Generalized radiopacities

Question 1

Disease mechanism:
• Is a localized change in normal bone metabolism that
results in the replacement of all the components of
cancellous bone by fibrous tissue containing varying
amounts of abnormal-appearing bone.
▪ Affects more than one bone
▪ Usually found in children younger than 10 years of age

Answer 1

Fibrous dysplasia (polyostotic)

Question 2

______ Syndrome or
- Polyostotic FD with cutaneous pigmentation (café au lait
spots)

Answer 2

Jaffe-Lichtenstein Syndrome or Jaffe type

Question 3

• Polyostotic FD with cutaneous pigmentation (café au lait
  spots) and endocrinopathies
• Affects almost exclusively women

Answer 3

McCune-Albright Syndrome

Question 4

______ is a widespread form of Periapical cemento-
osseous dysplasia (PCOD)
• If PCOD is identified in three or four quadrants or is
extensive throughout one jaw, it usually is classified as this
• Normal cancellous bone is replaced with dense,
acellular amorphous bone in a background of
fibrous connective tissue.
• Poor vascular supply (susceptibility to infection).
-Has radiolucent rim

Answer 4

Florid cemento-osseous dysplasia

FCOD

Question 5

Clinical Features:
• Most patients are female and middle-aged, although the age range is broad.
• Predilection for African Americans and Asians.
• Often FOD produces no symptoms (incidental finding).
• Extensive lesions often have an associated bony swelling.
• If the lesions become secondarily infected, features of osteomyelitis may develop
• Teeth in the involved bone are vital.
Location
• Usually bilateral and present in both jaws (if in one jaw, the
mandible is the more common).
• Within the alveolar process above the inferior alveolar canal
(mandible)
Periphery
• Usually well defined and has a sclerotic border that can vary in
width
• The soft tissue capsule may not be apparent in mature lesions.
Internal Structure
• Can vary from radiolucent - mixed -
almost totally radiopaque.
• The radiopaque regions can vary from
small oval and circular regions to large,
irregular and amorphous.
Effects on Surrounding Structures
• Large lesions can displace the inferior IAC inferiorly, the floor of the maxillary sinus superiorly and enlarge the alveolar bone.
• The roots of associated teeth may have hypercementosis.

Answer 5

Florid cemento-osseous dysplasia

FCOD

Question 6

______ (may appear similar to the sequestrum seen in
osteomyelitis): This is not to be confused with a situation where
FOD has become secondarily infected, resulting in osteomyelitis.
The foci of amorphous bone that are secondarily infected have a
wider and more profound radiolucent border.

Answer 6

Osteomyelitis

Question 7

Disease Mechanism
• Is a skeletal disorder involving osteoclasts resulting
in abnormal resorption and apposition of poor-
quality bone in one or more bones.
• May involve many bones, but it is not a generalized
skeletal disease.
• It is initiated by an intense wave of osteoclastic
activity, with resorption of normal bone resulting in
irregularly shaped resorption cavities. After a
period of time, osteoblastic activity starts.

Answer 7

Paget’s disease

Question 8

Is paget’s disease seen more in men or women? Old or young

Answer 8

Old men

Question 9

Clinical Features
• Affects later middle and old age (3.5% of individuals older than 40 years of age)
• At age 65 years, the incidence of involvement in men is approximately twice that
of women.
• Affected bone is enlarged and commonly deformed because of the poor quality
of bone formation, resulting in bowing of the legs, curvature of the spine, and
enlargement of the skull. The jaws also enlarge when affected.
• Separation and movement of teeth may occur, causing malocclusion. Dentures
may fit poorly.
• Jaw pain is uncommon.
• Patients may also have ill-defined neurologic pain as the result of bone
impingement on foramina and nerve canals.
• Patients have severely elevated levels of serum alkaline phosphatase

Answer 9

Paget’s disease

Question 10

Patients with pagets disease have what lab finding as far as lab work?

Answer 10

Elevated serum alkaline phosphatase

Question 11

Location:
• Often in the pelvis, femur, skull, and vertebrae and infrequently in the
jaws.
• It affects the maxilla about twice as often as the mandible.
• Although this disease is bilateral, occasionally it affects only one
maxilla, or the involvement may be significantly greater on one side.
• Generally, the appearance of the internal structure depends
on the developmental stage of the disease: three radiographic
stages although these often overlap in the clinical setting:
1. Early radiolucent resorptive stage.
2. A granular or ground-glass appearance.
3. A denser, more radiopaque appositional late stage.
These stages are less apparent in the jaws.

