have higher risk

Question 15

when is alveolar osteitis more common?

Answer 15

difficult extractions

highest incidence follows extraction of impacted mandibular third molars

Question 16

risk factor of dry socket?

Answer 16

smoking / tobacco use

• have certain systemic disease which affect the vasculature
• traumatic extraction
• hypercementosis
• ankylosis
• aggressive in extraction

Question 17

what is dry socket?

Answer 17

localised inflammation of bone following the failure of a blood clot to form, or the premature loss of disintegration of the blood clot

Question 18

why is dry socket more common in the mandible?

Answer 18

vasculature not as rich in mandible compared to maxilla

Question 19

why can blood clot fail to form?

Answer 19

• Poor blood supply:
• Osteopetrosis.
• Paget’s disease of bone.
• Following radiotherapy.
• Excessive use of vasoconstrictors in local anaesthesia.

Question 20

why can premature loss of blood clot occur?

Answer 20

• Clot washed away by excessive mouth rinsing.
• Disintegration due to fibrinolysis (infection by proteolytic bacteria).

Question 21

if a blood clot does not form or loss of blood clot cause dry socket?

Answer 21

• Food debris, bacteria and saliva collect in the empty socket.
• The bone becomes infected and necrotic.
• The infection is limited to the socket walls by the
  inflammatory reaction in the adjacent marrow.
• Sequestra are formed by the separation of dead bone by
  osteoclasts.

usually bone marrow produced inflammatory reaction to this so it limits the infection to the bony socket

osteoclasts activated and separate infected bone, so might be sequesta of one in the socket

Question 22

clinical appearance of alveolar osteitis?

Answer 22

• Severe pain 2-3 days after extraction.
• Radiating pain to the ear could be reported.
• Socket contains foul tasting and smelling decomposing food
  debris.
• Debris could be washed away to reveal the denuded bone.

Question 23

How to prevent alveolar osteitis?

Answer 23

• Identification of risk factors (history and clinical examination).
• Treating infection.
• Improving oral hygiene.
• Smoking- cessation advice.
• Minimizing trauma during extractions.
• Advising the patient to avoid excessive rinsing.

Question 24

management of alveolar osteitis?

Answer 24

• Radiograph to exclude retained fragments of tooth or foreign
  material.
• Socket should be irrigated with warmed saline and debris
  gently dislodged.
• Socket should be lightly packed with a dressing (obtundant for pain relief and a non- irritant antiseptic).
• Analgesics should be prescribed and the patient kept under review until they are pain- free and socket healing is ensured.
• May persist for 40 days and irrigation with application of a
  dressing may need to be repeated.

Question 25

Focal Sclerosing (Condensing) Osteitis?

Answer 25

low-grade infection that affects the tooth

• could spread to periapical bone

if immune system string could be and very low grade infection - you get sclerosis and excess bone in response to periapical inflammation

• see steosclerosis
• A bony reaction to a low grade periapical inflammation.
• At the apex of teeth especially the first permanent molar.

even after tooth treated endodontically, it will remain

need to make sure there is not ankylosis or it will need extraction

Question 26

What teeth do you see focal sclerosing (condensing) osteitis?

Answer 26

• At the apex of teeth especially the first permanent molar

Question 27

what disease is shown?

Answer 27

Focal Sclerosing (Condensing) Osteitis

Question 28

dental ankylosis?

Answer 28

Tooth ankylosis occurs when the periodontal ligament dissolves, causing the tooth to become fused directly to the jawbone

Question 29

what do you want to make sure doesn’t occur here?

Answer 29

ankylosis - tooth will need extracted

this image shown focal sclerosing osteitis

Question 30

differential diagnosis?

Answer 30

periapical cementoma

one of the fibro-osseous dysplasias

it is FOCAL SCLEROSING (CONDENSING) OSTEITIS
- if pt has has RCT or pulpitis then suspect bony sclerosis

Question 31

if you extract tooth does this sclerosis remian?

Answer 31

yes

called bone island

can also just be bony islands in bone - not necessarily related to infection

Question 32

what is shown?

Answer 32

focal sclerosing (condensing) osteitis

may remain after extraction (dense bone island)

Question 33

histology of focal sclerosing (condensing) osteitis?

Answer 33

• Localized increase in the number and thickness of bony trabiculae.
• Scattered lymphocytes and
  plasma cells.
• Scanty fibrosed marrow.

appear more radiopaque than normal bone

Question 34

why does Focal Sclerosing (Condensing) Osteitis appear more radiopaque than bone?

Answer 34

• Localized increase in the number and thickness of bony trabiculae.