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Infection of The Jaws and PeriostealReactions

Dr. Mustafa AlkhaderAssistant Professor of Oral Radiology

White & Pharoah, Oral Radiology Principles and Interpretation 6 th.Ed.

Ch. 20

I nfl ammatory L esions

Most common pathologic conditions of the jaws

Teeth create a direct pathway forinflammatory agents and pathogens toinvade the bone when caries and

periodontal disease are present

General clinical features

Cardinal signs ofinflammation: Swelling,redness, heat, pain, and lossof function.

Acute lesions: recent and rapid onset, pronounced pain,fever and swelling.

Chronic lesions: prolonged gradual course, mild pain,intermittent fever, slow swelling. Symptoms may be entirelysub-symptomatic.

General Radiographic features

Location: Periapical : epicenter at apex of a tooth. Periodontal lesions: at alveolar crest, furcation or even up to root

apex. Osteomyelitis: posterior mandible, rare in maxilla.

Periphery: ill defined.

Internal structure: Bone resorption, formation or combination of both. Sequestra : a radiopaque island of non-vital bone surrounded by

ill-defined radiolucency.

General Radiographic features

Effect on surrounding structures: Bone resorption, formation or combination of

both. Widening of PDLS. Root resorption. Cortical bone resorption. Periosteal elevation and new bone formation.

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Rarefying OsteitisA radiographic interpretation, not a diagnosis.

It refers to a localized inflammatoryresponse. The diagnosis of rarefying osteitiswill be abscess, cyst, or granuloma.

Infection of The Jaws and Periosteal Reactions Infection of The Jaws and Periosteal Reactions


Sclerosing OsteitisMay be present around the periphery of

rarefying osteitis or by itself


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Infection of The Jaws and Periosteal Reactions

Periapical Inflammatory Lesions

CariesPeriodontitis

TraumaNecrotic Pulp Apical periodontitis

Periapical Abscess

PeriapicalGranuloma

Osteomyelitis Periapicalcyst

Size EpicenterSequestra

Infection of The Jaws and Periosteal ReactionsPeriapical Inflammatory

Lesions

At least 60% demineralization must occur before the lesion can be seen on aradiograph. Therefore, it is inappropriate touse a radiograph as a vitality test

Histologically, the lesion is apical periodontitis, which is defined asaperiapical abscess or periapical granuloma

Periapical InflammatoryLesions

Clinically, the symptoms may include pain,swelling, fever, lymphadenopathy, or may

be asymptomatic

It is important to note that the clinical presentation may not correspond with thehistopathological or radiographic findings

Radiographic features

Location:

Periphery:

Internal structure:

Effect on surrounding structures:


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Halo Effect


Mucositis(Localized Mucositis)



Differential Diagnosis:

PCDEnostosisGranuloma.Cyst.Healing scarMalignancies (leukemia)Metastatic lesions.

Management:Elimination of cause: Endo Tx / Extraction. Antibiotics

Pericoronitis

Definition : inflammation oftissue surrounding a partiallyerupted tooth which extends tothe bone.

Clinically: Pain and swelling Trismus Ulcerated oberculum.

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PericoronitisRadiographic features

Either no changes or Localized rarifaction or sclerosis Mandibular wisdom is the most commonly

affected. Area of rarifaction that causes increase in the

width of folicular space.

PericoronitisRadiographic features

Normal Pericoronitis

Enlarged follicular space

Sclerotic bone

Osteomyelitis

Inflammation of the bone May spread to involve: Marrow Cortex Periosteum Cancellous portion

Caused by pyogenic organisms from abscessed

teeth, trauma, or surgery Source of infection can not always be identified

Bacteria and by-products stimulate aninflammatory reaction in bone

In young patients, the periosteum is lifted byinflammatory exudates. New bone is laid down.This is called Garres Osteomyelitis

Presence of sequestra is a hallmark of

osteomyelitis. These can be seen in both plainfilms and CT

Acute and chronic forms exist

Acute form demonstrates purulent drainage

Paresthesia of the lip may be present,suggesting a malignancy

Location

The most common location ofosteomyelitis of the jaws is the posterior

body of the mandible

Involvement of the maxilla is rare, perhapsdue to its excellent vascularity

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Borders

The borders of these lesions are illdefined,gradually blending into the normaltrabecular pattern

Internal architecture

Initially, there is a slight decrease in theradiodensity of the bone, with the trabeculae

becoming less well defined

There may be scattered areas of lucency in thearea

Later, areas of sclerotic bone are seen

Sequestra are most apparent in the chronic forms

Chronic osteomyelitis may arise from the acuteform or de novo

In the chronic form, the balance tips in favor ofosteoclastic activity

Trabeculae may be completely obscured, yieldinga uniformly opaque appearance to the bone

Sequestra are generally larger in the chronic form

Effects on adjacent structures

Surrounding bone may be resorbed or laid down

May cause resorption of the cortex

In Garres osteomyelitis, the cortex is expandedthrough deposition of new bone. The radiographicappearance of these new layers of bone is termedonion skin or proliferative periostitis

Chronic suppurative Osteomyelitis

Axial CT showing multiplesequestra

Coronal CT showing extensionto TMJ

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DD?

Osteoradionecrosis

High radiation dose (50 Gy) lowers the bone

blood supply and reparative power of osteocytes.A minor infection or trauma may lead toosteoradionecrosis.

More in posterior mandible.

More in male (susceptibility of carcinomas).

Osteoradionecrosis

Clinically: It resembles ch.supp.osteo. But it shows : More spread Late sequestration.Radiographically: Areas of RL,RO. More spread. No actual difference except with history of

radiation to head and neck.

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