Ragged Radiolucencies Flashcards
What are the examples of ragged radiolucencies?
➢Chronic Osteomyelitis
➢Osteoradionecrosis
➢Medication Related Osteonecrosis of the Jaws (MRONJ), (BRONJ)
➢Primary Epidermoid Carcinoma
➢Metastatic Disease
What are the radiographic features of ragged radiolucencies?
- Irregular sclerotic trabeculation
- Cortex changes
— thinning
— disruption - Sequestration
- Fracture (pathologic)
- Periosteal duplication
- Widened PDL
- Minimal displacement of teeth and bony outlines
What are the clinical features of ragged radiolucencies?
- Edema, purulence
- Increased mass
What is chronic osteomyelitis?
Localized inflammation and infection of alveolar bone, consequently it will be;
- around teeth
- generally milder than acute osteomyelitis
What is osteitis?
inflammation of alveolar bone caused by pathogenic organisms
What is osteomyeltitis?
inflammation of alveolar and basal bone caused by pathogenic organisms
What is the pathophysiology of chronic osteomyelitis?
- 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
How many days switches acute to chronic osteomyelitis?
Acute (< 30 days)
Vs.
Chronic (> 30 days)
What are the predisposing factors for chronic osteomyelitis?
- Reduced vascular supply; diabetes, PCOD, FCOD, osteopetrosis, Pagets, etc…
- Immunodeficient states: AIDS, leukemia, corticosteroid treatment, malnutrition, bisphosphonates, other medications
- Odontogenic infection, trauma, surgery
What are the clinical features of chronic osteomyelitis?
- Low grade fever
- Regional lymphadenopathy
- Atrophic ,erythematous mucosa
- Denuded bone
- Suppuration
What are the radiographic features of chronic osteomyelitis?
- radiolucency of variable size with irregular borders
- patches of reactive sclerotic bone
- Moth-eaten appearance
- Sequestration (island of irregular bone)
With increased chronicity of chronic osteomyelitis, and a ragged moth eaten appearance, there can be a…
pathologic fracture
What types of cortical disruption are invovled in chronic osteomyelitis?
- irregular pattern of
—thinning
—erosion - sequestration
- fracture
- periosteal duplication
What does chronic osteomyelitis have a tendency for?
proliferative periostitis
What is the predominant age and gender of chronic osteomyelitis?
Age: 40-80 years of age
Gender: Males
What is the main site for chronic msteomyelitis?
Body of mandible
What is the management for chronic osteomyelitis?
- Debride any necrotic tissue
- Antibiotic therapy
- Drain and irrigate the region
What is the classic triad for osteoradionecrosis (ORN)?
Radiation Therapy
Trauma
Infection
What is the pathophysiology of ORN?
- Marx in the early 1980’s: ORN was primarily a nonhealing wound secondary of endarteritis
- Effect of irradiation of bone
— decreased vascularity
— decreased cellularity
What are the predisoposing factors for ORN?
- Age
- Type and delivery of ionizing radiation
- Tumor site
- Diabetes
- Pagets Disease (Osteitis deformans)
- Hypertension
- Pre-existing Oral Status:untreated dental infections (pulpal and/or periodontal)
- Dental Extraction
- Poor-fitting dentures and other micro-traumas
What are the clinical features of osteoradionecrosis?
- Mild to intense pain
- Signs of inflammation (swelling, drainage)
- Tissue denudation
- Denuded bone, swelling and drainage
What are the different stages of ORN?
stages I, II, and III
What does ORN look like radiographically?
Areas of increased radiodensity interspersed with osteolytic regions
What is the predominant age and gender of ORN?
Age: 40-80 years of age
Gender: More common in males
What is the main site for ORN?
Body of mandible
What is the management for ORN?
- Hyperbaric oxygen
- Surgical debridement
- resection of nonviable tissues
- antibiotics
What diseases can lead to medication related osteonecrosis of the jaw (MRONJ) via treatment?
- Osteoporosis
- Pagets disease (osteitis deformans)
- Breast cancer
- Multiple myeloma
- Prostate CA
- Colon CA
all diseases treated with bisphosphonates
What types of medications cause MRONJ?
