2016 self-study two course - College of Dentistry · further treatment). Lesions above the inferior...

self-study course

2016 course two

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ABOUT this COURSE…

ABOUT your FREE CE…

The Ohio State University College of Dentistry is a recognized provider for ADA CERP credit. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to the Commission for Continuing Education Provider Recognition at www.ada.org/cerp. The Ohio State University College of Dentistry is approved by the Ohio State Dental Board as a permanent sponsor of continuing dental education. This continuing education activity has been planned and implemented in accordance with the standards of the ADA Continuing Education Recognition Program (ADA CERP) through joint efforts between The Ohio State University College of Dentistry Office of Continuing Dental Education and the Sterilization Monitoring Service (SMS).

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2016 course one

Bone Pathology: A Guide to Differential Diagnosis

Learning Objectives: 1. Be able to determine most likely diagnosis from clinical and

radiographic information 2. Recognize radiographic pathology and be able to produce a

reasonable differential 3. Recognize when radiographic findings warrant systemic work up 4. Use the radiographic and clinical features to determine when to treat or

watch 5. Differentiate between lesions that are quickly and slowly progressing

This is a OSDB Category B – Supervised self-instruction course.

written by Ashleigh Briody, DDS

edited by

Ross White, BS Jon Strasbourg, BA

release date

May 2, 2016 (7:30 AM EST)

last day to take the course at no charge

June 6, 2016 (3:30 PM EST)

last day course is available for credit December 31, 2018

INTRODUCTION

This course serves as a review of bone lesions seen on panoramic radiographs and periapical films. The radiographic appearance of a lesion or condition provides features that help to narrow down the differential diagnosis of a lesion. Systemic disorders can present as abnormal changes in the jaw obligating dentists to recognize the presentation before other symptoms arise. Location and extent of disease process can be helpful to guide a clinician to the correct differential diagnosis and necessary treatment (or negate the need for further treatment). Lesions above the inferior alveolar canal on the mandible and in proximity to the teeth of both the mandible and maxilla could be pathology of odontogenic origin (most likely) or other origin such as bone. Lesions within the alveolar canal are most likely neural (nerve tissue) or vascular (blood vessel) in origin. Changes below the inferior alveolar canal or not in close association with teeth on a panoramic radiograph could be bone pathology (more likely), odontogenic, or other entities such as salivary gland. It is prudent to note that depending on the angulation of the radiation source, lesions may appear more superior or inferior on a two-dimensional image. Well-defined lesions are typically benign, as the well-defined margin shows that the surrounding bone has had time to react to the process. Ill-defined margins suggest rapid processes such as infection and malignancy. This course focuses not on odontogenic cysts and neoplasms that occur in the bone but bone pathology itself.

CASE 1

A 52 year old male presents with chief concern of bone pieces extruding from the gingiva since extractions 3 months prior. One week prior to his appointment he reports seeing a dentist who referred him to OSU College of Dentistry. The patient stated that he attempted to extract a maxillary tooth on his own. He reports pain and numbness of the chin. Clinical exam revealed poor dentition, left facial swelling and an area of exposed bone. Radiographically, the left mandible shows diffuse moth-eaten radiolucencies. The remaining root tips from the maxillary and mandibular teeth are noted many of which are associated with periapical radiolucencies. The patient denied history of bisphosphonate use and radiation therapy. A biopsy was performed and a diagnosis of chronic osteomyelitis was rendered. The patient was prescribed systemic antibiotics, chlorhexidine and pain medications. Definitive treatment in this case involves resection and reconstruction of the jaw.

CASE 2

CASE 2, continued..

A 9 year old male was referred to OSU College of Dentistry for evaluation of a 3 month history of a swelling in the area of teeth #6-8. Tooth #7 was displaced distally and #6 was unerupted and in a similar location to the contralateral canine. Clinically, the lesion was expansile, firm and tender to palpation. The differential diagnosis included adenomatoid odontogenic tumor (AOT), central giant cell granuloma, and dentigerous cyst. The panoramic radiograph showed a poorly circumscribed intrabony radiolucency. On cone beam computed tomography (CBCT) images, a thin cortex of bone surrounded the expansile mass. The lesion showed a close association with #6, so an odontogenic lesion could not be ruled out. The patient underwent general anesthesia, the lesion was aspirated, and an incisional biopsy was performed. The pathologic diagnosis rendered was a central giant cell granuloma. Intraoperatively, tooth #7 was encased, had no bony support and was subsequently extracted. Tooth #8 expressed class II mobility but was spared along with the canine. Several weeks later the patient underwent excisional biopsy which showed a hybrid bone lesion showing central giant cell granuloma and ossifying fibroma.

