Oral Path Exam 2 - Mixed Lesions and Radiolucent or Mixed Lesions Part 2 (Malignancies) Flashcards
What type of lesion?
Malignancy showing malignant mesenchymal cells producing osteoid
Osteosarcoma
What type of lesion?
Most common primary bone malignancy (twice as common as chondrosarcoma)
Osteosarcoma
What type of lesion?
Fast growing mass around knees in children and young adults; only 6% of these affect the jaws
Osteosarcoma
What type of lesion?
Some cases arise in Paget Disease of bone or radiated bone
Osteosarcoma
What type of lesion?
Initial complaint is pain, followed by swelling, loose teeth, or paresthesia
Osteosarcoma
What type of lesion?
Mixed lesion with ill-defined borders
Symmetric widening of PDLs
Osteosarcoma
What type of lesion?
Growth of bone above crestal height
Osteosarcoma
What type of lesion?
“Sun burst” pattern is NOT common in jaws (unless lesion becomes very big)
Osteosarcoma
What type of lesion?
Tx = wide surgical resection (1-2 cm beyond border) w/ initial complete removal being the most important prognostic factor
Osteosarcoma
What is the most important prognostic factor of osteosarcoma in the jaws?
Wide surgical resection w/ initial complete removal
(survival is lower if it is not completely removed initially and it comes back)
What type of lesion?
Metastasizes to lungs and brain
Osteosarcoma
What type of lesion?
Death is due to uncontrolled local disease, tumor infiltrates beyond radiographic margins
Osteosarcoma
What is the most common cancer involving bone?
Metastatic carcinoma
What is occasionally affected in metastatic disease?
Jaw (mostly posterior mandible)
In metastatic disease, metastatic deposits from malignancies below the ________ may affect the jaws through Batson’s paravertebral plexus of _________ - no valves
neck; veins
In metastatic disease, over half of affected patients are over _______ years of age
50
Name the most common soft tissue affected by metastatic disease
Gingiva
What does gingiva affected by metastatic disease resemble?
Pyogenic granuloma
What makes up 61% of cases of metastatic disease?
Mandible
What makes up 24% of cases of metastatic disease?
Maxilla
What makes up 15% of cases of metastatic disease?
Soft tissue
What are the following symptoms an indication of?
Pain
Paresthesia
Swelling
Tooth mobility w/ PDL widening
Ill-defined radiolucency (less commonly radiopacity)
Hemorrhage
Pathologic fracture
Trismus
Metastatic disease
What % of jaw metastases represent the initial manifestation of the malignant process?
22%
What are the most common primary tumors that metastasize to the jaw?
Breast or prostate (these can be RO)
Lung
Kidney
Thyroid
Colon
What are the most common primary tumors that metastasize to the soft tissue?
Breast
Lung
Kidney
Melanoma
What type of malignancy?
Histology: looks like tissue of origin, may show diffuse infiltration or scattered tumor cells (“seeded” effect)
Metastatic disease
What should you consider clinically if you see a patient with lack of healing of a tooth socket?
Granulation tissue
Lymphoma
Metastatic disease
What type of malignancy?
Tumor cells look like where they came from
Metastatic disease
What is used to confirm prostate cancer?
Prostate Specific Antigen (PSA)
What type of malignancy?
Typically widely disseminated disease (stage IV) once it appears in the oral cavity
Metastatic disease
What type of malignancy?
Tx: palliation, usually radiation therapy; bisphosphonates given to slow progression of bone metastasis and decrease bone pain and fracture risk
Metastatic disease
What type of malignancy?
Prognosis: very poor, most pts die within 1 year of diagnosis
Metastatic disease
What type of infection
Acute or chronic inflammatory process in the medullary space or cortical surface of bone that extends away from initial site
Osteomyelitis
What are the 2 types of osteomyelitis?
Suppurative osteomyelitis
Diffuse sclerosing osteomyelitis
What type of osteomyelitis?
Caused by bacterial infection, causing expanding lytic destruction w/ suppuration and sequestra formation
Suppurative osteomyelitis
What type of osteomyelitis?
Arises after odontogenic infection or jaw fracture
Suppurative osteomyelitis
What type of osteomyelitis?
Occurs more in setting of immune suppression or diseases that decrease bone vascularity
Suppurative osteomyelitis
What type of osteomyelitis?
Idiopathic inflammation of bone without suppuration or sequestra
Diffuse sclerosing osteomyelitis
What type of osteomyelitis?
Non-responsive to antibiotics; leads to bone sclerosis
Diffuse sclerosing osteomyelitis
What type of osteomyelitis?
Spreads rapidly before body can react to the inflammatory infiltrate. Fever, leukocytosis, LAD, pain and soft tissue swelling for <1 month
Acute suppurative osteomyelitis
What type of osteomyelitis?
Can cause paresthesia of lower lip, mimicking malignancy
Acute suppurative osteomyelitis
What type of osteomyelitis?
Ill-defined radiolucency
Drainage or separation and exfoliation of necrotic bone (sequestrum)
Necrotic bone can be surrounded by new vital bone (involucrum)
Acute suppurative osteomyelitis
What type of osteomyelitis?
