Inflammatory lesions of the Jaws

1. Osteomyelitis .

1.1. 1. Osteomyelitis is an inflammatory reaction of bone to infection which

1.2. 2. originates from an abscessed tooth, fracture site, soft tissue wound or surgery site. .

1.3. 3. The dental infection may be from a root canal, a periodontal ligament or an extraction site

1.4. 4. Osteomyelitis involves all three components of bone: periosteum, cortex, and marrow.

1.5. 5. Usually there is an underlying predisposing factor like malnutrition, alcoholism, diabetes, leukemia or anemia.

1.6. 6. Other predisposing factors are those that are characterized by the formation of avascular bone for example, therapeutically irradiated bone, osteopetrosis, Paget's disease, and florid osseous dysplasia

1.7. 7. Osteomyelitis is more commonly observed in the mandible because of its poor blood supply as compared to the maxilla, and also because the dense mandibular cortical bone is more prone to damage and, therefore, to infection at the time of tooth extraction.

1.8. 8. Types acute and chronic due to special features

1.9. 9. Some forms of osteomyelitis have been described as separate entities because of their unique radiographic features. These are Garre`s osteomyelitis, focal and diffuse sclerosing osteomyelitis.

1.10. 1-Acute osteomyelitis

1.10.1. 1. is similar to an acute abscess, .

1.10.2. 2. the typical signs and symptoms of acute osteomyelitis are rapid onset, pain, swelling of the adjacent soft tissues, fever, lymphadenopathy, and leukocytosis.

1.10.3. 3. Purulent drainage also may be present. .

1.10.4. 4. The associated tooth may be mobile and sensitive to percussion

1.10.5. 5. Paresthesia of the lower lip is common

1.10.6. 6. since the onset and course may be so rapid that bone resorption has not occurred; so a radiolucency may not be present.

1.11. 2-Chronic osteomyelitis

1.11.1. represents a low-grade infection of bone. . , . .

1.11.2. Chronic osteomyelitis may arises de novo or as a sequela of inadequately treated acute osteomyelitis

1.11.3. radiographically as an ill defined radiolucency with ragged border (moth-eaten appearance).

1.11.4. It may demonstrate four distinct radiographic pictures:

1.11.4.1. completely radiolucent

1.11.4.2. mixed radiolucent and radiopaque

1.11.4.3. completely radiopaque ( focal and diffuse scleosing osteomyelitis),

1.11.4.4. and proliferative periostitis (Garre`s osteomyelitis)

1.11.5. More commonly, chronic osteomyelitis appears as a mixed radiolucent and radiopaque image. The radiopaque areas represent a sclerosed often nonvital bone (sequestra).

1.11.6. A fistulous tract may develop by the suppuration perforating the cortical bone and periosteum. The fistulous tract discharges pus onto the overlying skin or mucosa.

1.12. 3-Focal sclerosing osteomyelitis (Condensing osteitis)

1.12.1. 1. Condensing or sclerosing osteitis is a sclerosis of bone induced by an inflammation or infection

1.12.2. 2. The reaction in this lesion is a proliferation of bone tissue

1.12.3. 3. the pulp of the involved tooth is non-vita

1.12.4. 4. Also, since the process is so low grade, there is usually no pain, swelling, drainage, or associated lymphadenitis.

1.12.5. 5. Radiographically: the regions of sclerosis

1.12.6. 6. from a few millimeters to 2 or 3 cm in diameter.

1.12.7. 7. The shape may vary from irregular to round.

1.12.8. 8. The appearance of the lesions ranges from a slight or prominent accentuation of normal trabecular pattern to dense homogneous radio opacity

1.12.9. 9. margins may be smoothly contoured or ragged and well defined and tend to blend with adjacent normal bone

1.13. 13. Diffuse sclerosing osteomyelitis

1.13.1. chronic osteomyelitis in which the balance in bone metabolism is tipped toward increased bone formation, producing a subsequent sclerotic radiographic appearance.

1.14. 14. Garrés osteomyelitis (Osteomyelitis with proliferative periostitis)

1.14.1. 1. chronic osteomyelitis. I

1.14.2. 2. The process arises secondary to a low-grade chronic infection, usually from the apex of a carious mandibular first molar.

1.14.3. 3. t occurs almost exclusively in children and young adults as the periosteum has a high potential for osteoblastic activity.

1.14.4. 4. The infection spreads towards the surface of the bone, resulting in inflammation of the periosteum and deposition of new bone underneath the periosteum. .