CASE 3

A 67 year old man presented with chief concern of pain in the right posterior mandible. He reported that the day after the extraction of #28 and #29, he was admitted to the hospital for two weeks following a gastrointestinal biopsy procedure. After his hospital discharge, he noticed that the pain was now intermittent and felt numbness along the right mandible and chin. Clinically, there was significant expansion of the right mandible, although the extraction sites appeared to be healing without incident. A panoramic radiograph was taken and revealed an ill-defined radiolucency in the right mandible, posterior to #27. The margins appeared ragged and a biopsy was performed. The diagnosis rendered was diffuse large B-cell Lymphoma. Follow up revealed that the pathology of the mandibular lesion was consistent with that of the mass in the colon and the patient began chemotherapy treatment.

Periapical Radiopacities

Condensing osteitis: Tooth #18 tested nonvital. The bone surrounding the apices exhibits increased density (radiopacity). Picture on the left was before root canal therapy. Picture on the right was 6 years post endodontic therapy. (Courtesy of Dr. Kitrina Cordell, LSUHSC School of Dentistry) Condensing osteitis is an increased bone density in response to periapical disease. The radiograph of this lesion reveals a thickened periodontal ligament (PDL) in association with a uniform radiopacity adjacent to the apex of the diseased tooth. No expansion of the bone should be present. The treatment of this condition involves eliminating the source of infection. In most cases, the radiopacity will return to normal radiodensity. Persistence of a radiopacity in the area after definitive resolution of the source of infection is termed bone scar. The clinical significance of a bone scar is potential root resorption in an orthodontic patient if the scar is in the path of tooth movement. Idiopathic osteosclerosis: Radiopacity noted between the roots of #20 and #21. The lesion has blended borders with the surrounding bone. Both teeth are vital. (Courtesy of Dr. Kitrina Cordell, LSUHSC School of Dentistry)

Idiopathic osteosclerosis, continued… Idiopathic osteosclerosis is an asymptomatic benign process that results in increased bone density. Age of onset ranges from 20 to 40 years old and is more common in the posterior mandible. Radiographically, this presents as a singular or multiple well-defined radiopacities. As the name implies, this process is idiopathic; therefore, teeth in the area should be vital unlike in condensing osteitis. Over time, the lesion may remain unchanged or enlarge, although lesions usually stabilize once a patient reaches adulthood. In contrast to condensing osteitis, idiopathic osteosclerosis can be separate from the apices and teeth in the area will respond normally to vitality testing. This can be helpful in differentiating these two lesions and prevent the need for a biopsy. No treatment is required for this process; however, periodic radiographic evaluation may be helpful in monitoring the progression. Root resorption of adjacent teeth can occur. Radiographically, central osteomas can mimic idiopathic osteosclerosis. In the case of multiple areas of idiopathic osteosclerosis, further evaluation may be warranted to rule out Gardner’s syndrome, a syndrome characterized by several features, including multiple osteomas. Cemento-osseous dysplasia: Multiple areas of mixed density noted in lower right and anterior mandible. (Courtesy of Dr. Kitrina Cordell, LSUHSC School of Dentistry)

