Inflammatory Lesions
Most common
pathologic conditions of
the jaws
Teeth create a direct
pathway for
inflammatory agents
and pathogens to
invade the bone when
Inflammatory Lesions of the Jaws caries and periodontal
Steven R. Singer, DDS disease are present
Inflammatory Lesions Bone Metabolism
Inflammation is the Balance of bone resorption by
body’s response to
chemical, physical, or osteoclasts and bone deposition by
microbial injury osteoblasts
First, the inflammatory Osteoblasts mediate the resorptive
response destroys the
causative agent and activity of the osteoclasts
walls off the injured Inflammatory conditions of bone exist
area
along a continuum, with varying clinical
Second, it sets up an
environment for repair features
of the injured tissue
Inflammation of the Bone Inflammation of the Bone
Periapical
Inflammatory
Lesions
Periodontal
Osteomyelitis
Lesions
Pericoronitis
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The Cardinal Signs of
Inflammation Acute v. Chronic Lesions
Acute Lesions Chronic Lesions
Recent onset Long, insidious onset
Rapid Prolonged course
Pronounced pain Intermittent, low-
Often with fever and grade fever
Heat swelling Gradual swelling
Redness
Swelling
Pain
Loss of Function
Acute v. Chronic Lesions
Without a second
radiograph, exposed at
a different time, it is
often impossible to
determine if a lesion is
chronic or acute.
Therefore, temporal
descriptors are usually
omitted from
radiographic
descriptions
Radiographic Features Location
Periapical Inflammatory Lesions
Epicenter of the lesion is usually at the
apex
May also be along the lateral root
surface due to accessory canals, root
fractures, or iatrogenic perforations
Courtesy of USC School of
Dentistry
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Apical Rarefying Osteitis Location
Periodontal Lesions
Epicenter of the lesion is located at the
alveolar crest
Inflammatory changes in bone may
extend to the apex and into the
furcation of posterior teeth
Periodontal Disease and Apical
Rarefying Osteitis Location
Osteomyelitis
Usually found in the posterior mandible
Involvement of the maxilla is rare, due
to greater vascularity
Borders Apical Rarefying Osteitis
Generally poorly
demarcated
Blending into normal
trabeculation
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Internal Architecture Effects on Adjacent Structures
Resorption will give a radiolucent Stimulation of surrounding bone,
appearance to the lesion producing a sclerotic border
Bone formation (osteosclerosis) will give Bone resorption, resulting in radiolucent
trabeculation a denser and more areas
numerous appearance
Widening of the periodontal ligament
Usually, lesion will present as a
combination of altered density space. The greatest widening will be at
Osteomyelitis will often yield sequestra the epicenter of the lesion
of bone
Condensing Osteitis Osteomyelitis
Apical Rarefying Osteitis
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Periapical Inflammatory Periapical Inflammatory Lesions
Lesions Unacceptable Terminology
Synonyms
Acute apical Radicular cyst PAP or periapical
periodontitis Apical periodontitis* pathology
Chronic apical Apical rarefying Area
periodontitis osteitis * Endo tooth
Periapical abscess Sclerosing osteitis * Perio-endo lesion
Periapical granuloma Condensing osteitis* Endo-perio lesion
Radiology
*Preferred radiographic terminology!
Station
TM
Interrelationship of possible Apical Rarefying Osteitis and
results of periapical inflammation Sclerosing Osteitis
Caries Periapical abscess Osteomyelitis
Acute
Necrotic pulp Apical periodontitis
Chronic
Trauma Periapical granuloma Periapical cyst
From White and Pharoah, 5th edition p.367
Apical Rarefying Osteitis and Periapical Inflammatory
Sclerosing Osteitis Lesions
Local response of bone secondary to
pulpal necrosis or severe periodontal
disease
At least 60% demineralization must
occur before the lesion can be seen on
a radiograph. Therefore, it is
inappropriate to use a radiograph as a
vitality test
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Periapical Inflammatory Periapical Inflammatory
Lesions Lesions
Histologically, the lesion is apical
periodontitis, which is defined as a
periapical abscess or periapical
granuloma
The reaction is initiated by toxic
metabolites from the necrotic pulp
Clinically, the symptoms may include
pain, swelling, fever, lymphadenopathy,
or may be asymptomatic
Periapical Inflammatory Periapical Inflammatory
Lesions Lesions
Acute lesions may evolve into chronic Location
ones At the apex of a tooth
Therefore, it is important to note that May be along the root surface if
the clinical presentation may not associated with a lateral canal or
correspond with the histopathological or perforation from root canal treatment
radiographic findings
Periapical Inflammatory
Apical Rarefying Osteitis Lesions
Borders
Ill-defined, gradually blending with
normal trabeculation
Can occasionally have a well-
demarcated border
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Periapical Inflammatory Periapical Inflammatory
Lesions Lesions
Internal Architecture Internal Architecture
Earliest change is loss of bone density The region of the lesion closest to the
resulting in widening of periodontal apex is generally lucent, while the
ligament space periphery tends to be exhibit sclerotic
As the lesion progresses, loss of density changes
involves a larger area When the lesion is mostly lucent, the
As the lesion progresses, a mixed term Apical Rarefying Osteitis is used
rarefying and sclerotic appearance may When the lesion is mostly sclerotic, the
be seen. term Apical Condensing Osteitis is used
Periapical Inflammatory Periapical Inflammatory
Lesions Lesions
Internal Architecture Effects on adjacent structures
When closely examined, the sclerotic Lesions may stimulate resorption or
areas exhibit both increased number deposition of surrounding bone.
and thickness of trabeculae The sclerotic lesion may be localized or
may extend over a wider area
The lesion may destroy cortical borders,
such as the floor of the maxillary sinus
or cause displacement or remodeling.