1.14.5. 5. This results in peripheral thickening

1.14.6. 6. The inferior border of the mandible below the carious first molar is the most frequent site for the hard non-tender expansion of cortical bone.

1.14.7. 7. Radiographically, it often stimulates the formation of periosteal new bone, which is

1.14.8. 8. seen radiographically as a single radiopaque line or a series of radiopaque lines (similar to onion skin) parallel to the surface of the cortical bone.

2. APICAL SCAR

2.1. An inflammatory apical lesion treated by root canal therapy may respond well to treatment by filling new bone at the site of the lesion. However, the healing process may sometimes terminate and leave a small amount of scar tissue known as an apical scar.

2.2. Radiographic Features: An apical scar is a small, asymptomatic, nonenlarging radiolucency at the apex of endodontically treated tooth. When observed radiographically over the years, it will either remain constant in size or diminish slightly.

3. Special Features

3.1. 1. Inflammatory lesions are most common pathological condition of the jaws. .

3.2. 2. teeth creates a direct pathway for infectious and inflammatory agents to invade bone by means of caries and periodontal disease

3.3. 3. The inflammatory response destroys or walls off the injurious stimulus and sets up an environment for repair of the damaged tissue.

3.4. 4. When there is an inflammation, mediators of inflammation (cytokines, prostaglandins, and many growth factors) tip this balance to favor either bone resorption or bone formation.

3.5. 5. The type and progress of the inflammatory response at the apex and the subsequent spread of apical infection is dependent on several factors relating to: • The infecting organism including its virulence • The body's defence systems.

3.6. 6. Following pulpal necrosis, a wide spectrum of events happens (either acute or chronic responses). When the bony lesion is restricted to the region of the tooth, the condition is called a periapical inflammatory lesion. This ranges from a very rapidly spreading acute periapical abscess to a very slowly progressing chronic periapical granuloma or cyst. This variation in the underlying disease processes is mirrored radiographically, although it is often not possible to differentiate between an abscess, granuloma or cyst.

3.7. 7. When the infection spreads in the bone marrow and is no longer contained to the vicinity of the tooth root apex, it is called osteomyelitis.

3.8. 8. General Clinical Features The four cardinal signs of inflammation (redness, swelling, heat, and pain) may be observed in varying degrees with inflammation of the jaws. .

3.8.1. Acute lesions are those of recent onset. The onset typically is rapid, and these lesions cause pronounced pain, often accompanied by fever and swelling

3.8.2. Chronic lesions are characterized by a prolonged course with a longer onset and pain that is less intense. Fever may be intermittent and low-grade, and swelling may occur gradually. In fact, some chronic, low- grade infections may not produce any significant clinical symptoms

4. OSTEORADIONECROSIS ✅

4.1. 1. in therapeutic radiation for carcinomas of the head and neck, the jaws are subjected to high exposure doses of ionizing radiation. . . .

4.2. 2. This results in decreased vascularity of bone and makes them susceptible to infection and traumatic injury

4.3. 3. nfection may occur in irradiated bone from poor oral hygiene, extraction wound, periodontitis, denture sores, pulpal infection or dental treatment

4.4. 4. I. It is therefore advisable that a patient scheduled to undergo therapeutic radiation be given dental treatment prior to radiation therapy and that after radiation therapy the patient be taught to maintain good oral hygiene

4.5. 5. which is similar to chronic osteomyelitis

4.6. 6. The mandible is affected more commonly than the more vascular maxilla.

4.7. 7. Radiographically: Osteoradionecrosis appear as a radiopaque sequestra and surrounding radiolucent similar to that of chronic osteomyelitis except that subperiosteal new bone formation is not usually evident. A history of therapeutic radiation helps to differentiated radiographically.

5. PERIODONTAL DISEASE

5.1. Periodontal disease is considered because it produces a periapical radiolucency in the advanced stages. Usually there is crestal bone loss or even the entire bony support of the involved tooth may be completely destroyed so the tooth appears to be floating in radiolucency.

5.2. It should be noted that the tooth remains vital, and the demonstration of such vitality tests aids the clinician in differentiating a periodontal disease radiolucency from an inflammatory apical radiolucency (periapical granuloma, radicular cyst and apical abscess). A clinical examination of supporting tooth structures should be undertaken by probing all periodontal pockets.