Cemento-osseous dysplasia, continued… Cemento-osseous dysplasia (COD) is a benign fibro-osseous process that presents in several ways. As the name suggests, there is a soft tissue “fibro” component (radiolucent) and a hard tissue “cemento-osseous” component (radiopaque). In the first stage, the lesion will appear radiolucent, clinically mimicking periapical pathosis. Vitality testing would result in a normal response and this is essential in preventing unnecessary over treatment such as root canal therapy or extraction. As time progresses, COD will become progressively more radiopaque while retaining a radiolucent rim. The radiolucent rim is helpful in differentiating this process from condensing osteitis and idiopathic osteosclerosis as those entities typically lack this feature. Three forms of this lesion have been described: focal cemento osseous dysplasia, periapical cemento-osseous dysplasia, and florid cemento-osseous dysplasia. Focal cemento-osseous dysplasia occurs in a single site, most commonly in the posterior mandible. Periapical cemento-osseous dysplasia occurs in the anterior mandible area near the apices of the incisors and canines. Florid COD shows multifocal involvement, and in some cases all four quadrants are affected. Periapical COD and florid COD both have a marked predilection for black females. A significant predilection for females is seen in all types of COD. There is no treatment necessary for this entity and it is prudent to note that due to the abnormal bone in this area, a biopsy procedure can increase the risk for osteomyelitis. In the proper clinical setting, if COD is suspected, periodic radiographic follow up could be useful. Cementoblastoma: Cementoblastoma is a benign neoplasm of cementoblast origin. Radiographically, this lesion presents as a radiopacity attached to the root surface. Because the lesion is of cementoblast origin, it will be fused to the root surface and the PDL space will not be present between the lesion and the tooth. Most commonly, the lesion occurs in association with the distal root of a mandibular first molar. Pain and swelling has been reported in two-thirds of the cases and typically the tooth affected responds normally to vitality testing.

.

Treatment usually consists of surgical removal of the tooth and mass. Foreign bodies: 67 year old female with history of orthognathic surgery many years prior. Also note the tonsillar calcifications superimposed on the ramus/angle of the mandible bilarterally. Body modification, trauma, aesthetic surgery, orthognathic surgery and cultural traditions can also appear in unsuspecting ways on a radiograph. While not discussed in detail in this course, it is important to consider this entity in the right clinic setting. Hypercementosis: Tooth #19 shows an enlarged root surround by an intact PDL. In contrast to cementoblastoma, hypercementosis is not neoplastic and results from hyperplasia of the cementum layer on the surface of the root. Cemental and dentinal radiodensity is similar and often precludes evaluation of the extent of hypercementosis. In early stages, it can be difficult to distinguish

Hypercementosis, continued… hypercementosis from cementoblastoma. Radiographically, this lesion presents as an enlarged root with a PDL space visible between the enlarged root and bone. Causes of localized hypercementosis include occlusal trauma, adjacent inflammation, unopposed teeth, and repair of vital root fracture. Generalized hypercementosis has been reported to have a weak association with acromegaly and pituitary gigantism, arthritis, calcinosis, rheumatic fever, thyroid goiter, Garner syndrome, and a significantly stronger association with Paget Disease(discussed later). If Paget disease is suspected, the patient should be referred to his physician for evaluation of serum alkaline phosphatase level. In review, radiopacities near the apices of teeth can present in similar ways. Important clues include presence of a radiolucent rim (as seen in COD), absence of a radiolucent rim(as in condensing osteitis and idiopathic osteosclerosis), visible PDL space (widened in condensing osteitis, present in hypercementosis and cementoblastoma around the root expansion). Vitality testing prior to further treatment is imperative and can also help narrow the differential, making it an effective first step in the diagnosis. Another helpful feature is proximity to the root. Condensing osteitis occurs in close association with apices of teeth, whereas idiopathic osteosclerosis can present near the apices or in other areas.

(Images courtesy of Dr. Kitrina Cordell, LSUHSC School of Dentistry)

QUIZZES AND DISCUSSIONS

Quiz: A 53 year old Black female presents with multiple radiographic lesions. The patient is asymptomatic and clinical evaluation reveals no expansion. Lower anteriors responded normally to vitality testing. The most likely diagnosis would be: a. Idiopathic osteosclerosis b. Condensing osteitis c. Cemento-osseous dysplasia d. Hypercementosis Discussion: The panoramic radiograph above reveals multiple radiopacities of varying degrees that are well circumscribed by a radiolucent rim. The teeth in the lower anterior area were all vital which rules out condensing osteitis, a condition seen surrounding nonvital teeth. The well-defined radiolucency surrounding the radiopacity excludes idiopathic osteosclerosis, an entity that typically exhibits a radiopaque lesion that blends with the surrounding bone.

