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Radiographic Interpretation > Ragged Radiolucencies > Flashcards

Ragged Radiolucencies Flashcards

1
Q

Ragged Radiolucencies
(5)

A

➢Chronic Osteomyelitis
➢Osteoradionecrosis
➢Medication Related Osteonecrosis of
the Jaws (MRONJ), (BRONJ)
➢Primary Epidermoid Carcinoma
➢Metastatic Disease

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2
Q

Features of “ragged” bony
disease
Radiographic
(7)

A
  • Irregular sclerotic trabeculation
  • Cortex changes – thinning
    – disruption
  • Sequestration
  • Fracture (pathologic)
  • Periosteal duplication
  • Widened PDL
  • Minimal displacement of teeth and bony outlines
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3
Q

Features of “ragged” bony
disease
Clinical
(2)

A
  • Edema, purulence
  • Increased mass
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4
Q

Chronic Osteomyelitis

A

Chronic Osteomyelitis
* Terminology has been difficult in relation
to other common dental diseases

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5
Q

Chronic Osteomyelitis
Chronic Alveolar Abscess
Chronic Dentoalveolar Abscess
a.k.a.
Chronic Osteitis
* Localizes inflammation and infection of
alveolar bone, consequently it will be;
(2)

A
  • around teeth
  • generally milder than acute
    osteomyelitis
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6
Q

Osteitis

A
  • inflammation of alveolar bone caused by
    pathogenic organisms
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7
Q

Osteomyelitis

A
  • inflammation of alveolar and basal bone
    caused by pathogenic organisms
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8
Q

Chronic Osteomyelitis
Pathophysiology
* Primarily polymicrobes from
* (3)
* With increased chronicity other microbes
may include (4)

A

odontogenic infection; also from open fractures
streptococcus, Bacteroides, Polystrepto
Actinomyces, Eikenella, Klebsiella, M. tuberculosis, etc…

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9
Q

OSTEOMYELITIS
Acute ( < – days)
Vs.
Chronic (> – days)

A

30
30

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10
Q

Chronic Osteomyelitis
Predisposing Factors
(3)

A

1.Reduced vascular supply; diabetes,
PCOD, FCOD, osteopetrosis, Pagets,
etc…
2.Immunodeficient states: AIDS, leukemia,
corticosteroid treatment, malnutrition,
bisphosphonates, other medications
3.Odontogenic infection, trauma, surgery

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11
Q

Chronic Osteomyelitis
Clinical Features
(5)

A
  • Low grade fever
  • Regional lymphadenopathy
  • Atrophic ,erythematous mucosa
  • Denuded bone
  • Suppuration
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12
Q

Chronic Osteomyelitis
Radiographic
(2)

A

● radiolucency of variable size with irregular borders
● patches of reactive sclerotic bone

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13
Q

Chronic Osteomyelitis
Radiographic
(3)

A

 radiolucency of variable
size with irregular
borders
 Moth-eaten appearance
 Sequestration

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14
Q

Cortical Disruption
irregular pattern of
(5)

A

-thinning
-erosion
sequestration
fracture
periosteal duplication

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15
Q

Chronic Osteomyelitis
Radiographic
* With increased chronicity, and a ragged moth-
eaten appearance, there can be

A

pathologic
fracture

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16
Q

Chronic Osteomyelitis
*— pattern in low-grade
chronic conditions

A

sclerosing, granular trabecular

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17
Q

Chronic Osteomyelitis
 sclerosing, granular trabecular pattern in low-grade
chronic conditions
 Tendency for

A

proliferative periostitis

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18
Q

Chronic Osteomyelitis
Age
Site
Predominant Gender

A

40-80 years of age
Body of mandible
Males

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19
Q

Chronic Osteomyelitis
Management
(3)

A
  • Debride any necrotic tissue
  • Antibiotic therapy
  • Drain and irrigate the region
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20
Q

OSTEORADIONECROSIS
(a.k.a. ORN)
CLASSIC TRIAD
(3)

A

Radiation Therapy
Trauma
Infection

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21
Q

ORN
Pathophysiology
* Marx in the early 1980’s:

  • Effect of irradiation of bone
    (2)
A

ORN was primarily a non-
healing wound secondary of endarteritis

decreased vascularity
decreased cellularity

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22
Q

Predisposing Factors

A
  • Age
  • Type and delivery of
    ionizing radiation
  • Tumor site
  • Diabetes
  • Pagets Disease
  • Hypertension
  • Pre-existing Oral Status:
    untreated dental
    infections (pulpal and/or
    periodontal)
  • Dental Extraction
  • Poor-fitting dentures and
    other micro-traumas
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23
Q

Osteoradionecrosis
Clinical
(4)

A
  • Mild to intense pain
  • Signs of inflammation (swelling, drainage)
  • Tissue denudation
  • Denuded bone, swelling and drainage
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24
Q

Osteoradionecrosis
Radiographic

A

Areas of increased radiodensity interspersed with
osteolytic regions

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25
Q

Osteoradionecrosis
Age
Site
Predominant Gender

A

40-80 years of age.
Body of mandible
More common in males

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26
Q

Osteoradionecrosis
Management: (4)
Predisposing conditions: (4)

A

Hyperbaric oxygen. Surgical debridement,
resection of nonviable tissues, and antibiotics.

previous radiation,
trauma, diabetes, Pagets disease

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27
Q

Medication Related
Osteonecrosis of the Jaws
(MRONJ)
* Terminology

A

has been difficult in relation
to the multiple medications that can
cause these bony changes
Bisphosphonate Related
Osteonecrosis of the Jaws
(BRONJ)

28
Q

Medications that cause MRONJ
Antiresorptive medications

A

I. Bisphosphonates
non-nitrogen-containing bisphosphonates
● etidronate
● clodronate
● tiludronate
nitrogen-containing bisphosphonates
● alendronate (Fosomax) - PO
●pamidronate (Aredia) - IV
● zoledronic acid (Zometa) - IV
● ibandronate (Boniva)
● risedronate (Actonel)
II. Denosumab
Antiangiogenic medications
bevacizumab

29
Q

Diseases Treated
(5)

A
  • Osteoporosis
  • Breast cancer
  • Multiple myeloma
  • Prostate CA
  • Colon CA
30
Q

MRONJ – Dental Etiologies
(5)

A

Dental Etiologies
Extraction
Implants
Prosthesis trauma
spontaneous

31
Q

knowledge base and experience in
addressing MRONJ continues to evolve and
expand, necessitating — and
refinements to the previous position papers

A

modifications

32
Q

At-risk category

A

No apparent necrotic bone in patients who have been
treated with either oral or IV bisphosphonates

33
Q

Stage 0

A

No clinical evidence of necrotic bone, but non-specific
clinical findings, radiographic changes, and symptoms

34
Q

Stage 2

A

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

35
Q

Stage 3

A

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

36
Q

BRONJ – maxilla and zygoma
Radiographic
(5)

A
  • Irregular sclerotic
    trabeculation
  • Osteolysis
  • Sequestration
  • Periosteal duplication
  • Minimal displacement of
    teeth and bony outlines
37
Q

BRONJ – maxilla and zygoma
Clinical
(2)

A
  • Edema, purulence
  • Increased mass
38
Q

Features of “ragged” bony
disease
Radiographic
(7)

A
  • Irregular sclerotic trabeculation
  • Cortex changes – thinning
    – disruption
  • Sequestration
  • Fracture (pathologic)
  • Periosteal duplication
  • Widened PDL
  • Minimal displacement of teeth and bony outlines
39
Q

Features of “ragged” bony
disease
Clinical
(2)

A
  • Edema, purulence
  • Increased mass
40
Q

MRONJ - TREATMENT
(6)

A
  • monitoring
  • pharmacologic agents
  • minor debridement
  • major debridement
  • sequestrectomy
  • resection
41
Q

Ragged Radiolucencies
(5)

A

➢Chronic Osteomyelitis
➢Osteoradionecrosis
➢Bisphosphonate Osteonecrosis
➢Primary Epidermoid Carcinoma
➢Metastatic Disease

42
Q

Diffuse, Ragged Radiolucent Lesions
(2)

