Diseases of the Bone - Hereditary, Inflammatory, Metabolic and Cystic Flashcards
Describe the incidence of diseases of the bone
- Primary disorders are relatively rare
- Disease is usually secondary process involving the teeth
- May be part of a systemic disease
Describe the 2 parts of the classification of diseases of the bone
- Congenital
2. Acquired
Name 5 types of acquired diseases of the bone
- Inflammatory
- Metabolic
- Cystic
- Tumour-like
- Neoplastic
Name 2 examples of congenital diseases of the bone
- Osteogenesis imperfecta
2. Cleidocranial dysplasia
Name 2 examples of inflammatory diseases of the bone
- Acute alveolar osteitis
2. Suppurative osteomyelitis
Name an example of a metabolic disease of the bone
Hyperparathyroidism
Name 2 examples of cystic diseases of the bone
- Aneurysmal bone cyst
2. Giant cell granuloma
Name 3 tumour-like diseases of the bone
- Torus
- Fibrous dysplasia
- Paget’s diseasse
What is acute alveolar osteitis?
A common painful post-extraction condition characterised by the loss of the clot from the socket
Describe the general features of acute alveolar osteitis
- 3-4% of extractions
- M=f
- Peak in 3rd decade, rare in children
- More common in mandible
- More often with LA than GA
Name 5 predisposing factors to acute alveolar osteitis
- Traumatic extraction
- Impaired blood supply
- Smoking
- Oral contraceptives
- Osteosclerotic disease
Describe 5 clinical features of acute alveolar osteitis
- Severe throbbing pain 24-72 hours post extraction
- Bad taste
- Mucosa around socket painful and tender
- Debris and saliva in socket with no clot
- Lymphadenopathy is common
Describe the radiographic features of acute alveolar osteitis
- May be small fragments of dense bone within the socket
- Usually nothing of note will be seen
Describe the pathogenesis of acute alveolar osteitis
- Uncertain
- Destruction of blood clot, probably by fibrinolytic enzymes
- Trauma to bone will activate tissue-based fibrinolytic enzymes
- Bacteria may play a role by secreting proteolytic enzymes
Describe the pathology acute alveolar osteitis
- Rarely biopsied
- Non-specific
- Non-vital bone with neutrophils and bacterial colonies
- Small amount of granulation tissue
Describe the treatment of acute alveolar osteitis
- Explain problem and reassure patient
- Wash out socket with warm saline
- Place protective dressing into socket (alvogel)
- Prescribe NSAID for pain
- Review
Describe the effect of the 3 ingredients found in alvogel
- Butamben - Provides moderate anaesthetic
- Iodoform - Effective antimicrobial action
- Eugenol - Effective analgesic action
Describe the complications and prevention of acute alveolar osteitis
- Self-limiting condition but may progress to osteomyelitis if patient is immunocompromised or has had radiotherapy to jaw
- Reduce unnecessary trauma by accurate pre-operative assessment
- Prophylactic chlorhexidine helpful in difficult extractions
- Metronidazole often prescribed but no evidence that it’s effective
What is osteomyelitis?
An infection of the bone and marrow spaces with variety of clinical and radiographic appearances
Name 4 classifications of osteomyelitis
- Suppurative osteomyelitis
- Chronic sclerosing osteomyelitis
- Osteoradionecrosis
- Osteochemonecrosis
What is suppurative osteomyelitis?
Infection of the bone and marrow spaces resulting in bone necrosis and production of pus
Describe the general features of suppurative osteomyelitis
- Rare
- Usually in males and mandible
- May follow infections, fracture, surgery or apparently de novo
Name 3 predisposing factors for suppurative osteomyelitis
- Diabetes mellitus
- Immunodeficiency
- Paget’s disease
Describe 6 possible clinical features of suppurative osteomyelitis
- Pain which may be severe
- Regional lymphadenopathy
- Paraesthesia
- Areas of swollen mucosa over alveolus
- Teeth may be tender or mobile
- Sinuses with draining pus or dead bone fragments
Describe the radiographic features of suppurative osteomyelitis
- Bony changes not seen until 10 days
- Large, ill-defined, mottled radiolucency with focal radiodense areas
- New periosteal bone formation (esp lower boarder of mandible)
Describe the pathogenesis of suppurative osteomyelitis
- Infection triggers acute inflammatory response
- Fluid exudation in enclosed space of bone occludes vasculature
- Bone becomes necrotic and acts as foreign body, allowing bacterial proliferation
Describe the histopathology of suppurative osteomyelitis
- Necrotic bone protects bacteria from neutrophils
- Vital bone attempts sequestration via osteoclasts and new bone forms
- Necrotic bone surrounded by pus and granulation tissue
- Bacterial colonies on surface of the dead bone
- Sinus tract may become apparent
Name 3 treatments of suppurative osteomyelitis
- Surgical debridement
- Antibiotics
- Ultrasound therapy
Name 4 complications of suppurative osteomyelitis
- Extensive areas of bone may be lose
- Pathological fractures can occur
- Cellulitis or septicaemia may occur
- May become chronic
What is chronic sclerosing osteomyelitis?