The lack of radiographic changes on the root surface of the teeth in the area excludes hypercementosis. The most likely diagnosis is cemento-osseous dysplasia. Other factors that support this diagnosis include the age, race, and sex of the patient. Quiz: A 23 year old female presents with the asymptomatic isolated lesion shown below. The tooth in the area tests vital and has no previous restoration. The most likely diagnosis of this lesion is: a. Condensing osteitis b. Idiopathic osteosclerosis c. Cemento-osseous dysplasia d. Cementoblastoma e. Hypercementosis In this case, the patient has a radiopacity in association with the distal root of #31. The lesion has blended borders (most easily seen on the mesial) with no expansion. Absence of a radiolucent rim leads away from a diagnosis of cemento-osseous dysplasia. The lack of a large restoration and a normal response to vitality testing excludes condensing osteitis. While the location is good for cementoblastoma, the lesion is not fused to the root therefore hypercementosis and cementoblastoma can be excluded. The most likely diagnosis is idiopathic osteosclerosis. Remember, resorption can occur in idiopathic osteosclerosis. Quiz: A 61 year old female presents for routine dental care. Panoramic x-ray is shown below. Tooth #31 tested vital. The radiopacities associated with tooth #31 would most likely represent: a. Condensing osteitis b. Idiopathic osteosclerosis c. Cemento-osseous dysplasia d. Cementoblastoma e. Hypercementosis

Discussion: In this case, the lesion in question is radiopaque with a radiolucent rim. The vitality of #31, in conjunction with the presence of a radiolucent rim, excludes condensing osteitis. Because there is no radiolucency separating the radiodense lesion and the tooth, cemento-osseous dysplasia can most likely be excluded. The lesion is closely associated with the root of #31, which is not seen in idiopathic osteosclerosis. This leaves two entities, cementoblastoma and hypercementosis. Cementoblastomas typically arise in the 3rd decade of life and can behave aggressively causing expansion, erosion of the bone, tooth displacement, and local destruction. The most common location for a cementoblastoma is the distal root of the first mandibular molar. Hypercementosis can present radiographically similar to cementoblastoma, as seen in this case. Considering the age of the patient as well as the lack of expansion and pain, the most likely diagnosis is hypercementosis.

LOCALIZED RADIOPACITIES NOT IN ASSOCIATION WITH

TEETH Exostoses: Exostoses are benign bony hard growths that arise from the cortical plate of the maxilla and mandible. While the etiology is controversial, genetic and environmental influences(such as clenching and grinding) have been suggested. Most authors agree that both factors play a role in the development of exostoses. While most professionals in the dental field can easily recognize a palatal tori, lingual tori, and exostoses, the less commonly occurring unilateral palatal presentation can sometimes raise alarm. In this entity, a bony protuberance arises from the

palatal aspect of the maxillary tuberosity. Large exostoses can become ulcerated and painful which may warrant removal and/or biopsy if a definitive diagnosis is needed. Radiographically, these lesions present as well circumscribed radiopacities. Depending on the location, the differential could include a sialolith, osteoma, or other bony pathosis. Osteoma: Osteomas present as bony hard masses less than 2 cm in diameter. The most common location is the body of the mandible and condyle. This entity can occur on the bone surface, within the bone, or in extraosseous locations. Radiographically, osteomas are well defined round to ovoid radiopacities. No treatment is necessary for a majority of these lesions; however, if present in the condyle and symptomatic, removal may be warranted. If multiple osteomas are noted, a patient should be evaluated for Gardner’s syndrome. Gardner’s syndrome is characterized by precancerous intestinal polyps, multiple osteomas, and other tissue abnormalities. The clinical significance is paramount due to an almost 100% malignant transformation rate of the intestinal polyps by age 30. Treatment for Gardner’s syndrome includes prophylactic colectomy and close clinical follow up for other cancers. Osteoblastoma: Osteoblastomas are rare benign neoplasms of osteoblast origin. Osteoblastomas are commonly associated with dull pain and tenderness not relieved by non-steriodal anti-inflammatory drugs (NSAIDs). Radiographically, these lesions can be radiolucent to radiopaque with variable quantities of mineralization within. The size can vary from 2-4 cm; however, rarely, they can be up to 10 cm. An aggressive variant of this lesion exists and can cause more significant local destruction. Ossifying fibroma (Cemento-ossifying fibroma, central ossifying fibroma): Ossifying fibroma is a benign neoplasm of fibrous origin containing variable amounts of calcified tissue such as cementum and bone.

