Non-Odontogenic Poorly Defined Entities Flashcards
Inflammatory Lesions of Bone - WIDESPREAD
Non-Odontogenic Poorly Defined Entities
- Often (but not always) has poorly defined borders
- Pain is variable
- Often, not always surrounded by sclerotic bone
- May appear “moth eaten”
- Irregular patches of osteolysis surrounded by denser sclerotic bone
Bone healing
Non-Odontogenic Poorly Defined Entities
- Initial clot replaced by granulation tissue & woven bone
- Basic multicellular unit (BMU) = Group of osteoclasts, osteoblasts, local vascular supply
- BMUs perform final remodeling of bone
- Osteoclasts: Critical for signaling, resorption, and lamellar bone deposition & angiogenesis
Malignant Neoplasms of Bone
Non-Odontogenic Poorly Defined Entities
- Poorly defined; destroys anatomical structures
-
Most common malignant neoplasm of jaw: Metastatic carcinoma
- Does NOT originate from jaw; Originates from systemic source
- Most common malignancy of jaw arising from jaw: Osteosarcoma
- Mainly middle-aged or older pts
- Lymp nodes if palpable are hard, nontender, fixed
- May present as toothache
What is the most common malignant neoplasm of the jaw arising from systemic sources?
Metastatic carcinoma
What is the most common malignant neoplasm arising from the jaw?
Osteosarcoma
What is the most common form of cancer involving the skeleton in general and jaws in particular?
Metastatic carcinoma
Osteoradionecrosis
Non-Odontogenic Poorly Defined Inflammatory Lesions
- Chronic infection of bone
- Follows high dose radiation therapy to bone, usually tx for malignant neoplasms
- >75 gray - Significant incidence of osteoradionecrosis
- <60 gray - Minimal risk
- Characterized by pain, necrosis, sequestration
- More common in MN bc less vasculature there compared to MX, dentulous pts
- Often in the first 2yr after radiation therapy
- Diffuse infection causes necrosis of bone, periosteum, overlying mucosa
- Long term will develop sequestrum
- Extremely painful
Osteoradionecrosis: Predisposing factors
Non-Odontogenic Poorly Defined Inflammatory Lesions
- Post-radiation extractions
- Periodontal disease
- Irradiation of surgical site before healing has occurred
Osteoradionecrosis: Pathogenesis
Non-Odontogenic Poorly Defined Inflammatory Lesions
- Thickening of BVs
- Destruction of osteoblasts/osteocytes
- Absence of bone formation
- Trauma or infection
Osteoradionecrosis: Prevention
Non-Odontogenic Poorly Defined Inflammatory Lesions
- Prevention is easier than tx
- Extraction of diseased teeth in tx field prior to radiation
- Adequate time for surgical site to heal
- Meticulous OH
- Fluoride supps
- Do not construct dental prosthesis immediately after radiation therapy
Osteoradionecrosis: Tx
Non-Odontogenic Poorly Defined Inflammatory Lesions
- Abx
- Surgical removal of sequestrae
- Hyperbaric O2
- Radical surgical resection
Osteoradionecrosis: Complications
Non-Odontogenic Poorly Defined Inflammatory Lesions
- Bone deformity and pathologic fracture
- Orocutaneous fistulas
Medication-Related Osteonecrosis of Jaws (MRONJ)
Non-Odontogenic Poorly Defined Inflammatory Lesions
-
Antiresorptive agent
- Denossumab: Monoclonal ab that prevents osteoclastic maturation
- Used as anti-neoplastic medication or for osteoporosis
-
Antiangiogenic agents
- Attempt to decrease blood supply to malignancy
- Tyrosine kinase inhibitors or vascular endothelial inhibitor
-
BRONJ: Bisphosphonate-related osteonecrosis of jaw
- IV - cancer
- More likely to cause ONJ
- PO - osteoporosis
- IV - cancer
- ARONJ: Antiresorptive-related osteonecrosis of the jaw
- MROJ: Medication-related osteonecrosis of the jaw
- Painful
- Occurs more often in the MN
- Lingual side of MN in molar areas
- Most commonly occurs post-extraction
MRONJ: Rads
Non-Odontogenic Poorly Defined Inflammatory Lesions
- IO shows single or multifocal areas of exposed necrotic bone
- Rads may show increased RO prior to necrosis
MRONJ: Tx
Non-Odontogenic Poorly Defined Inflammatory Lesions
- Best approach is prevention
- Improve dental health before future procedures
- Never take them off bisphosphonates bc they are getting tx’d for cancer or to prevent broken hip and stuff
- 1/2 life of bisphosphonate is 12yr so even if you take them off, it’s in their system for awhile
- Eliminate/minimize pain
- Aggressive removal of necrotic bone results in further necrosis
- Symptomatic: Systemic abx. chlorhexidine
- Asymptomatic: Only chlorhexidine
- Exposed bone smoothed and loose sequestra removed carefully
What else would you include in a differential w/ MRONJ?
