Inflammatory Jaw Lesions

Question 1

what is chronic hyperplastic pulpitis?

Answer 1

occurs in children and young adults who have large exposures of pulp in which the entire dentinal roof often is missing.
most frequently involved teeth: deciduous or succedaneous molars
the apex maybe open reducing risk for pulpal necrosis
the tooth is asymptomatic except for possible feeling of pressure when it is placed into masticatory function.

Question 2

What is chronic hyperplastic pulpitis (pulp poly)? etiology?

Answer 2

Unique pattern of pulpal inflammation where pull tissue reacts to injury by undergoing hyperplasia.
Etiology: The combination of an open chronic pulpitis, ample blood supply and increased regenerate of capacities of young Pople tissue appeared to stimulate the pulpal tissue to proliferate or to produce granulation tissue.

Question 3

What is treatment for chronic hyperplastic pulpitis?

Answer 3

Extraction or by root canal therapy.

Question 4

What are pulpal calcifications?

Answer 4

• Calcification in the dental pulp.
• maybe present in both the coronal and root pulpal tissues
• whole calcification are not rare but the frequency is difficult to determine (8 to 90% rates)
• increased number of calcifications and older teeth and those exposed to trauma or caries

Question 5

What are pulpal calcifications: pulp stones? Diffuse linear calcifications?

Answer 5

Pulp stones: spherical calcifications formed within the coronal portions of the pulp. When they’re composed of predominantly Dentin, they are referred as true denticles.

Diffuse linear calcifications: diffuse linear, fine, irregular calcifications within the pulp chamber or and usually in the root canals.

increased prevalence of pulp stones associated with chronic pulp irritants

some pulp stones appear idiopathic or are associated with aging
prominent pulpal calcification have been seen in association with certain disease processes, such as Dentin dysplasia type II, Ehlers-Danlos syndrome and others

Question 6

What is for pulpal calcifications?

Answer 6

Treatment’s not required.

most pulpal calcifications are not associated with any significant clinical alteration.

Question 7

How do periapical lesions form? what is acute apical periodontitis?

Answer 7

In the early stages of infection, neutrophils predominate and radiographic alterations are not present, this phase is termed acute apical periodontitis and may or may not proceed to abscess formation.
Neutrophils release prostaglandins, which activates osteoclasts to resorb the surrounding bone, leading to a detectable periapical lesion.
With time, inflammatory cells begin to dominate the host response.
From its origins in the pulp, the inflammatory process extends into the periapical tissue.
If untreated infections, some clinical lesions may take place, depending on the type of the preceding pulpitis, virulence of the bacteria and presence or abscence of drainage.

Question 8

What is chronic apical periodontitis?

Answer 8

Chronic lesions are often asymptomatic and demonstrates little additional change radiographically.
Chronic apical periodontitis is a term used two denote the earliest radiographic evidence of the inflammatory process into the adjacent periodontal membrane around the apical foramen.
This condition is a transitory phase between pulpitis and more distinct forms of periapical lesions.

Question 9

What is a periapical granuloma?

Answer 9

Most periapical granulomas are asymptomatic, but pain and sensitivity can develop if acute exacerbation occur.
Most lesions are discovered on routine radiographic examination.
Radio graphically, a radiolucency associated with the apex of the tooth and typically loss of the apical lamina Dura. It may or may not show a surrounding radiopaque rim.
Root resorption may be present.
Periapical granuloma is a mass of chronically or subacutely inflamed granulation tissue at the apex of a non-vital tooth.
Periapical granulomas may arise after quiescence of a periapical abscess or may develop as initial periapical pathosis. These lesions are not neccesarily static.
Acute exacerbation of a chronic lesion has been termed “phoenix abscess”

Question 10

What is the treatment for a periapical granuloma?

Answer 10

Root canal therapy and periodic evaluation.
If conventional therapy is unsuccessful, after adequate endodontic treatment, periapical surgery including curretage of all periradicular soft tissue submitting for histopathological examination, aputation of the apical portion of the root, and sealing the foramen of the canal.
- Non-restorable teeth: extraction followed by curretage submitting the tissue for examination.
Complications: It may transform into periapical cyst.

Question 11

What is the source of epithelium for a periapical cyst? source of inflammation?

Answer 11

Source of epithelium:

• usually rest of Malassez
• crevicular epithelium
• sinus lining
• epithelial lining of fistulous tract

Source of inflammation:

• periodontal disease
• pulpal necrosis with spread throughout a lateral foramen

epithelium at the apex of non-vital tooth presumably can be stimulated by inflammation to form a true epithelium-lined cyst
75% of apical inflammatory lesions.

Question 12

What are variants of periapical cysts?

Answer 12

lateral radicular cyst: arise from periodontal disease OR pulp necrosis
residual cyst: a cyst that remains at the site of a previous extracted tooth.
It also denotes any cyst present in an edentulous area in which the origin of the epithelial lining is unknown.

Question 13

what are treatments for variants of periapical cysts?

Answer 13

• depends on a number of variables
• persist if treated by root canal treatment only, then cycstectomy with apicoectomy.
• other times enucleation of cyst after extraction

Question 14

what do I need to remember about cysts?