Some recent authorities suggest that this process is of odontogenic origin, due to its histopathologic similarity to cemento-osseous dysplasia. An x-ray of this lesion would reveal a central radiopacity with a radiolucent rim usually not in association with teeth. While radiographically similar to focal cemento-osseous dysplasia, this entity has the propensity to cause much more local destruction and disfigurement. These lesions are typically solitary although they can present multifocally. Multiple ossifying fibromas could warrant evaluation for hyperparathyroidism-jaw tumor syndrome. The treatment for ossifying fibroma is surgical excision and, classically, it shells out of the surrounding bone easily. This differs from focal COD which falls apart in many gritty pieces. A more aggressive variant, juvenile ossifying fibroma, typically occurs in a younger population and can cause significant expansion and swelling. The juvenile variant is more common in the maxilla, whereas traditional central ossifying fibroma usually occurs in the mandibular molar and premolar area. Malignancy - Osteosarcoma and chondrosarcoma: Osteosarcoma is a cancer which produces bone. Osteosarcoma of the jaw typically arises in the 3rd to 5th decade of life with a mean age in the 30s. The most common symptoms include pain and swelling although other signs of malignancy such as paresthesia and tooth mobility may present. The radiologic findings vary from case to case and may be completely radiopaque, mixed radiolucent/radiopaque, or completely radiolucent. Sunburst pattern can be seen in a quarter of the cases and external root resorption causing a spiked root appearance may be suggestive, though not specific to this malignancy. In review, location of radiopacities within or around the jaws can help narrow the differential. The differential for radiopaque lesions that do not necessarily occur in association with apices of teeth include exostoses, osteoma, osteoblastoma, central ossifying fibroma, odontogenic lesions (such as AOT, CEOT, COC, odontomas) and osseous malignancies such as

osteosarcoma, chondrosarcoma, and other cancers. Biopsy is required for definitive diagnosis; however, 6 month radiographic follow-up in an asymptomatic setting of a well circumscribed, unchanging, radiopaque lesion is often employed to reduce morbidity and unnecessary surgery of benign processes. Any ill-defined and/or progressive lesion should be biopsied to rule out a malignancy or destructive benign process. Quiz: A 53 year old female presents with radiopaque mass near the inferior border of the left mandible(Also present: an area of radiopacity surrounded by a radiolucent rim in the left posterior edentulous area, radiopaque areas near the apices of #30 and #31 and others). She reports that it has been there since she was a kid and it is asymptomatic. Clinically, there is left facial asymmetry and upon palpation of the external body of the mandible, the mass is bony hard. The most likely diagnosis of this lesion is: a. Exostosis b. Osteoma c. Osteoblastoma d. Ossifying fibroma e. Sialolith Discussion: In this case, the radiograph revealed an ovoid calcified mass on or near the left mandible. The lesion appears to be peripherally located (not within the mandible) due to its visibility below the inferior border. Clinical exam revealed that the mass was on the facial surface of the mandible, excluding exostosis and sialolith. The lack of a radiolucent rim surrounding the lesion suggests that is not an ossifying fibroma. While osteoblastoma can rarely occur on the surface of the bone, it more commonly occurs within the medullary space.