Non-Odontogenic Poorly Defined Inflammatory Lesions
- Osteomyelitis
- Radiation induced osteonecrosis
- Medication related osteonecrosis of jaw
- Consider malignancies and metastatic disease
Non-Odontogenic Poorly Defined Malignancies, Arise Primary in Jaws
- Osteosarcoma
- Chondrosarcoma
- Ewings Sarcoma
- Multiple myeloma
- Metastasis to the oral cavity
Osteosarcoma
Non-Odontogenic Poorly Defined Malignancies, Arise Primary in Jaws
- Swelling of bone
- Pain, toothache
- Paresthesia
- Loose or displaced teeth
- Ulceration
- Increased incidence of osteosarcoma in Paget’s disease of bone
- Osteoid production by malignant cells
- Normally older pts
Osteosarcoma: Rad
Non-Odontogenic Poorly Defined Malignancies, Arise Primary in Jaws
- RL, RO, or mixed
- Poorly defined margins
- “Sun Ray”/Sunburst Pattern: Bony trabeculae radiating from periosteum. Present in 25% of cases and NOT unique to osteosarcoma
- Early feature may be localized symmetrical widening of PDL space or MN canal
- Periphery of lesion is usually ill-defined
Osteosarcoma: Tx
Non-Odontogenic Poorly Defined Malignancies, Arise Primary in Jaws
- Radical surgery, usually supplemented by chemotherapy
- MN lesions have better px than MX lesions
- Px is improving but still not good
Chondrosarcoma
Non-Odontogenic Poorly Defined Malignancies, Arise Primary in Jaws
- Cancer characterized by formation of cartilage by the tumor
- About half as common as osteosarcomas
- Sometimes relatively slowly growing
- Normally older pts
Chondrosarcoma: Microscopic features
Non-Odontogenic Poorly Defined Malignancies, Arise Primary in Jaws
- Abnormal chondroblasts and cartilage
- May be difficult to distinguish from chondrosarcoma
Chondrosarcoma: Rad
Non-Odontogenic Poorly Defined Malignancies, Arise Primary in Jaws
- RL, RO, mixed
- Poorly defined margins
Chondrosarcoma: Tx
Non-Odontogenic Poorly Defined Malignancies, Arise Primary in Jaws
- Radical surgery
- Less likely to metastasize compared to osteosarcoma
Ewing Sarcoma
Non-Odontogenic Poorly Defined Malignancies, Arise Primary in Jaws
- Malignant tumor of bone
- Cells of neuroectodermal origin
- 3rd most common osseous malignant tumor
- 80-95% of cases - 11;22 translocation
-
Mainly in children and young adults
- Always <20yo - peak age 10-20yo
- Early s/s: Pain & swelling
Ewing Sarcoma: Rad
Non-Odontogenic Poorly Defined Malignancies, Arise Primary in Jaws
- Diffuse poorly defined RL lesion
- “Onion peel” appearance: May stimulate periosteum to produced layers of new bone; seen in numerous malignant and inflammatory diseases
Ewing Sarcoma: Tx
Non-Odontogenic Poorly Defined Malignancies, Arise Primary in Jaws
- 40-80% survival rates
- Metastasis is frequent
Multiple Myeloma
Non-Odontogenic Poorly Defined Malignancies, Arise Primary in Jaws
- Characterized by multiple tumors of plasma cells scattered throughout skeleton and sometimes ST
- Lesions most common in axial skeleton: Vertebrae, ribs, skull, pelvis
-
Rare before 40yo
- Does NOT occur before 40yo
- Bone pain, esp in back, is most common presenting manifestation
- Pathological fractures
- Fatigue (anemia)
- Fever (neutropenia)
- Neoplastic plasma cells produce high levels of monoclonal Igs in immunoelectrophoresis
- Hypercalcemia and renal disease might occur
- M-protein (Bence Jones protein) may be deposited in tongue, gingiva, salivary glands, skin
Multiple Myeloma: Rad
Non-Odontogenic Poorly Defined Malignancies, Arise Primary in Jaws
- Multiple punched out RL lesions w/o corticated borders, most commonly in jaws, skulls, vertebrae
Multiple Myeloma: Tx
Non-Odontogenic Poorly Defined Malignancies, Arise Primary in Jaws
- Chemotherapy is used for management
- Poor px
Metastasis to the Oral Cavity
Non-Odontogenic Poorly Defined Malignancies, Arise Primary in Jaws
- Only 1% of all oral ST and jaw cancers
- Malignant neoplasms metastasize to bone more often than ST
- Metastatic neoplasms are the most common malignant tumors IN the jaw
- 5th-7th decades of life
- MN more common than MX
- Molar area of MN is most common site
- Early manifestation:
- May be asymptomatic and detected upon routine rad exam
- Swelling, expansion, perforation of cortical plate
- Pain, paresthesia
- Tootache, increased tooth mobility
- Failure of extraction site to heal = worrisome
What is the most common malingant tumor IN the jaw?
Metastatic neoplasms
Metastasis to the Oral Cavity: Rad
Non-Odontogenic Poorly Defined Malignancies, Arise Primary in Jaws
- May be localized but w/o corticated borders
- Poorly defined w/ irregular margins
- Multiple, separate foci
- Occasionally RO: breast, prostate
Most common locations for metastasis to oral cavity
Non-Odontogenic Poorly Defined Malignancies, Arise Primary in Jaws
- Gingiva & tongue
- Early lesions can look benign
- Later lesions can look clinically aggressive
- ST tumors of gingiva may be arising from underlying bone
Non-Odontogenic Poorly Defined Inflammatory Lesions
- Osteoradionecrosis
- Medication Related Osteonecrosis of the Jaw
What are Non-Odontogenic Poorly Defined Malignancies that arise Primary in the jaws?
- Osteosarcoma
- Chondrosarcoma
- Ewings Sarcoma
- Multiple Myeloma
- Metastasis to the Oral Cavity