- Bisphosphonates
— non-nitrogen-containing bisphosphonates
— nitrogen-containing bisphosphonates - Denosumab – anti TNF
- Antiangiogenic medications
What are the dental etiologies for MRONJ?
Extraction
Implants
Prosthesis trauma
Spontaneous
What are the predisposing factors for MRONJ?
- Age
- Type and delivery of medication
- Tumor site
- Diabetes
- Hypertension
- Pre-existing Oral Status: untreated dental infections (pulpal and/or periodontal)
- Dental Extraction
- Poor-fitting dentures
What are the different stages of MRONJ?
- at risk category
- stage 0
- stage 1
- stage 2
- stage 3
What are the asymptomatic stages of MRONJ?
- at risk category
- stage 0
- stage 1
What are the symptomatic stages of MRONJ?
- stage 2
- stage 3
What are the clinical findings of stage 0 MRONJ?
No clinical evidence of necrotic bone, but non-specific clinical findings, radiographic changes, and symptoms
What are the clinical findings of stage 1 MRONJ?
Exposed and necrotic bone, or fistulae that probes to the bone in patients who are asymptomatic and have no evidence of infection
What are the clinical findings of stage 2 MRONJ?
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
What are the clinical findings of stage 3 MRONJ?
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 or sinus floor
What is BRONJ?
- maxilla and zygoma
What are the clinical features of BRONJ?
- Edema, purulence
- Increased mass
What are the radiographic features of BRONJ?
- Irregular sclerotic trabeculation
- Osteolysis
- Sequestration
- Periosteal duplication
- Minimal displacement of teeth and bony outlines
What is the treatment for MRONJ?
- monitoring
- pharmacologic agents
- minor debridement
- major debridement
- sequestrectomy
- resection
What are the two types of ragged radiolucencies that are diffuse?
➢Primary Epidermoid Carcinoma
➢Metastatic Disease
both malignancies
What is another name for primary epidermoid carcinoma?
Central squamous cell carcinoma
What are the properties of malignancies?
- poorly defined borders
- ragged irregular borders
- rapid growth
- follow path of least resistance
What are the main incidences of oral malignancy?
- Primary carcinoma (alveolar and mucosal)
- Metastatic carcinoma
- Others; lymphomas, sarcomas, etc…
What are the clinical features of Primary Intra-Alveolar Epidermoid Carcinoma?
- Normally asymptomatic
- Discovered on routine oral examination
What are the radiographic features of Primary Intra-Alveolar Epidermoid Carcinoma?
- Rarified trabecular pattern
- Radiolucency with ill-defined, irregular margins
- Rapid growth
- Wide PDL (irregular)
What is the management for primary intra-alveolar epidermoid carcinoma?
radiation therapy
surgery
both
___% of malignancies metastasize to the jaws
<1%
What are the routes of spread for malignancies?
- Local invasion
- Lymphatic spread
- Vascular spread
- Transcoelomic spread
What is a local invasion?
growth into adjacent tissue and soft nerves
What is lymphatic spread?
enter draining lymphatic vessels and then to local lymph nodes where the tumor grows
What is vascular spread?
- via veins draining the primary lesion. GI tumors to portal veins-liver
- Most common in lung, bone marrow, brain and adrenal glands
What is 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
What is the pathophysiology of metastatic tumor?
Usually there is a history of a primary tumor but occasionally the metastatic lesion is the initial presentation of the disease
What are the clinical features of metastatic tumor?
- May have no history of pain or previous malignancy
- Bone pain, paresthesia, tooth mobility, swelling and soft tissue masses
What are the radiographic features of metastatic tumor?
- Usually poorly defined with ragged borders
- May be expansive
- Some tend to be mixed radiolucent radiopaque lesions; e.g. thyroid, prostate, breast
What is the predominant age and gender of metastatic tumor?
Age: 40-80 years of age; mean age 56 years
Gender: dependent of the tumor type
What is the main site of metastatic tumor?
mandible:maxilla is 7:1
What is the managment for metastatic tumors?
- 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 multidisciplinary tumor board
What are the annual rates of occult disease?
- 1.8 x 10^6 - primary malignant osseous
tumors in skull and jaws - 0.3 x 10^6 - ameloblastoma
- 20.0 x 10^6 - non-inflammatory cysts
