Non-Odontogenic Poorly Defined Entities

Question 1

Inflammatory Lesions of Bone - WIDESPREAD

Answer 1

Non-Odontogenic Poorly Defined Entities

• Often (but not always) has poorly defined borders
• Pain is variable
• Often, not always surrounded by sclerotic bone
• May appear “moth eaten”
  
  • Irregular patches of osteolysis surrounded by denser sclerotic bone

Question 2

Bone healing

Answer 2

Non-Odontogenic Poorly Defined Entities

• Initial clot replaced by granulation tissue & woven bone
• Basic multicellular unit (BMU) = Group of osteoclasts, osteoblasts, local vascular supply
  
  • BMUs perform final remodeling of bone
• Osteoclasts: Critical for signaling, resorption, and lamellar bone deposition & angiogenesis

Question 3

Malignant Neoplasms of Bone

Answer 3

Non-Odontogenic Poorly Defined Entities

• Poorly defined; destroys anatomical structures
• Most common malignant neoplasm of jaw: Metastatic carcinoma
  
  • Does NOT originate from jaw; Originates from systemic source
  • Most common malignancy of jaw arising from jaw: Osteosarcoma
• Mainly middle-aged or older pts
• Lymp nodes if palpable are hard, nontender, fixed
• May present as toothache

Question 4

What is the most common malignant neoplasm of the jaw arising from systemic sources?

Answer 4

Metastatic carcinoma

Question 5

What is the most common malignant neoplasm arising from the jaw?

Answer 5

Osteosarcoma

Question 6

What is the most common form of cancer involving the skeleton in general and jaws in particular?

Answer 6

Metastatic carcinoma

Question 7

Osteoradionecrosis

Answer 7

Non-Odontogenic Poorly Defined Inflammatory Lesions

• Chronic infection of bone
• Follows high dose radiation therapy to bone, usually tx for malignant neoplasms
  
  • >75 gray - Significant incidence of osteoradionecrosis
  • <60 gray - Minimal risk
• Characterized by pain, necrosis, sequestration
• More common in MN bc less vasculature there compared to MX, dentulous pts
• Often in the first 2yr after radiation therapy
• Diffuse infection causes necrosis of bone, periosteum, overlying mucosa
• Long term will develop sequestrum
• Extremely painful

Question 8

Osteoradionecrosis: Predisposing factors

Answer 8

Non-Odontogenic Poorly Defined Inflammatory Lesions

• Post-radiation extractions
• Periodontal disease
• Irradiation of surgical site before healing has occurred

Question 9

Osteoradionecrosis: Pathogenesis

Answer 9

Non-Odontogenic Poorly Defined Inflammatory Lesions

• Thickening of BVs
• Destruction of osteoblasts/osteocytes
• Absence of bone formation
• Trauma or infection

Question 10

Osteoradionecrosis: Prevention

Answer 10

Non-Odontogenic Poorly Defined Inflammatory Lesions

• Prevention is easier than tx
• Extraction of diseased teeth in tx field prior to radiation
• Adequate time for surgical site to heal
• Meticulous OH
• Fluoride supps
• Do not construct dental prosthesis immediately after radiation therapy

Question 11

Osteoradionecrosis: Tx

Answer 11

Non-Odontogenic Poorly Defined Inflammatory Lesions

• Abx
• Surgical removal of sequestrae
• Hyperbaric O2
• Radical surgical resection

Question 12

Osteoradionecrosis: Complications

Answer 12

Non-Odontogenic Poorly Defined Inflammatory Lesions

• Bone deformity and pathologic fracture
• Orocutaneous fistulas

Question 13

Medication-Related Osteonecrosis of Jaws (MRONJ)

Answer 13

Non-Odontogenic Poorly Defined Inflammatory Lesions

• Antiresorptive agent
  
  • Denossumab: Monoclonal ab that prevents osteoclastic maturation
  • Used as anti-neoplastic medication or for osteoporosis
• Antiangiogenic agents
  
