OR signs of inflammation

Question 1

what is periosteal reaction

Answer 1

§ Periosteum lifted by inflammatory exudate
§ Stimulates osteoblasts to form new bone
§ Usually parallel layers- onion skin appearance
§ More typical in the mandible

Question 2

what are the inflammatory lesions that can take place at the PA and the jaw

Answer 2

§ Periapical
□ Apical rarefying osteitis (ARO)
□ Condensing osteitis( apical sclerosing osteitis)
□ Mixed of ARO and Condensing osteitis
§ Jaw
□ Osteomyelitis
□ ORN
□ MRONJ

Question 3

what are the hall mark features of PA lesion

Answer 3

associated with NV teeth

disruption of lamina dura, widening of PDL spaces

Question 4

what could widening PDL space be due to

Answer 4

§ Pulpal insult, TFO/attrition, iatrogenic, malignancy
○ Inflammatory exudate accumulates in PDL space
○ Clinical features
§ Can be asymptomatic or ttp

Question 5

what is the radiographic description of periapical granuloma

Answer 5

§ Circumscribe, well defined radiolucent area of bone loss at apex ( apical rarefying osteitis)

Question 6

what is the clinical symptoms of PA granuloma

Answer 6

○ Pulp necrosis, but usually asymptomatic
○ Little or no pain to percussion and palpation

Question 7

what is PA granuloma comprise of

Answer 7

○ Chronic inflammatory infiltrate of lymphocytes, histiocytes and plasma cells

Question 8

what is the radiographic features of PA cyst

Answer 8

similar to PA granuloma, but larger in size >1cm

Question 9

What is the hiisto of PA cyst

Answer 9

○ Central cavity lined by stratified squamous epithelium, origin from the cell rests of Malassez

Question 10

what is the clinical features of acute apical abscess

Answer 10

§ Pulp necrosis
§ Ttp, ttPp
§ Severe pain, swelling, mobility
§ Elevation of tooth involved
§ In severe cases can have systemic symptoms like fever, facial swelling, lyphadenopathy, esp when pt is immunocompromised

Question 11

what is the radiographic description of acute apical absces

Answer 11

§ Loss of apical lamina dura
§ Resorption of apical bone
§ Appearance may vary
§ Could have diffused, ill defined radiolucency for more destructive inflammation

Question 12

what is the radiographic description of condensing osteitis

Answer 12

§ Diffuse radiopaque dense sclerotic bone around root of tooth

Question 13

what are the clinical features of condensing osteitis

Answer 13

§ Occurs with pulpitis or pulp necrosis
§ Variable responses to vitality tests or percussion/palpation

Question 14

what is osteomyelitis

Answer 14

inflammation of the bone marrow not confined to localised area typically results in necrosis

Question 15

how does osteomyelities typically occur

Answer 15

from pyogenic bacteria introduced via
§ Abscessed tooth
§ Surgery
§ Hematogenous spread

	○ Stimulates reaction involving cancellous and cortical bone and periosteum
	○ Can range from acute to chronic
		§ Acute
			□ Rapid onset, pain, swelling of adjacent soft tissues, fever, lymphadenopathy, leukocytosis
			□ Associated teeth mobile, ttP
			□ Can have purulent drainage
			□ Can have paresthesia of lower lip
		§ Chronic
			□ Sequalae of acute phase
				® Intermittent recurrent episodes of usually less severe swelling, pain, fever, lymphadenopathy, can have paresthesia and drainage with sinus formation

Question 16

where is the more common site for osteomyelitis

Answer 16

mandible» maxilla due to better blood vascularity for maxilla

Question 17

What type of pt would be at greater risk for osteomyelitis

Answer 17

greater risk
§ Systemic factors
□ Malnutrition, DM, leukemia, alcoholism
§ Disorders of decreased vascularity
□ Sickle cell anemia
□ osteoporosis
§ Immunosuppression
□ aids
§ On medication
□ Steroids, chemo, bisphosphonates
○ Related conditions to osteomyelitis
§ Chronic recurrent multifocal osteomyelitis (CRMO)
§ Synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO)
§ Both occurs de novo without acute phase, without identifiable pathogenic microorganism

Question 18

what is the hallmark of osteomyelitis

Answer 18

sequestra

Question 19

what is the radiographic description of osteomyelitis

Answer 19

Subtle decrease in bone trabeculation, increase in radiolucency, ill corticated

Question 20

how does chronic osteomyelitis appear radiographically

Answer 20

□ Sequestrum, ranges in size
Starts to appear sclerotic, moth eaten appearance, often mixed radiolucent and radiopaque internally

Question 21

what is the histopathology of osteomyelitis

Answer 21

§ Necrotic bone, loss of osteocytes from lacunae
§ Inflammatory infiltrate/soft tissue component
§ Predominantly neutrophils> mononuclear cells

Question 22

what is the management of osteomyelitis

Answer 22

§ Must remove source of infection
□ Curettage, sequestrectomy, decortication( remove poorly vascularised bone and placing vascular periosteum next to bone marrow to induce healing), resection
□ Antibiotic therapy only effective if bacterial cultures are positive

