ragged lucencies Flashcards
potential ragged lucencies
➢Chronic Osteomyelitis
➢Osteoradionecrosis
➢Medication Related Osteonecrosis of the Jaws (MRONJ), (BRONJ)
➢Primary Epidermoid Carcinoma
➢Metastatic Disease
radiographic features of ragged lucencies
* trabeculation?
* Cortex changes?
* Sequestration?
* pathologic result?
* Periosteum?
* PDL
* teeth and bony outlines?
- Irregular sclerotic trabeculation
- Cortex changes – thinning or disruption
- Sequestration
- Fracture (pathologic)
- Periosteal duplication
- Widened PDL
- Minimal displacement of teeth and bony outlines
clinical features of ragged lucencies
- Edema, purulence
- Increased mass
Chronic Osteomyelitis can only occur when infection goes beyond?
beyond alveolar bone
why is chronic osteomyelitis less common in jaw?
good blood supply of alveolar bone, basal with lesser supply
Chronic Alveolar Abscess/ Chronic Dentoalveolar Abscess a.k.a. Chronic Osteitis
compared to acute osteomyelitis?
- Localizes inflammation and infection of alveolar bone, consequently it will be; around teeth and generally milder than acute osteomyelitis
osteitis vs osteomyelitis
Chronic Osteomyelitis
Pathophysiology
- Primarily polymicrobes from odontogenic infection; also from open fractures
- streptococcus, Bacteroides, Polystrepto
- With increased chronicity other microbes may include Actinomyces, Eikenella, Klebsiella, M. tuberculosis, etc.
osteomyelitis acute vs chronic time frame
Chronic Osteomyelitis
Predisposing Factors
1.Reduced vascular supply; diabetes, any COD, osteopetrosis, Pagets, etc…
2.Immunodeficient states: AIDS, leukemia, corticosteroid treatment, malnutrition, bisphosphonates, other medications
3.Odontogenic infection, trauma, surgery
Chronic Osteomyelitis Clinical Features:
* temp?
* LN?
* mucosa?
* bone?
* drainage?
- Low grade fever
- Regional lymphadenopathy
- Atrophic ,erythematous mucosa
- Denuded bone
- Suppuration
Chronic Osteomyelitis
Radiographic app
● radiolucency of variable size with irregular borders
● patches of reactive sclerotic bone
* Moth-eaten appearance
Sequestration (necrotic bone)
what can be seen here?
sequestration, may be seen with chronic osteomyelitis
what is marked by the arrow
pathologic fracture
- With increased chronicity, and a ragged moth-
eaten appearance, there can be what complication as a result?
in osteomyelitis
pathologic fracture
Chronic Osteomyelitis radio app in low grade chronic conditions
- sclerosing, granular trabecular pattern in low-grade chronic conditions
low grade chronic osteomyelitis has a tendency for what tissue rxn?
proliferative periostitis
what is seen? what may this indicate?
proliferative periostitis, low grade chronic osteomyelitis
Chronic Osteomyelitis
Age?
Site?
Predominant Gender?
40-80 years of age
Body of mandible
Males
Chronic Osteomyelitis Management
- Debride any necrotic tissue
- Antibiotic therapy
- Drain and irrigate the region
classic triad of ORN
Radiation Therapy
Trauma
Infection
Pathophysiology ORN
ORN was primarily a non- healing wound secondary of endarteritis
* Effect of irradiation of bone: decreased vascularity and decreased cellularity
Predisposing Factors of ORN
- Age
- Type and delivery of ionizing radiation
- Tumor site
- Diabetes
- Pagets Disease
- Hypertension
- Pre-existing Oral Status: untreated dental infections
- Dental Extraction
- Poor-fitting dentures and other micro-traumas
ORN clinical
- Mild to intense pain
- Signs of inflammation (swelling, drainage)
- Tissue denudation
- Denuded bone, swelling and drainage
what stages of ORN is denuded bone present?
stages 1, 2, 3
radio app of ORN
Areas of increased radiodensity interspersed with osteolytic regions
Osteoradionecrosis
Age
Site
Predominant Gender
40-80 years of age.
Body of mandible
More common in males
Osteoradionecrosis Management
Hyperbaric oxygen. Surgical debridement,
resection of nonviable tissues, and antibiotics.
