Ragged Radiolucencies Flashcards
Ragged Radiolucencies
(5)
➢Chronic Osteomyelitis
➢Osteoradionecrosis
➢Medication Related Osteonecrosis of
the Jaws (MRONJ), (BRONJ)
➢Primary Epidermoid Carcinoma
➢Metastatic Disease
Features of “ragged” bony
disease
Radiographic
(7)
- Irregular sclerotic trabeculation
- Cortex changes – thinning
– disruption - Sequestration
- Fracture (pathologic)
- Periosteal duplication
- Widened PDL
- Minimal displacement of teeth and bony outlines
Features of “ragged” bony
disease
Clinical
(2)
- Edema, purulence
- Increased mass
Chronic Osteomyelitis
Chronic Osteomyelitis
* Terminology has been difficult in relation
to other common dental diseases
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)
- around teeth
- generally milder than acute
osteomyelitis
Osteitis
- inflammation of alveolar bone caused by
pathogenic organisms
Osteomyelitis
- inflammation of alveolar and basal bone
caused by pathogenic organisms
Chronic Osteomyelitis
Pathophysiology
* Primarily polymicrobes from
* (3)
* With increased chronicity other microbes
may include (4)
odontogenic infection; also from open fractures
streptococcus, Bacteroides, Polystrepto
Actinomyces, Eikenella, Klebsiella, M. tuberculosis, etc…
OSTEOMYELITIS
Acute ( < – days)
Vs.
Chronic (> – days)
30
30
Chronic Osteomyelitis
Predisposing Factors
(3)
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
Chronic Osteomyelitis
Clinical Features
(5)
- Low grade fever
- Regional lymphadenopathy
- Atrophic ,erythematous mucosa
- Denuded bone
- Suppuration
Chronic Osteomyelitis
Radiographic
(2)
● radiolucency of variable size with irregular borders
● patches of reactive sclerotic bone
Chronic Osteomyelitis
Radiographic
(3)
radiolucency of variable
size with irregular
borders
Moth-eaten appearance
Sequestration
Cortical Disruption
irregular pattern of
(5)
-thinning
-erosion
sequestration
fracture
periosteal duplication
Chronic Osteomyelitis
Radiographic
* With increased chronicity, and a ragged moth-
eaten appearance, there can be
pathologic
fracture
Chronic Osteomyelitis
*— pattern in low-grade
chronic conditions
sclerosing, granular trabecular
Chronic Osteomyelitis
sclerosing, granular trabecular pattern in low-grade
chronic conditions
Tendency for
proliferative periostitis
Chronic Osteomyelitis
Age
Site
Predominant Gender
40-80 years of age
Body of mandible
Males
Chronic Osteomyelitis
Management
(3)
- Debride any necrotic tissue
- Antibiotic therapy
- Drain and irrigate the region
OSTEORADIONECROSIS
(a.k.a. ORN)
CLASSIC TRIAD
(3)
Radiation Therapy
Trauma
Infection
ORN
Pathophysiology
* Marx in the early 1980’s:
- Effect of irradiation of bone
(2)
ORN was primarily a non-
healing wound secondary of endarteritis
decreased vascularity
decreased cellularity
Predisposing Factors
- 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
Osteoradionecrosis
Clinical
(4)
- Mild to intense pain
- Signs of inflammation (swelling, drainage)
- Tissue denudation
- Denuded bone, swelling and drainage
Osteoradionecrosis
Radiographic
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: (4)
Predisposing conditions: (4)
Hyperbaric oxygen. Surgical debridement,
resection of nonviable tissues, and antibiotics.