Answer 14

because non-odontogenic and odontogenic cysts and tumors can mimic a residual cyst, all of these lesions should be excised surgically and be evaluated histologically
do tooth vitality test and periodontal evaluation for adjacent focus of infection when you are working the diagnosis of cystic lesions.

Question 15

what is a fibrous periapical scar?

Answer 15

On occasion, the defect created by a periapical lesion may be filled with dense fibrous tissue instead of bone
The fibrous (periapical) scars occur most frequently when both facial and lingual cortical plates have been lost, but they can arise in areas with intact cortical plates.
If during surgery both plates are noted to be missing, then the patient should be informed of the possibility of scar formation.
The development of a periapical scar is not an indication for further surgery.

Question 16

what is a periapical abscess?

Answer 16

accumulation of acute inflammatory cells at the apex of a non-vital tooth.
periapical abscesses should be designated as asymptomatic or symptomatic on the basis of their clinical presentation
periapical abscess become symptomatic as the purulent material accumulates
little radiographic evidence
it may show thickening of the apical periodontal ligament, and ill-defined radiolucency or both.
with progression, the abscess spreads along the path of least resistance.

Question 17

what are the spread of the abscesses called?

Answer 17

thru the surface of skin - cutaneous sinus
into the oral cavity - intraoral sinus tract - parulis
thru the facial planes of soft tissue - cellulitis
thru medullary spaces - osteomyelitis

Question 18

what is cellulitis ?

Answer 18

the spread of purulent exudate through facial planes of the soft tissue.
although several pattern of cellulitis can be seen from spread of dentl infections, two are especially dangerous forms: Ludwing angina and Cavernous sinus thrombosis.

Question 19

What is parulis (gum boil)?

Answer 19

Sinus tract: a drainage pathway from deep focus of acute infection through tissue, bone or both to an opening on the surface.
Parulis: a mass of subacutely inflamed granulation tissue at the site where a draining sinus reaches the surface
Clinically parulisusually appear as an asymptomatic yellow-red papule or nodule.
Sometimes the non-vital tooth associated with parulis may be difficult to determine, and insertion of a gutta percha point into the tract can aid in the detection of the offending tooth during radiographic examination.

Question 20

what is treatment for periapical abscess?

Answer 20

drainage and elimination of the focus of infection
abscesses associated with a patent sinus tract may be asymptomatic but should be treated
once the infection has been resolved by extraction or endodontic therapy, the affected bone typically heals
for sinus tracts that persists, surgical removal with curettage of the tract is required for resolution

Question 21

what is osteomyelitis?

Answer 21

an acute or chronic inflammatory process in the medullary spaces or cortical surfaces of bone that extends away from the initial site of involvement
the term osteomyelitis has been used to encompass a wide variety of pathoses
The vast majority of osteomyelitis cases are caused by bacterial infections and result in an expanding lytic destruction of the involved bone, with suppuration and sequestra formation.
Many believe that this condition is more appropriately termed suppurative osteomyelitis, bacterial osteomyelitis, or secondary osteomyelitis.

Question 22

What is acute suppurative osteomyelitis?

Answer 22

when an acute inflammation process spreads through the medullary spaces of the bone.
Ther eis insufficient time for the body to react to the presence of the inflammatory infiltrate.
Suppurative osteomyelitis is uncommon in developed countries.
Patients of all ages can be affected by osteomyelitis.
There is a strong male predominane (about 75% in some reviews).
Most cases involved the mandible

Question 23

what are predisposing factors for acute suppurative osteomyelitis?

Answer 23

chronic systemic diseases
immunocompromised status
disorders with decreased vascularity

increased frequency with:
tobacco use, alcohol abuse
intravenous drug abuse
diabetes mellitus
malnutrition
maliganncy 
aids

Question 24

what about osteomyelitis with radio stuff?

Answer 24

osteoradionecrosis is excluded from this discussion because this is primarily a problem of hypoxia, hypocellularity and hypovascularity with secondary bacteria colonization
bisphosphonates associated osteonecrosis is more related to altered bone metabolism

Question 25

what is the etiology of acute suppurative osteomyelitis?

Answer 25

most cases (in north america) arise after odontogenic infections or traumatic fracture of the jaws
Staphylococci and streptococci are the most frequent bacteria involved

Question 26

what about signs and symptoms of acute suppurative osteomyelitis?

Answer 26

signs and symptoms of an acute inflammatory process that have typically been less than 1 month in duration
May be present:
- fever
- lymphadenopathy
- leukocytosis
- significant sensitivity 
- soft tissue swelling

Question 27

what is sequestrum and involucrum in acute supperative osteomyelitis?

Answer 27

Drainage or exfoliation of fragments of necrotic bone may be found
Sequestrum: a fragment of necrotic bone that has separated form the adjacent vital bone (sequestra: plural)
Involucrum: fragments of necrotic bone may be surrounded by vital bone, and the dead bone is called involucrum

In the mandible the exudate with its accompanying bacterial toxins and lytic enzymes may involve the inferior alveolar canal, producing alteraitons in the conductivity of the nerve.
This often produces an alteration in the sensation (paresthesia) of the lower lip of the affected side .
The paresthesia can cause great concern because it is also a common presenting feature when a malignant neoplasm involves the mandible

Question 28

What are the radiographic features of acute suppurating osteomyelitis?