Tx: resolve source of infection, establish drainage, remove infected bone, empiric use of antibiotics while awaiting culture and antibiotic sensitivity results
Acute suppurative osteomyelitis
Which antibiotics are used to treat acute suppurative osteomyelitis?
Penicillin w/ metronidazole or clindamycin
What type of osteomyelitis?
Multiple procedures may be needed over days - weeks to eliminate infection and reconstruct the defect
Acute suppurative osteomyelitis
What type of osteomyelitis?
Defensive response produces granulation tissue that remodels into dense scar tissue attempting to wall off the infected area
This dead space harbors bacteria and antibiotics have difficulty reaching the area which can lead to a smoldering process with periodic acute exacerbations
Chronic suppurative osteomyelitis
What type of osteomyelitis?
Can arise de novo or from unresolved acute osteomyelitis
Chronic suppurative osteomyelitis
What type of osteomyelitis?
Swelling
Pain
Sinus formation
Purulent discharge
Sequestrum formation
Tooth loss
Pathologic fracture
Chronic suppurative osteomyelitis
What type of osteomyelitis?
Patchy, ragged, ill-defined radiolucency
Can have central radiopaque sequestra
Typically mixed appearance
Chronic suppurative osteomyelitis
What type of osteomyelitis?
Tx: IV antibiotics to get high dose to dead spaces, removal of all infected material down to good bleeding bone is mandatory, hyperbaric oxygen used in refractory cases or for disease in hypovascularized bone (osteoradionecrosis, Paget disease, cemento-osseous dysplasia)
Chronic suppurative osteomyelitis
What type of lesion is defined by the following?
Current or previous tx with certain class of meds
Exposed bone in maxillofacial region for > 8 weeks
No history of radtx or obvious metastatic disease to jaws
Medication-related osteonecrosis of the jaw
What type of lesion is defined by previous tx with the following classes of meds?
- Antiresorptive (bisphosphonates and denosumab) -> Treating osteoporosis or cancers involving bone (multiple myeloma, breast/prostate carcinoma)
- Antiangiogenic agents [tyrosine kinase inhibitors (Sunitinib, Sorafenib) and VEGF inhibitors (Bevacizumab)] -> Used to treat cancer
Medication-related osteonecrosis of the jaw
IV bisphosphonate for metastatic cancer (breast, prostate, myeloma) is intended
to prevent ________________ and _______________. What % of these patients will get medication-related osteonecrosis of the jaw?
bone resorption; hypercalcemia
1% of patients
______% of cases of medication-related osteonecrosis of the jaw occur in those receiving IV bisphosphonates for metastatic cancer
90%
Bisphosphonates for osteoporosis. Necrosis usually does not occur within first _______ years. How many people will be affected by medication-related osteonecrosis of the jaw?
2-4 years
1 in 10,000
What type of lesion?
Begins as increased radiopacity in crestal bone, then pain, necrosis, and infection
Either or both jaws can be involved
Medication-related osteonecrosis of the jaw
What type of lesion?
Can follow ext, minor trauma, or spontaneous
Medication-related osteonecrosis of the jaw
What type of lesion?
Tori often involved
Medication-related osteonecrosis of the jaw
What type of lesion?
Small areas of necrosis rinsed w/ CHX may heal slowly without surgery
Medication-related osteonecrosis of the jaw
What type of lesion?
Large areas of necrosis are difficult to treat surgically
Medication-related osteonecrosis of the jaw
Anticancer therapy kills __________ cells and tissues with rapid turnover
normal
What are the 2 oral complications of chemotherapy?
Hemorrhage
Oral mucositis
Which oral complication of chemotherapy is caused by the following?
Thrombocytopenia from bone marrow suppression
Reduced clotting factors from intestinal or hepatic damage
Hemorrhage
What are the 6 oral complications of radiation therapy?
Oral mucositis
Dermatitis
Xerostomia
Taste change
Trismus
Osteoradionecrosis
Which type of infection?
Single most debilitating complication of chemotx (most often for stem cell transplant- called “myeloablative therapy”) or radiation of the head and neck for head and neck cancer
Oral mucositis
Which type of infection?
Increases need for total parenteral (IV or tube) nutrition and risk for sepsis
Oral mucositis
Which type of infection?
Virtually all oral cancer pts will develop this
Oral mucositis
Chemo or radiation?
Oral mucositis develops a few days after start of treatment
Chemo
Chemo or radiation?
Oral mucositis involves mostly non-keratinized surfaces (spares the hard palate, gingiva and dorsal tongue)
Chemo
Chemo or radiation?
Oral mucositis begins during 2nd week of therapy (tx usually lasts 7 weeks)
Radiation
Chemo or radiation?
Oral mucositis affects tissues in the direct portal of radiation
Radiation
How long does oral mucositis resolve after cessation of chemo or radiation?
2-3 weeks after cessation
What type of infection?
Whitish discoloration that sloughs showing atrophic, edematous, erythematous and friable layers that then ulcerate (yellow fibrinopurulent surface membrane); very painful
Oral mucositis
What medication is a keratinocyte growth factor used for HSCT for hematologic cancers, NOT metastatic carcinoma?