previous radiation,
trauma, diabetes, Pagets disease
Medication Related
Osteonecrosis of the Jaws
(MRONJ)
* Terminology
has been difficult in relation
to the multiple medications that can
cause these bony changes
Bisphosphonate Related
Osteonecrosis of the Jaws
(BRONJ)
Medications that cause MRONJ
Antiresorptive medications
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
Diseases Treated
(5)
- Osteoporosis
- Breast cancer
- Multiple myeloma
- Prostate CA
- Colon CA
MRONJ – Dental Etiologies
(5)
Dental Etiologies
Extraction
Implants
Prosthesis trauma
spontaneous
knowledge base and experience in
addressing MRONJ continues to evolve and
expand, necessitating — and
refinements to the previous position papers
modifications
At-risk category
No apparent necrotic bone in patients who have been
treated with either oral or IV bisphosphonates
Stage 0
No clinical evidence of necrotic bone, but non-specific
clinical findings, radiographic changes, and symptoms
Stage 2
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
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
BRONJ – maxilla and zygoma
Radiographic
(5)
- Irregular sclerotic
trabeculation - Osteolysis
- Sequestration
- Periosteal duplication
- Minimal displacement of
teeth and bony outlines
BRONJ – maxilla and zygoma
Clinical
(2)
- Edema, purulence
- Increased mass
Features of “ragged” bony
disease
Radiographic
(7)
- Irregular sclerotic trabeculation
- Cortex changes – thinning
– disruption - Sequestration
- Fracture (pathologic)
- Periosteal duplication
- Widened PDL
- Minimal displacement of teeth and bony outlines
Features of “ragged” bony
disease
Clinical
(2)
- Edema, purulence
- Increased mass
MRONJ - TREATMENT
(6)
- monitoring
- pharmacologic agents
- minor debridement
- major debridement
- sequestrectomy
- resection
Ragged Radiolucencies
(5)
➢Chronic Osteomyelitis
➢Osteoradionecrosis
➢Bisphosphonate Osteonecrosis
➢Primary Epidermoid Carcinoma
➢Metastatic Disease
Diffuse, Ragged Radiolucent Lesions
(2)
- Primary Epidermoid Carcinoma a.k.a. Squamous
Cell Carcinoma - Metastatic Disease (various types)
Primary intra-alveolar epidermoid
carcinoma
a.k.a.
(2)
Central squamous cell carcinoma
Primary epidermoid carcinoma
Malignancies
(4)
poorly defined borders
ragged irregular borders
rapid growth
follow path of least resistance
Primary Intra-Alveolar Epidermoid
Carcinoma
Incidence of Oral Malignancy
(3)
- Primary carcinoma
(alveolar and mucosal) - Metastatic carcinoma
- Others; lymphomas, sarcomas,
etc..
Primary Intra-Alveolar Epidermoid
Carcinoma
Clinical
(2)
- Normally asymptomatic
- Discovered on routine oral examination
Primary Intra-Alveolar Epidermoid
Carcinoma
Radiographic
(4)
- Rarified trabecular pattern
- Radiolucency with ill-defined, irregular
margins - Rapid growth
- Wide PDL (irregular)
Primary Intra-Alveolar Epidermoid
Carcinoma
Management
(3)
radiation therapy
surgery
both
Diffuse, Ragged Radiolucent Lesions
(2)
- Primary Epidermoid Carcinoma a.k.a. Squamous
Cell Carcinoma - Metastatic Disease (various types)
METASTATIC CARCINOMA
—% of malignancies metastasize to the
jaws
<1%
ROUTES OF SPREAD
Called Metastasis
* LOCAL INVASION:
growth into adjacent
tissue and soft nerves
ROUTES OF SPREAD
Called Metastasis
* LYMPHATIC SPREAD:
enter draining
lymphatic vessels and then to local
lymph nodes where the tumor grows
ROUTES OF SPREAD
Called Metastasis
* VASCULAR SPREAD:
via veins draining the primary lesion. GI tumors to
portal veins-liver. Most common in lung, bone
marrow, brain and adrenal glands
ROUTES OF SPREAD
Called Metastasis
* 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 Tumors
Incidence of Oral Malignancy
(3)
- Primary carcinoma (alveolar and
mucosal) - Metastatic carcinoma
- Others; lymphomas, sarcomas, etc
Metastatic Tumors
Clinical
(2)
- May have no history of pain or
previous malignancy - Bone pain, paresthesia, tooth mobility,
swelling and soft tissue masses
Metastatic Tumors
Radiographic
(3)
- Usually poorly defined with ragged borders
- May be expansive
- Some tend to be mixed radiolucent-
radiopaque lesions; e.g. thyroid, prostate,
breast
Metastatic Tumors
PLAG
Prevalence
~ malignant osseous tumors in skull & jaws
% of malignancies metastasize to the jaws
1.8 x 106 - 10
less than 1
Metastatic Tumors
PLAG
Location
mandible:maxilla is 7:1
Metastatic Tumors
PLAG
Age
40-80 years of age; mean age 56 years
Metastatic Tumors
PLAG
Gender
Gender predilection is dependent of the 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
Annual Rates of Occult Disease
— malignant osseous
tumors in
skull and jaws
— - ameloblastoma
— - non-inflammatory cysts
1.8 x 106 - 10
0.3 x 106
20.0 x 106
Period Prevalences for 30 million
health insurance records
malignant lesions:
benign lesions:
< 5 cases/million/year
~100 cases/million/year