A
  • Primary Epidermoid Carcinoma a.k.a. Squamous
    Cell Carcinoma
  • Metastatic Disease (various types)
43
Q

Primary intra-alveolar epidermoid
carcinoma
a.k.a.
(2)

A

Central squamous cell carcinoma
Primary epidermoid carcinoma

44
Q

Malignancies
(4)

A

poorly defined borders
ragged irregular borders
rapid growth
follow path of least resistance

45
Q

Primary Intra-Alveolar Epidermoid
Carcinoma
Incidence of Oral Malignancy
(3)

A
  1. Primary carcinoma
    (alveolar and mucosal)
  2. Metastatic carcinoma
  3. Others; lymphomas, sarcomas,
    etc..
46
Q

Primary Intra-Alveolar Epidermoid
Carcinoma
Clinical
(2)

A
  • Normally asymptomatic
  • Discovered on routine oral examination
47
Q

Primary Intra-Alveolar Epidermoid
Carcinoma
Radiographic
(4)

A
  1. Rarified trabecular pattern
  2. Radiolucency with ill-defined, irregular
    margins
  3. Rapid growth
  4. Wide PDL (irregular)
48
Q

Primary Intra-Alveolar Epidermoid
Carcinoma
Management
(3)

A

radiation therapy
surgery
both

49
Q

Diffuse, Ragged Radiolucent Lesions
(2)

A
  • Primary Epidermoid Carcinoma a.k.a. Squamous
    Cell Carcinoma
  • Metastatic Disease (various types)
50
Q

METASTATIC CARCINOMA
—% of malignancies metastasize to the
jaws

A

<1%

51
Q

ROUTES OF SPREAD
Called Metastasis
* LOCAL INVASION:

A

growth into adjacent
tissue and soft nerves

52
Q

ROUTES OF SPREAD
Called Metastasis
* LYMPHATIC SPREAD:

A

enter draining
lymphatic vessels and then to local
lymph nodes where the tumor grows

53
Q

ROUTES OF SPREAD
Called Metastasis
* VASCULAR SPREAD:

A

via veins draining the primary lesion. GI tumors to
portal veins-liver. Most common in lung, bone
marrow, brain and adrenal glands

54
Q

ROUTES OF SPREAD
Called Metastasis
* TRANSCOELOMIC SPREAD:

A

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.

55
Q

Metastatic Tumors
Pathophysiology
* Usually there is a history of a primary
tumor but occasionally

A

the metastatic
lesion is the initial presentation of the
disease

56
Q

Metastatic Tumors
Incidence of Oral Malignancy
(3)

A
  1. Primary carcinoma (alveolar and
    mucosal)
  2. Metastatic carcinoma
  3. Others; lymphomas, sarcomas, etc
57
Q

Metastatic Tumors
Clinical
(2)

A
  • May have no history of pain or
    previous malignancy
  • Bone pain, paresthesia, tooth mobility,
    swelling and soft tissue masses
58
Q

Metastatic Tumors
Radiographic
(3)

A
  1. Usually poorly defined with ragged borders
  2. May be expansive
  3. Some tend to be mixed radiolucent-
    radiopaque lesions; e.g. thyroid, prostate,
    breast
59
Q

Metastatic Tumors
PLAG
Prevalence
~ malignant osseous tumors in skull & jaws
% of malignancies metastasize to the jaws

A

1.8 x 106 - 10
less than 1

60
Q

Metastatic Tumors
PLAG
Location

A

mandible:maxilla is 7:1

61
Q

Metastatic Tumors
PLAG
Age

A

40-80 years of age; mean age 56 years

62
Q

Metastatic Tumors
PLAG
Gender

A

Gender predilection is dependent of the tumor type

63
Q

Metastatic Tumors
Management

A

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

64
Q

Annual Rates of Occult Disease
 — malignant osseous
tumors in
skull and jaws
 — - ameloblastoma
— - non-inflammatory cysts

A

1.8 x 106 - 10
0.3 x 106
20.0 x 106

65
Q

Period Prevalences for 30 million
health insurance records
malignant lesions:
benign lesions:

A

< 5 cases/million/year
~100 cases/million/year

Radiographic Interpretation (13 decks)

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