Answer 11

Paget’s

Question 12

What are the 3 patterns of radiogrpahic presentation of paget’s?

Answer 12

Linear
Granular
Cotton-wool

Question 13

Internal Structure: Radiographic pattern
• Linear: The trabeculae may be long and may align
themselves in a linear pattern, which is more common
in the mandible.
• Granular: Similar to that of fibrous dysplasia.
• Cotton-wool appearance.
Effects on Surrounding Structures:
• Always enlarges an affected bone (3x, 4x)
• The outer cortex may be thinned but remains intact.
• The lamina dura may become less evident and may be altered
into the abnormal bone pattern.
• Exuberant and irregular hypercementosis
• The teeth may become spaced or displaced in the enlarging
jaw.
Management
• Usually managed medically (bisphosphonates).
• Surgery may be required to correct deformities
• Extraction sites heal slowly.
• Higher incidence of osteomyelitis
• 10% of cases develop osteosarcomas

Answer 13

Paget’s disease

Question 14

Disease Mechanism
▪ Is an inherited disorder of bone that results from a defect in the
differentiation and function of osteoclasts →Abnormal formation of
bone and abnormal bone turnover thereafter.
▪ The failure of bone to remodel causes the bones to become densely
mineralized, fragile, and susceptible to fracture and infection
▪ Hematopoiesis is retarded and cranial nerves may be compressed
▪ Prevalence: 1 in 100,000 to 500,000.

Answer 14

Osteopetrosis

Question 15

Clinical Features
▪ Three clinical forms:
▪ Infantile malignant: Autosomal recessive. Apparent short after birth. Fatal within the first few years of
life
▪ Intermediate: Autosomal recessive or dominant. Occurs in the first decades of life and can allow a
normal life expectancy. Severity is variable
▪ Benign or Adult type: Autosomal dominant. Full life expectancy. Mild symptoms in late childhood to
adulthood.
▪ Infantile:
▪ Progressive deposition of bone results in narrowing of bony canals and foramina →sensorineural and
sensorimotor deficits including hydrocephalus, blindness, deafness, vestibular nerve dysfunction, and
facial nerve paralysis, etc
▪ Diminished marrow spaces→ Affects hematopoietic development of blood cells
▪ Delayed dental eruption
Frontal bossing, hypertelorism, flat nose, broad face

Answer 15

Osteopetrosis

Question 16

▪ Adult:
▪ May be entirely asymptomatic or have mild signs and
symptoms.
▪ It may be discovered at any time from childhood into
adulthood as an incidental finding, or it may manifest as a
bone fracture.
▪ Diminished marrow spaces secondary to the deposition of
bone → Affects hematopoietic development of blood cells
→anemia, leukopenia, and thrombocytopenia.
▪ The increased bone density and relatively poor vascularity:
Higher risk of osteomyelitis.
Increased risk of fracture

Answer 16

Osteopetrosis

Question 17

▪ Because this condition is systemic, the changes affect all bones
(it is bilateral and symmetrical)
▪ The bone may be so dense that teeth roots and other
structures within the bone may not be apparent
▪ The lamina dura and cortical boundaries are thickened or
blended into the surrounding dense bone
▪ Effects on teeth: missing teeth, malformed roots and crowns,
poorly calcified teeth and delayed eruption as a result of the
increased bone density.

Answer 17

Osteopetrosis

Question 18

How do you treat osteopetrosis?

Answer 18

Bone marrow transplant

Question 19

If osteomyelitis develops from osteopetrosis, what is tx?

Answer 19

Abx and Hyperbaric oxygen therapy

Question 20

______ is a widespread inflammation on the bone marrow.
▪ Most commonly from a dental infection that spread to the bone
marrow
▪ The hallmark is the development of sequestra. A
sequestrum is a segment of bone that has become necrotic because
of ischemic injury caused by the inflammatory process.
▪ This periosteal reaction or periosteal new bone formation is a
characteristic, but not pathognomonic, feature of osteomyelitis. The
periosteum is lifted up by inflammatory exudate, and new bone is laid
down.

