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Radiographic Interpretation > Ragged Radiolucencies > Flashcards

Ragged Radiolucencies Flashcards

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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
Osteoradionecrosis Age Site Predominant Gender
40-80 years of age. Body of mandible More common in males
26
Osteoradionecrosis Management: (4) Predisposing conditions: (4)
Hyperbaric oxygen. Surgical debridement, resection of nonviable tissues, and antibiotics. previous radiation, trauma, diabetes, Pagets disease
27
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)
28
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
29
Diseases Treated (5)
* Osteoporosis * Breast cancer * Multiple myeloma * Prostate CA * Colon CA
30
MRONJ – Dental Etiologies (5)
Dental Etiologies Extraction Implants Prosthesis trauma spontaneous
31
knowledge base and experience in addressing MRONJ continues to evolve and expand, necessitating --- and refinements to the previous position papers
modifications
32
At-risk category
No apparent necrotic bone in patients who have been treated with either oral or IV bisphosphonates
33
Stage 0
No clinical evidence of necrotic bone, but non-specific clinical findings, radiographic changes, and symptoms
34
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
35
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
36
BRONJ – maxilla and zygoma Radiographic (5)
* Irregular sclerotic trabeculation * Osteolysis * Sequestration * Periosteal duplication * Minimal displacement of teeth and bony outlines
37
BRONJ – maxilla and zygoma Clinical (2)
* Edema, purulence * Increased mass
38
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
39
Features of “ragged” bony disease Clinical (2)
* Edema, purulence * Increased mass
40
MRONJ - TREATMENT (6)
* monitoring * pharmacologic agents * minor debridement * major debridement * sequestrectomy * resection
41
Ragged Radiolucencies (5)
➢Chronic Osteomyelitis ➢Osteoradionecrosis ➢Bisphosphonate Osteonecrosis ➢Primary Epidermoid Carcinoma ➢Metastatic Disease
42
Diffuse, Ragged Radiolucent Lesions (2)
* Primary Epidermoid Carcinoma a.k.a. Squamous Cell Carcinoma * Metastatic Disease (various types)
43
Primary intra-alveolar epidermoid carcinoma a.k.a. (2)
Central squamous cell carcinoma Primary epidermoid carcinoma
44
Malignancies (4)
poorly defined borders ragged irregular borders rapid growth follow path of least resistance
45
Primary Intra-Alveolar Epidermoid Carcinoma Incidence of Oral Malignancy (3)
1. Primary carcinoma (alveolar and mucosal) 2. Metastatic carcinoma 3. Others; lymphomas, sarcomas, etc..
46
Primary Intra-Alveolar Epidermoid Carcinoma Clinical (2)
* Normally asymptomatic * Discovered on routine oral examination
47
Primary Intra-Alveolar Epidermoid Carcinoma Radiographic (4)
1. Rarified trabecular pattern 2. Radiolucency with ill-defined, irregular margins 3. Rapid growth 4. Wide PDL (irregular)
48
Primary Intra-Alveolar Epidermoid Carcinoma Management (3)
radiation therapy surgery both
49
Diffuse, Ragged Radiolucent Lesions (2)
* Primary Epidermoid Carcinoma a.k.a. Squamous Cell Carcinoma * Metastatic Disease (various types)
50
METASTATIC CARCINOMA ---% of malignancies metastasize to the jaws
<1%
51
ROUTES OF SPREAD Called Metastasis * LOCAL INVASION:
growth into adjacent tissue and soft nerves
52
ROUTES OF SPREAD Called Metastasis * LYMPHATIC SPREAD:
enter draining lymphatic vessels and then to local lymph nodes where the tumor grows
53
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
54
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.
55
Metastatic Tumors Pathophysiology * Usually there is a history of a primary tumor but occasionally
the metastatic lesion is the initial presentation of the disease
56
Metastatic Tumors Incidence of Oral Malignancy (3)
1. Primary carcinoma (alveolar and mucosal) 2. Metastatic carcinoma 3. Others; lymphomas, sarcomas, etc
57
Metastatic Tumors Clinical (2)
* May have no history of pain or previous malignancy * Bone pain, paresthesia, tooth mobility, swelling and soft tissue masses
58
Metastatic Tumors Radiographic (3)
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
Metastatic Tumors PLAG Prevalence ~ malignant osseous tumors in skull & jaws % of malignancies metastasize to the jaws
1.8 x 106 - 10 less than 1
60
Metastatic Tumors PLAG Location
mandible:maxilla is 7:1
61
Metastatic Tumors PLAG Age
40-80 years of age; mean age 56 years
62
Metastatic Tumors PLAG Gender
Gender predilection is dependent of the tumor type
63
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
64
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
65
Period Prevalences for 30 million health insurance records malignant lesions: benign lesions:
< 5 cases/million/year ~100 cases/million/year

Radiographic Interpretation (13 decks)

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