Exam 2 - Malignant Bone Lesions Flashcards
Malignancy showing malignant mesenchymal cells producing _______ (ugly looking pleomorphic cells that make bone).
Fill in the blank and name that lesion.
osteoid; osteosarcoma
What is the most common primary (originating within) bone malignancy?
Note: twice as common chondrosarcoma
osteosarcoma
Name the lesion:
Typically fast-growing mass around knees in children and young adults (mean age = 18 yrs. old)
Osteosarcoma
T/F Individuals who have osteosarcoma will often see metastasis to the jaws.
False there can be but its not often only 6% affect the jaws with the means age being around 33 yrs old
some cases of osteosarcoma arise in ______ disease or ______ bone.
Pagets; radiated
T/F - In osteosarcoma the “sunburst” pattern is uncommon in jaws.
True - sunburst pattern is usually not in the jaws more likely to be in knees of children etc.
Name the lesion:
* Usually mixed lesion with ill-defined borders
* Symmetrically widened PDL of teeth in the area may be seen
* Growth of bone above the crestal height
* “Sunburst” pattern is uncommon in jaws but common in knees
* Metastasis to lung and brain
* Bone production
Osteosarcoma
What is the most common cancer involving bone?
Metastatic carcinoma
__________ __________: Metastatic deposits from malignancies below the neck may affect the jaw through _________ ___________ plexus of veins - no valves.
Metastatic carcinoma; Batson’s paravertebral
T/F The jaw is commonly affected if a pt has metastatic carcinoma.
False; only occasionally
What is the demographic for metastatic carcinoma?
Over half of affected pt are over the age of 50
Metastatic disease stats:
Mandible is affected in ___% of cases
Maxilla is affected in ___% of cases
Soft tissue is affected in __% of cases
Mandible is affected in 61% of cases
Maxilla is affected in 24% of cases
Soft tissue is affected in 15% of cases
If metastatic carcinoma is in the soft tissue what does the gingiva often resemble?
Pyogenic granuloma
Name the lesion:
* Pain, paresthesia (NUMB CHIN syndrome).
* Tooth mobility (mimicking periodontal disease) with PDL widening
* Swelling
* Hemorrhage
* Pathologic Fracture
* Trismus
metastatic carcinoma
Numb chin syndrome was talked about with what malignant lesion?
Metastatic carcinoma
T/F Most of the time metastatic carcinoma is RL.
True
Name the pathology:
Pathologic fracture
Trismus
Poorly defined “moth eaten” RL less commonly RO
Metastatic carcinoma
Metastatic carcinoma:
___% of jaw metastasis represent the initial manifestation of the malignant process. (Meaning dentist first to diagnose pt has cancer)
22%
Most common primary tumors that metastasize to the jaw are:
________ or __________(May be RO)
Thyroid, lung, kidney, colon
Breast or prostate
Most common primary tumors that metastasize to the jaw are:
Breast or prostate (May be RO)
_____, ________, _______, _________
Thyroid, lung, kidney, colon
In soft tissue metastasis - most often see primary tumors from _______, __________, ________, and ________
breast, lung, kidney and melanoma
Describe metastatic carcinoma radiographically
Poorly defined, “moth eaten” RL less commonly RO
With Lack of healing of a tooth socket clinically consider: (3 things)
Granulation tissue
Lymphoma
Metastatic Disease
What is the histology of Metastatic carcinoma?
Looks like tissue of origin, may show diffuse infiltration or scattered tumor cells (“seeded” effect)
T/F Once metastatic disease found in the mouth the disease is typically widely disseminate disease (Stage IV) once it appears in the oral cavity.
True
What is metastatic disease prognosis?
Very poor; most pt die within one year of diagnosis
How to tx metastatic disease?
Palliation, usually with radiation therapy
Bisphosphonates given to slow progression of bone mets and decrease bone pain and fracture risk
Name the lesion: Acute or chronic inflammatory process in the medullary space or cortical surface of bone that extends away from initial site of infection. “Inflammation of the bone”
Osteomyelitis
What are the two main types of osteomyelitis?
- Bacterial related - “suppurative osteomyelitis”
- “Diffuse sclerosing osteomyelitis” Idiopathic inflammation of bone w/out suppuration or sequestra
Describe Suppurative osteomyelitis
Lytic destruction with suppuration and sequestra formation (dead pieces of bone coming off); bacterial in origin
What does Suppurative osteomyelitis often arise from?
Tooth infection
Trauma/fracture that gets secondarily infected
Setting of immunosuppression or diseases that decrease bone vascularity
T/F Diffuse sclerosing osteomyelitis / idiopathic inflammation has no sequestra but has suppuration. It is non-responsive to antibiotics.