  • Attempt to decrease blood supply to malignancy
  • Tyrosine kinase inhibitors or vascular endothelial inhibitor
• ​BRONJ: Bisphosphonate-related osteonecrosis of jaw
  
  • IV - cancer
    
    • More likely to cause ONJ
  • PO - osteoporosis
• ARONJ: Antiresorptive-related osteonecrosis of the jaw
• MROJ: Medication-related osteonecrosis of the jaw
• Painful
• Occurs more often in the MN
  
  • Lingual side of MN in molar areas
• Most commonly occurs post-extraction

Question 14

MRONJ: Rads

Answer 14

Non-Odontogenic Poorly Defined Inflammatory Lesions

• IO shows single or multifocal areas of exposed necrotic bone
• Rads may show increased RO prior to necrosis

Question 15

MRONJ: Tx

Answer 15

Non-Odontogenic Poorly Defined Inflammatory Lesions

• Best approach is prevention
• Improve dental health before future procedures
• Never take them off bisphosphonates bc they are getting tx’d for cancer or to prevent broken hip and stuff
• 1/2 life of bisphosphonate is 12yr so even if you take them off, it’s in their system for awhile
• Eliminate/minimize pain
• Aggressive removal of necrotic bone results in further necrosis
• Symptomatic: Systemic abx. chlorhexidine
• Asymptomatic: Only chlorhexidine
• Exposed bone smoothed and loose sequestra removed carefully

Question 16

What else would you include in a differential w/ MRONJ?

Answer 16

Non-Odontogenic Poorly Defined Inflammatory Lesions

• Osteomyelitis
• Radiation induced osteonecrosis
• Medication related osteonecrosis of jaw
• Consider malignancies and metastatic disease

Question 17

Non-Odontogenic Poorly Defined Malignancies, Arise Primary in Jaws

Answer 17

• Osteosarcoma
• Chondrosarcoma
• Ewings Sarcoma
• Multiple myeloma
• Metastasis to the oral cavity

Question 18

Osteosarcoma

Answer 18

Non-Odontogenic Poorly Defined Malignancies, Arise Primary in Jaws

• Swelling of bone
• Pain, toothache
• Paresthesia
• Loose or displaced teeth
• Ulceration
• Increased incidence of osteosarcoma in Paget’s disease of bone
• Osteoid production by malignant cells
• Normally older pts

Question 19

Osteosarcoma: Rad

Answer 19

Non-Odontogenic Poorly Defined Malignancies, Arise Primary in Jaws

• RL, RO, or mixed
• ​Poorly defined margins
• “Sun Ray”/Sunburst Pattern: Bony trabeculae radiating from periosteum. Present in 25% of cases and NOT unique to osteosarcoma
• Early feature may be localized symmetrical widening of PDL space or MN canal
• Periphery of lesion is usually ill-defined

Question 20

Osteosarcoma: Tx

Answer 20

Non-Odontogenic Poorly Defined Malignancies, Arise Primary in Jaws

• Radical surgery, usually supplemented by chemotherapy
• MN lesions have better px than MX lesions
• Px is improving but still not good

Question 21

Chondrosarcoma

Answer 21

Non-Odontogenic Poorly Defined Malignancies, Arise Primary in Jaws

• Cancer characterized by formation of cartilage by the tumor
• About half as common as osteosarcomas
• Sometimes relatively slowly growing
• Normally older pts

Question 22

Chondrosarcoma: Microscopic features

Answer 22

Non-Odontogenic Poorly Defined Malignancies, Arise Primary in Jaws

• Abnormal chondroblasts and cartilage
• May be difficult to distinguish from chondrosarcoma