Palifermin
What is used 5 minutes before to 30 mins after chemo?
Oral cryotherapy (ice chips, ice water, ice cream, popsicle)
What is used for prevention of oral mucositis related to chemo and radiation?
Benzydamine mouthwash
Honey
What is used for prevention of oral mucositis in HSCT patients and TBI?
Low-level laser therapy
What is used for prevention of oral mucositis in HN cancer patients receiving chemo or radiation?
Topical morphine mouthwash
What type of dermatitis from radiation?
Erythema, edema, burning, pruritis that resolves in 2-3 weeks after therapy then hyperpigmentation and variable hair loss
Mild acute dermatitis
What type of dermatitis from radiation?
Erythema, edema with erosions/ulcerations. Resolves within 3 months with possible permanent hair loss, hyperpigmentation and scarring
Moderate acute dermatitis
What type of dermatitis from radiation?
Necrosis and deep ulcerations
Severe acute dermatitis
What type of dermatitis from radiation?
Dry, smooth, shiny telangiectactic or ulcerated areas
Chronic dermatitis
Which chronic effect of radiation?
Salivary glands are very sensitive to radiation (>40Gy is irreversible)
Xerostomia
Which chronic effect of radiation?
Serous glands are affected the most- parotids affected dramatically and irreversibly.
Mucous glands partially recover, possibly up to 50% over several months
Xerostomia
With chronic xerostomia due to radiation, which glands are affected the most?
Serous glands -> parotid glands are dramatically and irreversibly affected
With chronic xerostomia due to radiation, which glands partially recover up to 50% over several months?
Mucous glands
Which chronic effect of radiation?
Effects begin within 1 week of radiation initiation with dramatic decrease in salivary flow during first 6 weeks of tx. Can continue to decrease for 3 years
Xerostomia
Which chronic effect of radiation?
Affects speech, eating, denture wear, sleep
and can lead to caries (extensive cervical decay)
Xerostomia
Which chronic effect of radiation?
Prevention includes:
IMRT to reduce damage to glands
Surgical transfer of submandibular gland to the submental space
Xerostomia
What should patients with xerostomia from radiation avoid?
Alcohol + tobacco (dries the mouth)
Low pH/sugary drinks
What should patients with xerostomia from radiation apply daily?
Topical fluoride
What should patients with xerostomia from radiation be monitored for?
Candidiasis
What else can patients with xerostomia from radiation use to help dry mouth?
Sialagogues
Moisturizing gels/sprays
Fluoridated tap water
Which chronic effect of radiation?
Occurs within several weeks and usually returns within 4 months for most patients
Reduced taste (hypogeusia)
Which chronic effect of radiation?
Can be permanent or have persistent altered taste
Dysguesia
Which chronic effect of radiation?
Zinc sulfate supplement may help
Taste changes
Which chronic effect of radiation?
Due to fibrosis or spasm of muscle and TMJ capsule
Trismus
Which chronic effect of radiation?
Jaw-opening exercises are important to maintain max opening
Trismus
What type of infection?
Radiation damages osteoblasts and endothelium (occluding blood vessels in bone)
Osteoradionecrosis
What type of infection?
Mature bone is stable unless injured (ext, perio, mucosal perforation, trauma)
Vascular infarct occurs (i.e. exposed nonvital irradiated bone for longer than 3 months)
Osteoradionecrosis
What type of infection?
Exposed nonvital irradiated bone for longer than 3 months
Osteoradionecrosis
What type of infection?
5% prevalence
Most occur 4 months - 3 years after radiation
Osteoradionecrosis
What type of infection?
Unexpected until radiation dose is > 60Gy
Osteoradionecrosis
What type of infection?
Almost always in mandible
More common in dentate patients
Osteoradionecrosis
What type of infection?
Ill-defined radiolucency w/ zones of radiopacity (dead bone)
Osteoradionecrosis
What type of infection?
Pain
Cortical perforation
Fistula formation
Surface ulceration
Pathologic fracture
Osteoradionecrosis
What type of infection?
Tx: surgery to remove dead bone + antibiotics
Osteoradionecrosis
What type of infection can be prevented by the following?
Eliminate all oral foci of infection and maintain excellent OH
Osteoradionecrosis
What type of infection can be prevented by the following?
Ext all non-restorable or periodontally involved lower teeth in field of radiation, especially if salivary glands are radiated
Osteoradionecrosis
When is the best opportunity to ext teeth before radiation to prevent osteoradionecrosis?
1 month before radiation
T/F: Never extract teeth during radiation treatment
True
When is it ok to extract teeth after radiation treatment?
Within 4 months after treatment but NOT after this
For patients with osteoradionecrosis and need exts, effect slowly improves over time, but this is always vulnerability. Exts must be atraumatic, and give __________ and ___________ to improve blood flow. May also need to give clodronate, which is a bisphosphonate
Vitamin E
Pentoxifylline
For pts with osteonecrosis, you should wait on ___________ after a full mouth ext. You can wait for less time if it is a previous denture wearer with a good, smooth ridge
dentures
T/F: For pts with osteonecrosis, sore spots from denture are an emergency
True!