False It has no sequestra or suppuration.
It does lead to bone sclerosing and is non-responsive to antibiotics.
T/F Acute suppurative osteomyelitis can cause paresthesia of lower lip mimicking malignancy.
True
Describe process of acute suppurative osteomyelitis:
Starts off as an Ill-defined RL with drainage or separation and exfoliation of necrotic bone (called these pieces sequestrum).
Then Necrotic bone can be surrounded by new vital bone (called involucrum).
All of this process is happening over the course of <1 month
S/S: Fever, leukocytosis, LAD, pain and soft tissue swelling for <1 month
How do you tx acute suppurative osteomyelitis?
Resolve source of infection (EXT tooth or fix fracture)
Remove infected bone
Drain
Empiris use of antibiotics while awaiting culture and antibiotic sensitivity results to make sure the antibiotics you are giving the bacterial organism are sensitive to (PCN with metronidazole or clindamycin)
Multiple procedures may be require over days to weeks to eliminate infection and reconstruct
T/F acute suppurative osteomyelitis is mostly RL.
True
Name the pathology:
Defensive response produces granulation tissue that remodels into dense scar tissue attempting to wall off the infected area. This dead space harbors bacteria and antibiotics have difficulty reaching the area which can lead to a smoldering process with periodic acute exacerbations.
Chronic Suppurative Osteomyelitis
How does Chronic suppurative osteomyelitis arise?
Can arise de novo or from unresolved acute osteomyelitis
What space harbors bacteria in Chronic suppurative osteomyelitis?
The dead space
Note: antibiotics have difficulty reaching the area which can lead to a smoldering process with periodic acute exacerbations.
In Chronic suppurative osteomyelitis _______ have difficulty reaching the area which can lead to a _______ process with periodic acute exacerbations.
antibiotics; smoldering
T/F Radiographically chronic suppurative osteomyelitis has more of a mixed appearance compared to acute suppurative osteomyelitis.
True - chronic has more opaque sequestra where as acute is more RL
How do you treat chronic suppurative osteomyelitis?
Removal of all infected material to good bleeding bone (ranges from resection to curretage)
Hyperbaric oxygen used in refractory cases or for disease arising in hypervascularized bone (osteoradionecrosis, paget disease, COD)
IV Antibiotics to get high dose to dead space
T/F IV antibiotics is used to tx acute suppurative osteomyelitis.
False that is for chronic suppurative osteomyelitis
What is Hyperbaric oxygen used for?
To tx Chronic suppurative osteomyelitis
- used in refractory cases
- diseases arising in hypervascularized bone
Medication-related to osteonecrosis of the jaw (MRONJ)
Is defined by current or previous tx with either class of medication:
______________ (bisphosphonate and denosumab).
______________ agents [tyrosine kinase inhibitors (sunitinib, sorafenib), VEGF inhibitors (Bevacizumab)]. —- Cancer therapies designed to stop the growth of ________ _________.
Antiresorptive (bisphosphonate and denosumab).
Antiangiogenic agents [tyrosine kinase inhibitors (sunitinib, sorafenib), VEGF inhibitors (Bevacizumab)].
Blood Vessels
Name the pathology: Exposed bone in maxillofacial region for > 8 weeks
No hx of radtx or obvious metastatic disease to jaw.
Medication-related to osteonecrosis of the jaw (MRONJ)
Name the medications:
A. Used to treat cancer. Designed to stop growth of blood vessels.
B. Treating osteoporosis or cancer involving bone (multiple myeloma, breast/prostate carcinoma)
A. Antiangiogenic agents - tyrosine kinase inhibitors (Suni and Soraf), VEGF inhibitors (Bevacizumab)
B.Antiresorptive - bisphosphonate and denosumab
Name the pathology: Exposed bone in the maxillofacial region for > 8 wks. No hx of radtx or obvious metastatic disease.
Medication-related Osteonecrosis of the Jaw (MRONJ)
~90% of MRONJ cases occur in pt receiving ___ _________ for metastatic cancer.
IV bisphosphonates
__% of pt taking IV bisphosphonates develop MRONJ.
1%
Bisphosphonates for osteoporosis differs in that ____% of pt will develop MRONJ. Also in these pt necrosis usually does not occur within the first ___ - _____ years.
0.01% ; 2-4 yrs
Describe MRONJ (5 things)
- Begins as increased RO of the crestal bone
- Then pain, necrosis, and infection
- Both jaws can be involved
- Can happen after trauma, or follow EXT, or spontaneously
- Tori often involved because mucosa is thin
Decribe MRONJ
1. Begins as increased RO of the _____ bone
2. Then pain, necrosis, and infection
3._____ ______ can be involved
4. Can happen after trauma, or follow EXT, or spontaneously
5. _____ often involved because mucosa is thin
crestal; Both jaws; spontaneously; tori
With MRONJ tori are often involved because of thin mucosa.