This remodeling is called halo effect
Periapical Inflammatory
Halo Effect Lesions
Effects on adjacent structures
Chronic lesions may result in root
resorption
If the cortical border of the maxillary
sinus is perforated, there may be a
localized thickening of the schneiderian
membrane. This is called mucositis
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Root Resorption Halo Effect and Mucositis
Mucositis Mucositis
Periapical Inflammatory
Lesions Internal Resorption
Effects on adjacent structures
Internal or external resorption of the
root, calcification of the pulp chamber,
and wide appearance of the pulp
chamber may be evident
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Internal Resorption Internal Resorption
Periapical Inflammatory Periapical Inflammatory
Lesions Lesions
Differential Diagnosis
Early lesions of Periapical Cemental
Dysplasia (PCD) often have an
appearance similar to that of a
periapical inflammatory lesion. Pulp
vitality testing must be performed to
differentiate the two lesions.
Idiopathic osteosclerosis 8/06 3/07
Differential Diagnosis
Periapical Cemental Dysplasia
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Periapical Cemental Dysplasia Periapical Cemental Dysplasia
Idiopathic Osteosclerosis Idiopathic Osteosclerosis
Case courtesy of Ohio State Case courtesy of Ohio State
University College of Dentistry University College of Dentistry
Idiopathic Osteosclerosis Bone Marrow Defect
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Pericoronitis
Inflammation of the tissues surrounding
a partially erupted tooth.
Usually occurs around 3rd molars
Starts in soft tissue surrounding
erupting tooth
May extend into the bone surrounding
the tooth
Often associated with trismus
Radiographic Features of
Pericoronitis Pericoronitis
Location
Early lesions may show no radiographic
features
Follicular space may be expanded
around the crown. >3mm should be
monitored
Radiographic Features of Radiographic Features of
Pericoronitis Pericoronitis
Borders Internal Architecture
May be ill defined Radiolucent, with thin, sparse
A sclerotic border is not unusual trabeculae
Increased trabeculation toward
periphery
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Radiographic Features of Radiographic Features of
Pericoronitis Pericoronitis
Effects on adjacent structures Differential diagnoses
Sclerotic border Enostoses and osteosclerosis
In larger lesions, periosteal new bone Fibrous dysplasia
formation may be evident Malignancies such as osteosarcoma and
squamous cell carcinoma
Pericoronitis
Osteomyelitis Osteomyelitis
Inflammation of the bone Bacteria and by-products stimulate an
May spread to involve: inflammatory reaction in bone
Marrow In young patients, the periosteum is
Cortex Periosteum lifted by inflammatory exudates. New
Cancellous portion bone is laid down. This is called Garre’s
Caused by pyogenic organisms from Osteomyelitis
abscessed teeth, trauma, or surgery Presence of sequestra is a hallmark of
Source of infection can not always be osteomyelitis. These can be seen in
identified both plain films and CT
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Radiographic features of
Osteomyelitis Osteomyelitis
Acute and chronic forms exist Location
Acute form demonstrates purulent The most common location of
drainage osteomyelitis of the jaws is the
Paresthesia of the lip may be present, posterior body of the mandible
suggesting a malignancy Involvement of the maxilla is rare,
perhaps due to its excellent vascularity
Radiographic features of Radiographic features of
Osteomyelitis Osteomyelitis
Borders Internal architecture
The borders of these lesions are ill- Initially, there is a slight decrease in the
defined, gradually blending into the radiodensity of the bone, with the
normal trabecular pattern trabeculae becoming less well defined
There may be scattered areas of
lucency in the area
Later, areas of sclerotic bone are seen
Sequestra are most apparent in the
chronic forms
Radiographic features of Radiographic features of
Osteomyelitis Osteomyelitis
Internal architecture Effects on adjacent structures
Chronic osteomyelitis may arise from the Surrounding bone may be resorbed or
acute form or de novo laid down
In the chronic form, the balance tips in favor
of osteoclastic activity May cause resorption of the cortex
Trabeculae may be completely obscured, In Garre’s osteomyelitis, the cortex is
yielding a uniformly opaque appearance to expanded through deposition of new
the bone bone. The radiographic appearance of
Sequestra are generally larger in the chronic these new layers of bone is termed
form onion skin or proliferative periostitis
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Osteomyelitis Osteomyelitis in a 12 yo male
Case courtesy of Dr. Grace
Petrikowski
Osteomyelitis in a 12 yo male Osteomyelitis in a 12 yo male
Case courtesy of Dr. Grace Case courtesy of Dr. Grace
Petrikowski Petrikowski
Osteomyelitis in a 12 yo male Osteomyelitis and FCOD
Case courtesy of Dr. Grace
Petrikowski
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Sequestrum of Osteomyelitis Garre’s Osteitis
Garre’s Osteitis
Photo credit:
Betty Huang ‘09
Osteonecrosis of the Jaw ONJ Case 1
(ONJ) ONJ – Case #1
Found in patients using
Bisphosphonates for chemotherapy
May also be found in patients using
Phosamax for osteoporosis
Radiographic appearance resembles
chronic sclerosing osteomyelitis
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ONJ Case 1 ONJ Case 1
ONJ – Case #1 ONJ – Case #1
ONJ Case 2 ONJ Case 2
ONJ – Case #2 ONJ – Case #2
Radiographic features of Did I just sleep
through the
Osteomyelitis entire lecture?
Differential diagnosis
Fibrous dysplasia
Pagets disease of bone
Osteosarcoma
Osteonecrosis of the Jaw (ONJ)
The patient’s age and clinical presentation
may help in the diagnosis
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Thanks!
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