Inflammatory Lesions of the Jaw Flashcards
Classification of Inflammatory lesions of the jaw?
- Localised Lesions -a Acute: -Periapical -b Chronic: -Radiolucent: peri granuloma, radicular cyst, residual cyst, paradental cysts - Radiopaque: Condensing osteitis 2. Diffuse lesions -a Acute: - Acute suppuration osteomyelitis -b Chronic - Chronic suppurative osteomyelitis (mixed (bacterial) or specific (TB) infection) - Chronic diffuse sclerosing osteomyelitis - Proliferative periostitis or Garres osteomyelitis
What are the chronic localized radiolucent lesions of the jaw?
- Periapical granuloma 2. Radicular cysts
What are the features of periapical granulomas?
Frequently seen from inflammation (pulp irritation). - Neutrophils (acute) > protoglandins/inflame mediators > increased periapical osteoclast activity > bone resorption -Presentation: dull throb, TTP and negative pulp. asymp if chronic -loss of PDL or nothing on radiographs -Histology: RCT/review, exo and curratage, apecetomy -can get post op periapical scare (fibrous tissue
What are the features of radicular cysts?
epithelial lining from rests of malessez (SSE with fibrous CT infiltrate), 30% chronic. -radiographically. well circumscribed at root apex or from lateral foramen. growth into medullary cavity -ddx: unicystic ameloblastoma, lateral cyst
What are the mixed inflammatory lesions of the jaw?
- Osteomyelitis (acute suppurative, chronic suppurative, Primary chronic osteomyelitis, osteomyelitis with proliferative periostitis (garres) 2. Osteonecrosis 3. Osteo radio necrosis
What is osteomyelitis in general?
inflammation of the medullary cavity, often due to infection, hydrostatic pressure necrosis occurs creating necrotic bone with islands/squestra of bone. -mandible usually compared to maxilla due to maxilla better blood supply in the maxilla. -bacterial infection leads to lytic expansion, suppuration and sequestra. -trauma, infeciton, idiopathic, immune compromised,
What is acute suppurative osteomyelitis? radiographic histo tests tx
-< 4 weeks with symptoms - acute inflammatory symptoms (febrile) - purulent discharge with exposed ridge, 50% paresthesia and sequestra. - Radiographic: CT, CBCT, OPG, periapical - diffuse lytic lesion with PDL widening and sequestra. - Histological; loss of osteocytes, necrotic bone, neutrophils - Tests: increased WBC, CRP, ESR, microbiology (strep, bacteroids, pepto) -Tx: ABs, sequestrectomy, surgical excision
What is chronic suppurative osteomyelitis? radiographic histo tests tx
->4 weeks with symptoms -granulation tissue formation leading to circumferential fibrous layer to wall off infection ‘dead space’ -path: strep, staph, actinomycyes, provotella - unresponsive acute or low grade chronic disease -swelling, pain, sinus, purulent discharge with squestrea. - from tooth loss, pathological fracture, acute spidosed, nerve defect. -radiographic: moth eaten ill defined with central opacities. (osteosclerosis or osteolytic) - Histological: inflammatory infiltrate -Tx; exclude secondary chronic myelitis (MRONJ, ORN), ABs, squestra, decronation, resection (KoRKOASKI)
What is primary chronic osteomyelitis? radiographic histo tests tx
non odontogenic, non suppurative, non bacterial, autoimmune, lack of vasculature. -Younger, 10-20 or over 50s. mandible. -pain, but no pus formation. -test: ESR increase -radiographically: variable: osteolysis, periosteal onion ringing. -histology: chronic infection, medullary fistula and necrosis and subperiosteal bone formation, lymphocytes, plasma cells, pagetoid bone. Tx: surgical decoronation, remove necrotic tissue, long term ABs, NSAIDs, biphos (good long term, 2001 soubrier)
What is osteomyelitis wuth proliferating periostitis?
Garres. - periosteal inflammation and radiographically PSO. -separate disease with infective cause. unilateral, and PCO. -radiographically: CBCT for extent, distinct thickening of periosteum, onion skinning -histological: high cellularity, reative woven bone, interconnected network, tx: rule out malignancy, fibrosseous lesions, elimate infection (6-12 months)
How is osteonecrosis staged?
AAOMS 2014 -0. no clinical signs, symptoms, non specific changes -1. exposed bone/fistula, asymp, no infection -2. exposed bone/fistula with infection -3. infection with complication
What is osteonecrosis of the jaw?
-dysregulation of bone healing due to inbalance of osetoclasts and osteoblasts -medication induced MRONJ - RANKL, angiogenic I, chemo, TKI, immunotherapy, bisphos. -denosumab: monclonic antibody target, binds to rankL ligand and prevents activation of RANK L pathway of osteoclasts (impedes formation and function and survival).
What is the aetiology of MRONJ?
not fully understood, bone turnover affected
- risks: dentures, perio, meds, OH/Smoking, comorbs, >3 years of tx with high dose (IV), 90% in bone met pts, MRONJ risks with Zoendronic acid and denousmab
What is Osteoradionecrosis?
- Rivero 2019.
- > 3 months of non healing bones with history of radiation of the H and N without neoplasm.
- 2.6-18% radiation induced fibrosis
What are the stages of ORN?
- Endotherlial prefibrotic pjase (inflam and free radicals)
- Consitiutuive phase (abnormal fibroblasts and ECM lose organisation)
- Late Fibrotophic phase - remodelling, reactive inflammation when local injury > fibrosis, thrombosis, remodelling, necrosis.