True
MRONJ Tx:
Small areas of necrosis usually tx with _____ may heal slowly without surgery.
Large areas of necrosis much more difficult to tx surgically.
chlorhexidine
ChemoTx Oral complication include
1. Hemorrhage caused by ______________ from bone marrow suppression and/or _________ __________ ____________ from intestinal or hepatic damage
2. Oral Mucositis
Thrombocytopenia (low platelet count) ; reduced clotting factors
ChemoTx Oral complication include
1. _________ caused by thrombocytopenia from bone marrow suppression and/or _________ __________ ____________ from intestinal or hepatic damage
2. Oral Mucositis
Hemorrhage; reduced clotting factors
What oral complication is Single most debilitating complication of chemotx (most often for stem cell transplant called “myeloablative therapy”) or radiation of the head and neck for H&N cancers?
Oral Mucositis
T/F Oral Mucositis increases need for total parenteral nutrition and risk for sepsis.
Virtually all oral cancer pt will develop this.
True
Mucositis develops a few days after start of tx; involves mostly nonkerat surface sparing hard palate, gingiva, and dorsal tongue.
Is this for chemo or Radtx?
Chemo tx
When does mucositis begin typically for chemo vs radtx?
Chemo - few days after start of tx
Radtx - during the 2nd week of therapy (noteradtx therapy is usually 7 weeks)
How long does it take for mucositis to resolve after treatment?
2-3 weeks after cessation of tx of chemo and radtx
Does mucositis involve kerat or non-kerat tissues?
Non kerat
Describe Clinical appearance of oral mucositis.
whitish discoloration that sloughs showing atrophic, edematous, erythematous and friable layers that then ulcerate (yellow fibrinopurulent surface membrane). Very painful
Recommendation for tx of Mucositis.
________ (keratinocyte growth factor) - for HSCT for hematologic cancers not metastatic ________ (because this would stimulate the epithelial tissue in carcinoma to grow and you don’t want the cancer growing).
Oral cryotherapy (ice chips, ic-cold water, ice cream, popsicles) __ min before and ___ min after
_________ mouthwash - prevention RT, CT
_______ _______ ________therapy - prevention in HSCT patients and TBI
Honey - prevention in RT or CT
Topical morphine (physician would give)
Radiation blocks - limits rad exposure (includes cotton rolls/splints)
Saline or baking soda
Paliferm (keratinocyte growth factor) - for HSCT for hematologic cancers not metastatic carcinoma (because this would stimulate the epithelial tissue in carcinoma to grow and you don’t want the cancer growing)
Oral cryotherapy (ice chips, ic-cold water, ice cream, popsicles) 5 min before and 30 min after
Benzydamine mouthwash - prevention RT, CT
Low level laser therapy - prevention in HSCT patients and TBI
Honey - prevention in RT or CT
Topical morphine (physician would give)
Radiation blocks - limits rad exposure (includes cotton rolls/splints)
Recommendation for tx of Mucositis.
__________ (keratinocyte growth factor) - for HSCT for hematologic cancers not metastatic carcinoma (because this would stimulate the epithelial tissue in carcinoma to grow and you don’t want the cancer growing)
Oral cryotherapy (ice chips, ic-cold water, ice cream, popsicles) 5 min before and 30 min after
Benzydamine mouthwash - prevention RT, CT
Low level laser therapy - prevention in HSCT patients and TBI
_____ - prevention in RT or CT
Topical _______ (physician would give)
Radiation blocks - limits rad exposure (includes cotton rolls/splints)
Saline or baking soda
Paliferm (keratinocyte growth factor) - for HSCT for hematologic cancers not metastatic carcinoma (because this would stimulate the epithelial tissue in carcinoma to grow and you don’t want the cancer growing)
Oral cryotherapy (ice chips, ic-cold water, ice cream, popsicles) 5 min before and 30 min after
Benzydamine mouthwash - prevention RT, CT
Low level laser therapy - prevention in HSCT patients and TBI
Honey - prevention in RT or CT
Topical morphine (physician would give)
Radiation blocks - limits rad exposure (includes cotton rolls/splints)
What is the newer agent talked about with treating oral mucositis?