Answer 28

Radiographic features are usually not immediately present and are only observed until the trabecular bone has undergone a significant amount of resorption.
Dental radiographs may show ill-defined radiolucency, occasionally combined with widening of the periodontal ligament, loss of lamina Dura or loss of circumscription of the inferior inferior alveolar canal or mental foramen.
Initially the area is faintly visible and eventually appears diffusely blotchy or mottled with indistinct margins and islands of residual bone (sequestra) May be seen.

Question 29

What is therapy for acute suppurative osteomyelitis?

Answer 29

Therapy centers around the surgical intervention to:
Resolve the source of infection
Establish drainage
Removal of obvious infected bone
Obtain bacterial logic samples for culture and antibiotic sensitivity testing
Multiple procedures may be needed to completely eliminate the infection and reconstruction of the bone defect

Question 30

What is chronic suppurative osteomyelitis?

Answer 30

When the defensive response leads to production of granulation tissue, which subsequently forms dense scar in an attempt to wall off the infected area.
The encircle dead space acts as a reservoir for bacteria, and antibiotics have great difficulty reaching the site.
This pattern begins to evolve about one month after the spread of the initial acute infection.

Question 31

What is the etiology and clinical features of chronic suppurative osteomyelitis?

Answer 31

Etiology: if acute osteomyelitis is not resolved expeditiously, chronic osteomyelitis occurs.
This may arise primarily without previous acute episode.

Clinical features:
Swellingormation, purulent discharge, sequestrum formation, tooth loss or pathologic fractures may be seen.
Patients may experience acute exacerbations.

Question 32

What are the radiographic features and treatment for chronic suppurative osteomyelitis?

Answer 32

Radiographs show a patchy ragged, ill-defined to radiolucency that may contain central radiopaque sequestra and the intermixed with zones of radiodensity.

Treatment:
Surgical intervention is mandatory: removal of infected and necrotic tissue
Culture
Antibiotics as in acute form but intravenously and high doses
Weekend Jaw - immobilization
Hyperbaric oxygen is only for patients that do not respond to standard therapy to stimulate vascularization, collagen synthesis, osteogenesis

Question 33

What is diffuse sclerosing osteomyelitis?

Answer 33

It is an ill-defined, highly controversial, evolving area of dental medicine.
This diagnosis encompasses a group of presentations that are characterized by pain, inflammation and varying degrees of gnathic periosteal hyperplasia, sclerosis and lucency.
Three pathoses are included in this category: diffuse sclerosing osteomyelitis, primary chronic osteomyelitis and chronic tendoperiostitis

Diffuse sclerosing osteomyelitis this term should be used only when an obvious infectious process directly is responsible for sclerosis of bone.
Almost exclusively in adult hood
Primarily occurs in the mandible

Question 34

What are the radiographic features of diffuse sclerosing osteomyelitis? Treatment?

Answer 34

The increased radiodensity develops around the sites of chronic infection such as periodontitis, pericoronitis and apical inflammatory disease
The sclerosis centers on the crestal portions of the tooth bearing alveolar ridge

Treatment:
Based on resolution of the adjacent foci of chronic inflammation.
After resolution of infection, the sclerosis remodels in some cases but remains in others.
The persistent sclerotic bone is hypovascular and sensitive to inflammation.
Preventive measures and follow up.

Question 35

What is condensing osteitis (focal sclerosing osteomyelitis)?

Answer 35

A localized area of bone sclerosis associated with the apex of a tooth with long-standing pulpitis (large caries lesions or deep coronal restorations) or pulpal necrosis
Most frequently in children and young adults, but can see also in older adults.
Asymptomatic
Clinical expansion should not be present.

Usually mandibular premolars and molars
Localized a uniform radiopacity adjacent to the apex of a tooth that exhibits a thickened periodontal ligament space
No radiolucent border
Thickening of periodontal ligament
Radiopacity is not separated from the apex

Question 36

What is treatment for condensing osteitis?

Answer 36

Resolution of the odontogenic focus of infection.

A residual area of condensing osteitis that remains after resolution of the inflammatory focus is termed a bone scar

Question 37

What is osteomyelitis with proliferative periostitis (periostitis ossificans or Garres osteomyelitis)?

Answer 37

It represents a prominent periosteal reaction to the presence of inflammation.
Primarily children and young adults (mean age of 13 years)
Most common in premolar molar area
Most frequent cause dental caries associated with. Apical inflammation but cases associated with periodontal infections, buccal furcation cyst and nondontogenic infections have been reported
Asymptomatic bony hard swelling along the lower border of the mandible
Onion skin appearance radio graphically.

Question 38

What is the treatment for osteomyelitis with proliferative periostitis?

Answer 38

Eliminate the source of infection
Remodeling occurs without surgery
Remodeling occurs within 6 to 12 months
Biopsy is usually not required unless the clinical diagnosis is in question.