Question 23

what is osteoradionecrosis

Answer 23

presence of exposed bone for 3 months or more following radiotherapy

Question 24

what is the disease mechanism for ORN

Answer 24

○ Disease mechanism
§ Bone necrosis from high doses of radiation
§ Exaerbated by infections, dental extractions, dental trauma
§ Mandible» maxila due to blood supply difference

Question 25

pathophysiology of ORN

Answer 25

§ Low doses stimulates osteoblasts, leading to bone formation
§ Intermediate doses causes osteoblast/chondroblast cell death
§ High doses damage mature intact bone
§ Radiotherapy also causes damage to endothelial cells in smaller vessels.
□ Leads to bone hypoxia–> hypocellular and hypovascular bone

Question 26

what is marx staging for ORN based on? how many stages are there

Answer 26

based on response to Hyperbaric oxygen therapy, 3 stages

Question 27

what is the clinical features of ORN

Answer 27

§ Most common in posterior mandible( direction of radiotherapy beam)
§ Exposed bone may or may not have sequestration
§ Intermittent swelling
§ Extra oral damage
May or may not have pain

Question 28

what is the radiographic features of ORN

Answer 28

§ Similar to osteomyelitis but periosteal reaction is rare, because radiotherapy has killed off osteoblasts
§ Ill defined non corticated moth eaten, mixed. Sequestrum present

Question 29

what is the management of ORN

Answer 29

□ Dental clearance prior to radiation therapy is crucial
□ Preventive dental treatment ( maintaining OH, denture hygiene)
□ Surgical intervention (curettage, decortication, sequestrectomy)
Hyperbaric oxygen with antibiotics

Question 30

what is MRONJ

Answer 30

○ Typically associated wiith anti resorptive medications used for
§ Cancer related conditions including hypercalcemia of malignancy
§ Complications from bone metasteses from breast, prostate and lung CA, such as spinal cord compression and pathologic fractures; bone pain
§ Multiple myeloma
§ Osteoporosis related fracture
§ Metabolic bone diseases like paget’s disease, osteogenesis imperfecta
§ Others like giant cell tumour of bone, fibrous dysplasia
§ DRUG FOR BISPHOSPHONATES:
□ ORAL: alendronate(fosamax), risedronate (actonel)
□ IV: ibandronate (boniva), zoledronic acid (reclast)/ zolendronate(zometa)
denosumab, romosozumab

Question 31

what is aaoms criteria for MRONJ

Answer 31

§ Current or previous tx with anti resorptive therapy alone or in combination with immune modulators or antiangiogenic agents
§ Exposed bone or bone that can be probed through an intraoral or extraoral fistula in the maxillofacial regions that has persisted for more than 8 weeks
No history of radiation therapy to jaws or metastatic disease to the jaws

Question 32

what is stage 2 of MROnJ

Answer 32

□ Exposed and necrotic bone or fistula that probes to the bone in pt who are
® Symptomatic
® Have evidence of infection/inflammation
May present with stage 0 radiographic findings localised to alveolar bone

Question 33

what is stage 3 of mronj

Answer 33

□ Exposed and necrotic bone or fistula that probes to the bone in pt with
® Evidence of infection
® And one of the following
◊ Extra oral fistua
◊ Pathologic fracture
◊ Extra oral fistula
◊ Oro antral/oral nasal communication
Osteoysis extending to inferior border of mandible or sinus floor

Question 33

what is the pathophysiology of MRONJ

Answer 33

nhibition of bone remodelling
□ Antiresorptive drugs inhibit osteoclast formation, differentiation and function–> decreased bone resorption and remodelling, causing delayed healing
§ Infection and inflammation
□ Presence of inflammatory cytokines at MRONJ sites, poor OH and biofilm presence associated with development of MRONJ
§ Inhibition of angiogenesis
□ Some bisphosphonates directly inhibit angiogenesis, decrease vascularity at MRONJ sites
□ Antiangiogenic drugs associated with MRONJ
§ Innate or acquired immune dysfunction
□ Patients with metastatic or primary bone CA, in immunocompromised states, or those on immune modulating drugs at higher risk for MRONJ

Question 33

what are the risk factors for MRONJ

Answer 33

malignnacy

those taking denosumba higher risk than bisphosphonate

the longer the duration on antiresorptive, increased risk of MRONJ

local factors like dentoalvelar ops

mandible»maxilla

female higher prevelance

Question 33

management strategies for MRONJ

Answer 33

§ Education about risks of MRONJ
§ Dental clearance prior to start of antiresorptive therapy especially when AR therapy indicated for malignant diseases
§ Identify sites of acute or potential infection
§ Remove teeth with poor prognosis
§ Continued preventive maintenance after start of AR therapy ( perio maintainence)

Question 34

what are the risk of MRONJ pt

Answer 34

® Osteoporotic pt on BP –> 0-0.15%
® Osteoporotic pt on DMB–> 1%
Cancer pt on BP–> 1.6-14.8%