A form of osteomyelitis characterised by bone sclerosis rather than bone destruction and without the formation of pus
Describe the classification of chronic sclerosing osteomyelitis
Focal - Usually young patients, symptomless
Diffuse - Usually older patients which may have dull pain
Describe the clinical features of focal chronic sclerosing osteomyelitis
- Associated with root of non-vital tooth
- Well defined area of dense bone
- Probably due to high local resistance and / or low grade infection
Describe the clinical features of diffuse chronic sclerosing osteomyelitis
- May be associated with teeth
- Relative well defined areas of dense bone
- Uncertain aetiology
Describe the pathology of diffuse chronic sclerosing osteomyelitis
- Irregular, dense sclerotic bone with areas of reduced vitality
- Intertrabecular spaces have mild chronic inflammatory infiltrate
Describe the treatment of focal chronic sclerosing osteomyelitis
Endodontics or extraction
Describe the treatment of diffuse chronic sclerosing osteomyelitis
Extractions, debridement and antibiotics
What is osteogenesis imperfecta?
Group of genetically-determined disorders of bone characterised by excessive fragility and tendency to easy fracturing
Describe the classification of osteogenesis imperfecta
- 4 types with subdivision into 9 subtypes
- Based on clinical findings, genetic pattern of inheritance and biochemical collagen defect
Describe the general features of osteogenesis imperfecta
- Can be autosomal dominant, autosomal recessive and X-linked
- Range of bony fragility depending on nature of biochemical effect
- Range of deformities and weakening
- Connective tissue defects in joints and skin
Describe the clinical features of osteogenesis imperfecta
- Skeletal deformity may be severe
- Blue sclera in eye
- Patients may have dentinogenesis imperfecta
- May be deaf
Describe the HPC of osteogenesis imperfecta
- Rarely present to dentist
- History of multiple fractures since birth
- Teeth may be abnormal
Describe the radiographic features of osteogenesis imperfecta
- Reduced density of bone with sparse trabeculation and poor cortical markings
- Fractures of varying ages may be present
- Teeth may show features of dentinogenesis imperfecta
Describe the histopathology of osteogenesis imperfecta
- Bone shows reduced trabeculation and abnormal configurations
- Fracture callus may be exuberant and very bizarre
Describe the treatment of osteogenesis imperfecta
- No cure is available
- Diet rich in calcium and vitamin D
- Physiotherapy
- Physical aids
- Bisphosphonates
- Surgery
What is giant cell granuloma?
Relatively uncommon benign tumour like lesion of jaw bones characterised by numerous osteoclast-like giant cells
Describe the classification of giant cell granuloma
- Central / Reparative Granuloma (within bone)
2. Peripheral / Giant Cell Epulis (on gum)
Describe the general features of central giant cell granuloma
- Any age but usually 10-25 years
- Usually mandible and often anteriorly
- 2F : M
Describe the clinical features of central giant cell granuloma
- May be silent and painless
- Bony swelling
- Loosening and displacement of teeth
- Ulceration of alveolar mucosa
- Usually slow growth but occasionally rapid
Describe the radiographic features of central giant cell granuloma
Extent: May be large, rounded
Quality: Radiolucency, may have areas of trabeculation
Margin: Localised but often ill defined edges
Adjacent Anatomy: May perforate alveolar bond and extend into mouth
Describe the histopathology of central giant cell granuloma
- Lobulated mass of plump spindle cells
- Numerous osteoclast like giant cells
- Trabecular of osteoid or woven bone at edges
- Areas of old and recent haemorrhage
- Areas of haemorrhage may be prominent, forming large cystic blood filled spaces
- Similar to aneurysmal bone cyst
Describe the treatment for central giant cell granuloma
- Curettage usually curative
- Extraction of loosened teeth
- Exclude hyperparathyroidism
- Large lesions may respond slowly to calcitonin
Describe hyperparathyroidism
State of excessive parathyroid hormone secrtion
Name 2 issues with regards to bone caused by hyperparathyroidism
- Bone resorption
2. Hypercalcaemia
Describe the function parathyroid hormone
Regulates serum calcium through its effects on bone, kidney and the intestine
Describe primary hyperparathyroidism
Results from a hyperfunction of parathyroid glands themselves e.g due to adenoma
Describe secondary hyperparathyroidism
Due to physiological secretion of parathyroid hormone by glands in response to hypocalcamia
Name 2 most common causes of secondary hyperparathyroidism
- Chronic kidney failure
2. Vitamin D deficiency
Describe the general features of hyperparathyroidism
- Uncommon and in adults
- Non-specific symptoms
- Bones, stones, moans and groans
Describe bones, stones, moans and groans as a features of hyperparathyroidism
Bone - Calcium resorption from bones leading to osteoporosis or osteopenia
Stones - Kidney stones
Moans and Groans - High BP, muscle weakness, fatigue, depression
Describe the HPC of hyperparathyroidism
May be gradual onset or an incidental finding
Describe the clinical features of hyperparathyroidism
- Usually normal mouth
- May suffer from xerostomia
- May have giant cell granulomata
Describe the radiological features of hyperparathyroidism
- Bone changes usually minimal
- Advanced cases show loss of bone markings, including lamina dura
- May have cystic area which is giant cell granuloma
Describe the pathology of hyperparathyroidism
Parathyroid hormone activates osteoclasts via mediation of osteoblasts
Name 3 ways to diagnose hyperparathyroidism
- Blood tests
- Intact parathyroid hormone levels
- Bone profile (calcium and alkaline phosphatase levels)
Describe the treatment of hyperparathyroidism
Correction of underlying lesion