ORN predispoing conditions
previous radiation, trauma, diabetes, Pagets disease
Medication Related Osteonecrosis of the Jaws (MRONJ) vs. Bisphosphonate Related Osteonecrosis of the Jaws
(BRONJ)
- Terminology has been difficult in relation to the multiple medications that can cause these bony changes
Medications that cause MRONJ
antiresorptive medications:
non-nitrogen-containing bisphosphonates
● etidronate
● clodronate
nitrogen-containing bisphosphonates
● alendronate (Fosomax) - PO
dx tx with antiresorpative meds
- Osteoporosis
- Breast cancer
- Multiple myeloma
- Prostate CA
- Colon CA
MRONJ – Dental Etiologies
Extraction
Implants
Prosthesis trauma
spontaneous
MRNOJ stages
at risk
stage 0-3
which MRNOJ stages are symptomatic
2 and 3
at risk for MRNOJ findings
No apparent necrotic bone in patients who have been
treated with either oral or IV bisphosphonates
stage 0 mrnoj clinical findings
No clinical evidence of necrotic bone, but non-specific
clinical findings, radiographic changes, and symptoms
stage 1 mnroj clinical findings
Exposed and necrotic bone, or fistulae that probes to the bone in patients who are asymptomatic and have no evidence of infection
stage 2 mnroj clinical findings
Exposed and necrotic bone, or fistulae that probes to the bone, associated with infection as evidenced by pain and erythema in the region of the exposed bone, with or without purulent drainage
stage 3 mnroj clinical findings
Exposed and necrotic bone or a fistula that probes to bone in patients with pain, infection, and one or more of the following: exposed and necrotic bone extending beyond the region of alveolar bone (i.e., inferior border and ramus in the mandible, maxillary sinus, and zygoma in the maxilla) resulting in pathologic fracture, extra-oral fistula, oral-antral/oral-nasal communication or osteolysis extending to the inferior border of the mandible of sinus floor
mrnoj stage? pt has no symptoms/denuded bone
0
mrnoj stage? (PT without symptoms)
1
BRONJ – maxilla and zygoma clinical findings
- Edema, purulence
- Increased mass
BRONJ – maxilla and zygoma radio findings
- Irregular sclerotic trabeculation
- Osteolysis
- Sequestration
- Periosteal duplication
- Minimal displacement of teeth and bony outlines
MRONJ - TREATMENT
- monitoring
- pharmacologic agents
- minor debridement or major debridement
- sequestrectomy
- resection
primary epidermoid carcinoma known as?
SCCa
benign vs malignant changes and tooth displacement?
bening will displace teeth, malignant may not
benign vs malignant changes and the periosteum/cortex?
bening causes a onion skin reaction (proliferation of periosteum), malignant causes a blow out of cortex
malignancies radio app
Commonality of Oral Malignancies
- Primary carcinoma (alveolar and mucosal), most common
- Metastatic carcinoma
- Others; lymphomas, sarcomas, etc.
Primary Intra-Alveolar Epidermoid Carcinoma Clinical
* Normally?
* Discovered how?
- Normally asymptomatic
- Discovered on routine oral examination
Primary Intra-Alveolar Epidermoid
Carcinoma Radiographic findings
1. trabecular pattern?
2. margins?
3. growth rate?
4. PDL ?
- Rarified trabecular pattern
- Radiolucency with ill-defined, irregular
margins - Rapid growth
- Wide PDL (irregular)
rarefied pattern
desrcribe the trabeculae
rarefied
are these central or perihperal lesions
peripheral
what can be seen here? what should be suspected?
widened PDL, SCCa (Primary Intra Alveolar Epidermoid Carcinoma)
Primary Intra-Alveolar Epidermoid Carcinoma
Management
radiation therapy, surgery, both
METASTATIC CARCINOMA at jaws commonality?
<1% of malignancies metastasize to the
jaws
ROUTES OF SPREAD for metastasis
- LOCAL INVASION: growth into adjacent tissue and soft nerves
- LYMPHATIC SPREAD: enter draining lymphatic vessels and then to local lymph nodes where the tumor grows
- VASCULAR SPREAD: via veins draining the primary lesion. GI tumors to portal veins-liver. Most common in lung, bone marrow, brain and adrenal glands.
- TRANSCOELOMIC SPREAD: primary tumor in abdominal cavity or thorax and then spreads via peritoneal or pleural fluids. Start on surfaces and seed to organs in the area
Metastatic Tumors
Pathophysiology
- Usually there is a history of a primary tumor but occasionally the metastatic lesion is the initial presentation of the disease
metastatic carcinomas commonality in the oral cavity
2nd most common oral malignancy
Metastatic Tumors
Clinical
- May have no history of pain or previous malignancy
- Bone pain, paresthesia, tooth mobility, swelling and soft tissue masses
Metastatic Tumors Radiographic app
1. Usual app?
2. expansion?
3. Some tend to appear as? which ones?
- Usually poorly defined with ragged borders
- May be expansive
- Some tend to be mixed radiolucent- radiopaque lesions; thyroid, prostate, breast
teeth and metastasis
can be dsiplaced by the mass (supererupted, drift, etc.)
metastasis growth rates
rapid growth occurs like other malignancies
prevalence metastatic tumors of the jaw
~ 1.8 x 106 - 10 malignant osseous tumors in skull & jaws
less than 1% of malignancies metastasize to the jaw
metastasis in jaw arch ratio
mandible:maxilla is 7:1
age for metastasis to the jaw
40-80 years of age; mean age 56 years
gender predilection for metastasis to jaw
based on tumor type
Metastatic Tumors
Management
Management by tumor board
Treatment may include surgery, radiation, and/or
chemotherapy
Ultimate decisions are dependent on the type of
primary malignancy and the decision of the multi-
disciplinary tumor board