Question 23

Chondrosarcoma: Rad

Answer 23

Non-Odontogenic Poorly Defined Malignancies, Arise Primary in Jaws

• RL, RO, mixed
• Poorly defined margins

Question 24

Chondrosarcoma: Tx

Answer 24

Non-Odontogenic Poorly Defined Malignancies, Arise Primary in Jaws

• Radical surgery
• Less likely to metastasize compared to osteosarcoma

Question 25

Ewing Sarcoma

Answer 25

Non-Odontogenic Poorly Defined Malignancies, Arise Primary in Jaws * Malignant tumor of bone * Cells of neuroectodermal origin * **3rd most common osseous malignant tumor** * **80-95% of cases - 11;22 translocation** * **Mainly in children and young adults** * ​Always \<20yo - peak age 10-20yo * Early s/s: **Pain & swelling**

Question 26

Ewing Sarcoma: Rad

Answer 26

Non-Odontogenic Poorly Defined Malignancies, Arise Primary in Jaws * Diffuse **poorly defined RL lesion** * **"Onion peel" appearance:** May stimulate periosteum to produced layers of new bone; seen in numerous malignant and inflammatory diseases

Question 27

Ewing Sarcoma: Tx

Answer 27

Non-Odontogenic Poorly Defined Malignancies, Arise Primary in Jaws * 40-80% survival rates * Metastasis is frequent

Question 28

Multiple Myeloma

Answer 28

Non-Odontogenic Poorly Defined Malignancies, Arise Primary in Jaws * Characterized by multiple tumors of **plasma cells** scattered throughout skeleton and sometimes ST * Lesions most common in axial skeleton: Vertebrae, ribs, skull, pelvis * **Rare before 40yo****​** * Does NOT occur before 40yo * **Bone pain, esp in back, is most common presenting manifestation** * Pathological fractures * Fatigue (anemia) * Fever (neutropenia) * Neoplastic plasma cells produce high levels of monoclonal Igs in immunoelectrophoresis * Hypercalcemia and renal disease might occur * **M-protein (Bence Jones protein)** may be deposited in tongue, gingiva, salivary glands, skin

Question 29

Multiple Myeloma: Rad

Answer 29

Non-Odontogenic Poorly Defined Malignancies, Arise Primary in Jaws * **Multiple punched out RL lesions w/o corticated borders,** most commonly in jaws, skulls, vertebrae

Question 30

Multiple Myeloma: Tx

Answer 30

Non-Odontogenic Poorly Defined Malignancies, Arise Primary in Jaws * **Chemotherapy is used for management** * **Poor px**

Question 31

Metastasis to the Oral Cavity

Answer 31

Non-Odontogenic Poorly Defined Malignancies, Arise Primary in Jaws * Only 1% of all oral ST and jaw cancers * Malignant neoplasms metastasize to bone more often than ST * **Metastatic neoplasms are the most common malignant tumors IN the jaw** * **5th-7th decades of life** * MN more common than MX * Molar area of MN is most common site * Early manifestation: * May be asymptomatic and detected upon routine rad exam * Swelling, expansion, perforation of cortical plate * Pain, paresthesia * Tootache, increased tooth mobility * Failure of extraction site to heal = worrisome

Question 32

What is the most common malingant tumor IN the jaw?

Answer 32

Metastatic neoplasms

Question 33

Metastasis to the Oral Cavity: Rad

Answer 33

Non-Odontogenic Poorly Defined Malignancies, Arise Primary in Jaws * May be localized but w/o corticated borders * **Poorly defined w/ irregular margins** * **Multiple, separate foci** * Occasionally RO: breast, prostate

Question 34

Most common locations for metastasis to oral cavity

Answer 34

Non-Odontogenic Poorly Defined Malignancies, Arise Primary in Jaws * Gingiva & tongue * Early lesions can look benign * Later lesions can look clinically aggressive * ST tumors of gingiva may be arising from underlying bone

Question 35

Non-Odontogenic Poorly Defined Inflammatory Lesions

Answer 35

* Osteoradionecrosis * Medication Related Osteonecrosis of the Jaw

Question 36

What are Non-Odontogenic Poorly Defined Malignancies that arise Primary in the jaws?

Answer 36

* Osteosarcoma * Chondrosarcoma * Ewings Sarcoma * Multiple Myeloma * Metastasis to the Oral Cavity