High potency polymerized cross linked sucralfate
Although there is not enough evidence… possible managements of oral mucositis inculde:
- magic mouth was (antacid, antihistamine, anesthetic, antifungal, antibiotic or corticosteroid)
- zinc supplementation suppose to help with taste
What type of Acute Dermatitis is the description below
erythema, edema, burning pruritus that resolves in 2-3 wks after therapy then hyperpigmentation and variable hair loss
Mild
What type of Acute Dermatitis is the description below
erythema, edema with ulcerations/erosions. Resolves within 3 months with possible permanent hair loss, hyperpigmentation and scarring
Moderate
What type of Acute Dermatitis is the description below
necrosis and deep ulcerations
Severe
Describe Chronic Dermatitis
Dry, smooth, shiny, telangiectatic or ulcerate areas
What are the 6 oral complication of Radtx?
Oral mucositis
Dermatitis
Xerostomia
Taste change
Trismus
Osteoradionecrosis
T/F Salivary glands are very sensitive to radiation (>40 Gy is irreversible, which pt are almost always above).
True
> ______ Gy is irreversible.
40
What type of glands are affected the most?
Serous glands - parotid glands affected dramatically and irreversibly
T/F Mucous glands fully recover from Radtx.
False:
Mucous glands partially recover, possibly up to 50% over several months
Effects of radtx cause xerostomia that begin within ____ of radtx initiation. There is a dramatic decrease in salivary flow during the first ______ of tx. Can continue to decrease for _____ years.
Effects of radtx cause xerostomia that begin within 1 week of radtx initiation with dramatic decrease in salivary flow during the first 6 weeks of tx. Can continue to decrease for 3 years.
T/F Xerostomia affects speech, eating, denture wear, sleep and can lead to xerostomia related caries (extensive cervical decay).
True
How do physicians prevent xerostomia during radtx? (2 things)
- Use of IMRT reduces damage to gland
- Surgical transfer of submd gland to submental space
What is the dental management for xerostomia?
Aggressive pre-screening of oral disease
Avoid ________, ________ (dries the mouth)
Daily topical fluoride (1.1% neutral sodium fluoride)
Monitor for and treat ______
Avoid low pH and sugary liquids
Sialogogues (pilocarpine, cevimeline), moisturizing gels/sprays etc. fluoridated tap water
Alcohol. Tobacco
Candidiasis
When does taste usually return after Radtx?
Hypoguesia for several weeks and usually return within 4 months for most pt.
Bute good to note may be permanent loss of taste or have persistent altered taste (dysgeusia).
Reduced taste =
Hypoguesia
Altered taste =
dysgeusia
What may help with getting taste back after radtx?
Zinc sulfate supplement
T/F Trismus is a complication of Chemotx so jaw exercises are important to maintain maximum opening.
False Radtx not chemo
In osteoradionecrosis radiation damages __________ and __________, which ________ blood vessels in bone
osteoblastoma and endothelium; occludes
Mature bone is stable unless injured (EXT, perio disease, mucosal perforation, trauma) - vascular infarct occurs causing _________________.
Osteoradionecrosis
How is osteoradionecrosis defined?
exposed nonvital irradiated bone for longer than 3 months
What is the prevalence of osteoradionecrosis and when does it usually occurs?
5% and occurs 4months-3 yrs after radtx usually
Osteoradionecrosis is unexptected until dose >____ Gy.
60
T/F Osteonecrosis is more common in edentulous pt.
False
T/F Osteoradionecrosis is almost always in the mandible.
True
This is because maxilla tends to have more vascularity so it’s not as affected.
Describe Osteoradionecrosis.
Ill defined RL with zone of RO (dead bone)
Pain, cortical perforation, fistula formation, surface ulceration and pathologic fracture.
How do you tx osteoradionecrosis?
Surgery to remove dead bone and antibiotics
Note: Hard to get back good bone because of poor vascularization
It is important to EXT all non restorable and advanced periodontal disease teeth that are involved in the field of radiation especially if salivary glands are radiated.
When is the best time to EXT teeth to prevent osteoradionecrosis associated with Radtx?
A month or more before Radtx
NEVER DURING TX
Can start 4 months after tx with EXT, it actually gets worse later on. SO NOT AFTER 4 months
Never Ext after 4 months of Radtx. Though the effect slowly improves over time they pt is still vulnerable so ext must be atraumatic. Give pt _____ and ____ (both improve blood flow) and maybe ________ (a bisphosphonate).
Vit. E and pentoxifylline; clodronate
After a full mouth EXT wait on dentures, unless previous denture pt. What are important features of the denture to prevent osteonecrosis of the jaw after Radtx?
Want it be highly polished, short flange, maximize bearing area, flat plane teeth, good horizontal overlap
What can cause paresthesia of lower lip mimicking malignancy?
Acute suppartive osteomyelitis