Answer 20

Osteomyelitis

Question 21

______ is a segment of bone that has become necrotic because
of ischemic injury caused by the inflammatory process.
-Gets pushed out of the body

Answer 21

sequestrum

Question 22

What is the cutoff to determine if osteomyelitis is chronic or acute?

Answer 22

4 weeks

Question 23

________: is a chronic form of osteomyelitis with a

pronounced sclerotic response.

Answer 23

Diffuse sclerosing osteomyelitis

Question 24

_________: is an exuberant periosteal response to inflammation.

Answer 24

Garre’s osteomyelitis

Question 25

Clinical features of ___ phase of osteomyelitis
➢ All ages and male predilection
➢ More common in the mandible than in the maxilla.
➢ Rapid onset, pain, swelling of the adjacent soft tissues, fever, lymphadenopathy, and leukocytosis.
➢ The associated teeth may be mobile, sensitive to percussion or have purulent drainage.
➢ Paresthesia of the lower lip.

Answer 25

Acute phase of osteomyelitis

Question 26

Imaging features of the ____ phase of osteomyelitis
▪ Very early in the disease, no changes may be identifiable.
▪ Either MDCT or CBCT imaging is the imaging method of choice:
Better detecting periosteal new bone and sequestra.
▪ Location: most common location is the posterior body of the
mandible.
▪ Periphery: ill defined, with a gradual transition of the normal
trabecular pattern.
▪ Internal structure:
▪ Slight decrease in the density of the involved bone, with a
loss of sharpness of the existing trabeculae.
▪ Sequestra may be present but usually are more apparent in
chronic forms.

Answer 26

acute phase

Question 27

Management of _______
➢ Removal of the source of inflammation is the primary
goal of therapy.
➢ Extraction or root canal therapy may be indicated.
➢ Antimicrobial treatment, along with surgical incision and
drainage.

Answer 27

Acute Osteomyelitis

Question 28

Osteomyelitis _____ Phase
▪ A sequela of wrongly treated acute osteomyelitis, or it may arise de novo.
▪ The balance in bone metabolism is tipped towards increased bone formation (sclerotic
bone pattern).
▪ Intermittent, recurrent episodes of swelling, pain, fever, and lymphadenopathy.
▪ Imaging Features
▪ MDCT or CBCT imaging of choice: reveal more bone surface for detecting periosteal new
bone and sequestra.
▪ Location: the most common location is the posterior body of the mandible.
▪ Periphery: better defined, with a gradual transition of the normal trabecular pattern and
dense granular pattern.
▪ Regions of greater and lesser radiopacity compared with surrounding normal bone (most
of the lesion is usually sclerotic).

Answer 28

Osteomyelitis Chronic Phase

Question 29

Management of ______
▪ More difficult to eradicate than the acute form.
▪ Hyperbaric oxygen therapy and antibiotic have been used with
limited success.
▪ Surgical intervention often is necessary.
▪ Cultures negative: Anti-inflammatory agents are more effective.
▪ More recently, the use of bisphosphonate therapy has provided
some therapeutic success.

Answer 29

Chronic Osteomyelitis

Question 30

▪ Chronic phase of osteomyelitis but may never be an acute phase
▪ Causes deposition of bone creating scleroticenlarged bone mass
▪ Etiology not always certain
▪ Chronic inflammatory infiltrate of cancellous spaces with areas of marrow fibrosis
▪ Etiology often difficult to determine and therefore difficult to treat

Answer 30

Diffuse sclerosing osteomyelitis

Question 31

Clinical Presentation
▪ Low-grade but persistent swelling, pain, fever, 
lymphadenopathy
▪ May be drainage 
▪ Occasional paresthesia
Radiographic Presentation
▪ Enlarged bone
▪ Sclerotic regions replace the cancellous component
▪ Periostitis possible

Answer 31

Diffuse sclerosing osteomyelitis

Question 32

Age
▪ Adolescent to Adult age range (most commonly)
Site
▪ Most common in posterior mandible
Management
▪ Long term antibiotics, hyperbaric O2
▪ NSAIDs, steroids, bisphosphonates
▪ Surgery

Answer 32

Diffuse sclerosing osteomyelitis