6. Apical Periodontitis

6.1. picture

6.2. 2. the periodontal ligament  widens space caused by edema due to accumulation of inflamatory fluid exudate

6.3. result of infection, trauma, orthodontic treatment, or tooth extrusion

6.4. 4either returns to its normal appearance after the elimination of the trauma or may form a chronic apical inflammatory lesion such as an apical granuloma, a radicular cyst, or an apical abscess.

6.5. 5. Pariapical Cemental Dysplasia

7. Surgical Defect

7.1. It is frequently seen periapically after root resection in which the site is filled with fibrous (collagen) tissue instead of bone. It is an asymptomatic radiolucency.

8. PERIAPICAL GRANULOMA, RADICULAR CYST AND APICAL ABSCESS

8.1. 1- A granuloma

8.1.1. 1. A granuloma is a low grade inflammation formed .

8.1.2. from the successful attempt of the periapical tissues to neutralize and confine the irritating toxic products escaping from the root canal

8.1.3. 2. usually asymptomatic

8.1.4. 3. but may sometimes exhibit mild pain and sensitivity to percussion. The affected tooth is nonvital.

8.1.5. A granuloma may progress into a radicular cyst or an apical abscess.

8.1.6. 4. Radiographically granulomas form small well defined radiolucencies. Rounded and surrounding the apex of the tooth.

8.1.7. 5. small

8.1.8. 6. They are the most common periapical lesions.

8.2. 2-A cyst

8.2.1. a space in the jaw a central pathological cavity lined by epithelium supported by fibrous ct wall containing fluid or semisolid material

8.2.1.1. Parts:

8.2.1.1.1. wall of ct

8.2.1.1.2. epithelial lining lumen of cyst

8.2.2. might be in bone or in soft tissue those not lined with epithelium is false cyst

8.2.3. any location in mandible or maxilla

8.2.4. odontogenic in tooth bearing area

8.2.5. in mandible above inf qlveolar canal

8.2.6. well defined corticated

8.2.7. usually round

8.2.8. totally radiolucent

8.2.9. multilocular or unilocular

8.2.10. grow slowly causing displacement and resorption

8.2.11. thinning of buccal or lingual plate

8.2.12. displace inf alveolar canal or invaginate maxillary sinus

8.2.13. Classification:

8.2.13.1. Epithelial

8.2.13.1.1. Odontogenic Cyst

8.2.13.1.2. Non odontogenic

8.2.13.1.3. Pseudocyst Non Epithelial Cyst

8.3. 3- Apical Abscess

8.3.1. called dentoalveolar abscess. Abscess may be of the chronic or the acute type, depending on the number and virulence of the invading organisms, the resistance of the host, and the type and timing of the treatment.

8.3.2. In the acute stage

8.3.2.1. Radiographic Features: The onset of infection is so sudden that no radiographic evidence of an apical lesion is present or may appear as widening of the periodontal membrane space.

8.3.2.2. If circumstances are unfavorable, such as lowered host resistance (diabetes), combined with virulent multiplying organisms and inadequate early treatment, serious complications may occur as osteomyelitis.

8.3.2.3. , the associated tooth show features such as deep restorations, caries which suggest the pulp is nonvital.

8.3.2.4. The tooth is very painful, extremely sensitive to percussion, and often slightly extruded. The patient will complain that the tooth feels "high" when it occludes with the opposing tooth. The tooth may demonstrate increased mobility.

8.3.3. In case of chronic abscess

8.3.3.1. the associated tooth may be asymptomatic or may be sensitive to percussion and mobile.

8.3.3.2. If untreated, the chronic abscess frequently forms a sinus tract, permitting the pus to drain to the surface. When drainage is established, pain is relieved, since the pain- producing pressure of the abscess is reduced

8.3.3.3. Radiographic Features: appears as radiolucency with diffuse irregular ill-defined border.

9. Multilocluar

9.1. 1- OKC

9.2. 2- Aneurysmal bone cyst

9.3. 3- Lateral PDL botryoid

9.4. 4- Osteomyelitis

10. Sequence

10.1. Acute Apical periodontitis

10.2. Acute PA abscess

10.3. Chronic PA abscess

10.4. Sclerosing oseitis

10.5. periapical granuloma and radicular cyst

10.6. should be differentiated from cemental dysplasia and periapical scar

11. Interpretation

11.1. explanation of what is viewed on the radiograph

11.2. interpration is a step in diagnosis

11.3. Steps of interpretation

11.3.1. 1. Localization

11.3.2. 2. Observation

11.3.3. 3. General Consideration

11.3.4. 4. Interpration

11.3.5. 5. Correlation