Diffuse/Generalized Inflammatory Lesions

Question 1

PA abscess possible sequela

Answer 1

• Occurs w/ spread of infection/inflammation through adjacent structures
• Infection/inflammation at distant location from origin

Question 2

Sinus tract - PA abscess w/ purulence

Answer 2

• Pus dissects through bone, destroying bone
• Perforates cortical plate of bone, extending to ST
• Tends to follow path of least resistance
• Finds a point of exit and drains purulence
• May be intermittant drainage

Question 3

PA abscess possible sequela - Sinus tract

Answer 3

• Purulent material collects at apex of non-vital tooth
• Abscess progresses, more pus collects, starts spreading along path of least resistance
• Pus starts dissecting through and destroying bone - when you start seeing RL on rad
  
  • Can take different paths = different sequela
• In case of sinus tract, purulence perforates cortex and goes into ST Once in the ST, it channelizes through overlying ST, perforates through surface epithelium, draining purulence

Question 4

Drainage pathways of PA abscesses

Answer 4

• Determined by anatomic position of root apex

1. Surface of gingiva - Parulis
2. Palate - Palatal abscess
3. MX sinus
4. ST spaces, superior (MX) and inferior (MN) to buccinator m. - Cellulitis
5. FOM - Ludwig angina

Question 5

Why do most dental-related abscess perforate buccally?

Answer 5

Bc the bone is thinner on the buccal surface

Question 6

Infections in what locations typically drain through the lingual cortical plate?

Answer 6

• MX lats
• Palatal roots of MX molars
• MN M2 and M3

Question 7

Parulis

Answer 7

• Erythematous mass of granulation tissue at IO opening of sinus tract
• Two types
  
  • Hole w/ surrounding redness
  • Enlarged nodular mass
    
    • Yellow to white red to purple
    • Sessile or polypoid

Question 8

Cutaneous Sinus Tract/Parulis

Answer 8

• Typically enlarged nodular mass
• Red and yellow/white/purple
• W/ MN teeth most commonly

Question 9

Osteomyelitis

Answer 9

• Acute/chronic inflammation of bone away from initial site
• Diffuse​ area involved, not localized and not well defined
• Leads to bone necrosis and sequestrae
  
  • Sequestrum: Piece of necrotic bone that is separated from surrounding viable bone w/ RL area
  • Spreads normally bc immunocompromised

Question 10

Osteomyelitis: Cause

Answer 10

• Most common cause: Tooth related infection
• Vast majority caused by bacterial infections
  
  • Pyogenic organisms: Staph & Strep

Question 11

Osteomyelitis: Predisposing conditions

Answer 11

• Decreased host resistance
• Decreased vascular supply to bone

Question 12

Osteomyelitis: Pathogenesis

Answer 12

• Acute suppurative inflammation
• Interruption of vascular supply
• Necrosis & resorption of bone
  
  • Formation of sequestrum & involucrum
    
    • Sequestrum: Fragment of necrotic bone
    • Involucrum: Sequestrum that has new vital bone around it
  • Very weak bone; fractures easily

Question 13

Osteomyelitis: Clinical features

Answer 13

• Pain
• Swelling, purulent drainage
• Fever, leukocytosis, tender lymphadenopathy
• More common in MN
• Complications
  
  • Cellulitis and/or pathologic fracture

Question 14

Where does osteomyelitis most commonly occur?

Answer 14

MN

Question 15

Osteomyelitis: Radiographic features

Answer 15

• No rad changes during first week
• Later, diffuse RL areas
• RO areas representing sequestrae

Question 16

Osteomyelitis: Acute

Answer 16

• <1mo
• Ill-defined RL which may contain fragments of necrotic bone separated from adjacent normal bone (sequestrum)
• Mothy appearance w/ sclerotic bone
• Necrotic bone & acute infiltrate composed mainly of neutrophils

Question 17

Osteomyelitis: Chronic

Answer 17

• >1mo
• Patchy, ill-defined RL w/ mote-eaten appearance
• Necrotic bone & chronic inflammatory infiltrate composed mainly of lymphocytes

Question 18

Osteomyelitis Tx: Acute & Chronic

Answer 18

• Acute
  
  • Abx
  • Surgery may or may not be required
• Chronic
  
  • Difficult to manage (fibrous wall blocks abx)
  • Surgical intervention is mandatory
  • Abx administered IV

Question 19

Osteomyelitis w/ Proliferative Periostitis

Answer 19

• Periosteal rxn to presence of inflammation
• Most common cause: Caries leading to PA inflammation spreading to periosteum
  
  • ​Periosteum responds by depositing bone
• Mostly seen in PM and M areas of MN
• “Onion skin” pattern: Usually on buccal; bone deposited in layers parallel to bony cortex
• Occurs mainly in young people and MN
• Bony swelling, but not painful
• Rad: Parallel layers of new bone deposited b/w cortex & periosteum
• Proliferative periostitis: Swelling of border of MN

Question 20

Osteomyelitis w/ Proliferative Periostitis Tx

Answer 20

• ID & Tx source of inflammation
• Bone remodeling occurs 6-12mo

Question 21

Causes of Periosteal New Bone Formation

Answer 21

• Osteomyelitis
• Neoplasms, often malignant (classically Ewings sarcoma, osteosarcoma)
• Cysts
• Trauma

Question 22

Cellulitis

Answer 22

• Purulence perforates cortex and spreads diffusely through overlying ST instead of draining/cannot establish drainage point
• Typically spreads through tissue layers between fascial planes, often producing space infections
• Can lead to two life-threatening conditions
  
  • Ludwig’s angina
  • Cavernous sinus thrombosis

Question 23

What two life threatening conditions can cellulitis lead to?

Answer 23

• Ludwig’s angina
• Cavernous sinus thrombosis

Question 24

Ludwig’s Angina

Answer 24

• Drainage of PA abscess in the MN (FOM)
• Cellulitis of subMN region
• 70% of cases develop from abscess of MN molar
• Rapid swelling of sublingual, subMN, submental spaces
• May extend to spaces around the throat and close off airway
• DEATH CAN OCCUR
• Creates massive swelling of neck
• Sublingual involvement causes swelling and elevation of tongue = “woody tongue”
• SubMN space spread causes enlargement and tenderness of neck = “bull neck”

Question 25

Ludwig’s Angina Tx

Answer 25

• Need to be hospitalized
• Tx usually center around 4 things
  
  • Maintain airway
    
    • Most important thing!
  • I & D
  • Abx
  • Eliminate original focus of infection
• Systemic corticosteroids can help reduce cellulitis
  high dose PCN is drug of choice

Question 26

Cavernous Sinus Thrombosis

Answer 26

• Results from abscess of MX anterior or PM
• K9 is often source of infection
• Appears as edematous periorbital enlargement w/ involvement of eyelids & conjunctiva
• Swelling typically presents along lateral border of nose
• Can occur from anterior or posterior pathway
• Possible sequelae
  
  • Protrusion & fixation of eyeball
  • Pupil dilation w/ photophobia
  • Excessive lacrimation
  • Loss of sight in involved eye
  • Meningitis
  • Brains abscess
  • Death is possible

Question 27

Cavernous Sinus Thrombosis Tx

Answer 27

• Surgical drainage
• High dose abx therapy
• Extract offending tooth

Question 28

What are the Diffuse/Generalized Inflammatory Lesions?

Answer 28

• Osteomyelitis
• Osteomyelitis w/ Proliferative Periostitis
• Osteoradionecrosis (in another category too)
• Bisphosphonate Osteonecrosis of the Jaws (in another category too)