This entity was ruled out due to history of unchanged lesion for more than 50 years and lack of pain. In addition, osteoblastoma typically appears as a radiolucency with areas of radiopacity within, whereas this lesion appears as a uniform radiopacity. The most likely diagnosis of this lesion is osteoma. The lesion superior to the osteoma in the left posterior mandible exhibiting a radiolucent rim with varying degrees of radiopacity is suggestive of a benign fibro-osseous process. In conjunction with the radiographic changes in the periapical area and posterior right mandible, the multifocal presentation is most consistent with cemento-osseous dysplasia. The radiopacity surrounding the roots of #30 suggests condensing osteitis, characterized by bony changes in response to a nonvital tooth. This case was included in this course to remind the dental health team that a patient can present with one lesion or multiple unrelated lesions. Quiz: A 67 year old female presents with this radiopaque mass near the area of the apices of #20-23. #21 and #22 tested vital. Which of the following would NOT be considered in the differential? a. Exostosis b. Osteoma c. Sialolith d. Idiopathic osteosclerosis Discussion: This is a trick question. All of these could be considered in the differential. When looking at a panoramic x-ray, its necessary to determine if the lesion is within bone(such as idiopathic osteosclerosis), on the bony surface (such as an osteoma or exostosis), or superimposed on bone (such as a sialolith in Wharton’s duct). After some questioning, the patient reported that her sialolith was present for 15 years.

RADIOLUCENT LESIONS OF BONE (SINGLE)

Central giant cell granuloma (CGCG) (see case 2): Central giant cell granuloma is a benign lesion of unknown cause. It usually arises before age 30 and is more common in the mandible. Radiographically, the lesions may be unilocular or multilocular radiolucencies and are often seen crossing the midline. This entity can mimic the radiographic presentation of periapical disease if small, or any of the other multilocular lesions (ameloblastoma, odontogenic keracyst (OKC), hemangioma) if large. A diagnosis of central giant cell granuloma warrants further work up to rule out hyperparathyroidism. Multiple CGCGs could represent cherubism or other inherited conditions, therefore, patients should be referred for further evaluation. Simple bone cyst (traumatic bone cyst): Simple bone cyst shown with corresponding CBCT images (Courtesy of Dr. David Barnett and Dr. Kitrina Cordell, LSUHSC School of Dentistry)

Simple bone cyst is a lesion that results from trauma to the jaw. Patients may not remember the traumatic event so a lack of trauma would not preclude this entity from the differential. Radiographically, this lesion is radiolucent and often scallops between the roots of the teeth. Upon biopsy, a surgeon is met with an empty cavity. Though it is called a cyst, this lesion lacks an epithelial lining. Treatment includes curettage of the walls of the cyst to promote bleeding which in turn will promote bone remodeling. Central hemangioma: Hemangioma is a neoplasm of vascular origin. This lesion typically occurs in the 2nd to 3rd decade of life and has a female predilection. The radiographic appearance exhibits a unilocular or multilocular radiolucency and the margins vary from well to ill defined. Expansion has been reported in larger lesions. The treatment often consists of “watch and wait” because in many instances, the lesions involute on their own. If biopsy is warranted, it is absolutely imperative that a surgeon aspirates prior to removal to prevent significant blood loss. Generalized/diffuse radiopacities: When bony changes appear diffuse or generalized, other differential diagnoses should be considered. Abnormal bone density can suggest conditions such as Paget Disease, osteopetrosis, osteomyelitis, fibrous dysplasia, malignancy, and other systemic disorders. Paget disease: Paget disease is a metabolic bone disorder that results in abnormal bone remodeling. It occurs in the 5th decade and presents as a diffuse radiolucent (lytic phase) to radiopaque(sclerotic phase) abnormality of the jaw(s) affected. Classically, the radiograph of Paget disease will reveal a cotton wool pattern. It most commonly affects the posterior maxilla and causes expansion. Intraorally, a patient may experience tooth movement or report that his/her denture is too tight. Generalized hypercementosis has been associated with Paget Disease, and if noted, may warrant blood studies to be ruled out. Florid cemento-osseous dysplasia can also mimic this process and in the clinical setting of significant

expansion, blood studies may be prudent. Blood tests showing elevated serum alkaline phosphatase with normal blood calcium and phosphorus levels could be suggestive of Paget disease; however, other conditions should be ruled out first. The final diagnosis results from a combination of clinical, radiographic, and blood tests. The clinical significance of a patient with Paget disease in the dental office must not be overlooked, as complications can occur. Complications include difficult extractions due to hypercementosis, potentially significant bleeding episodes if surgery is performed during the lytic phase of abnormal remodeling, infection and slow wound healing in the sclerotic phase, and possible development of medication-related osteonecrosis of the jaws (MRONJ) from bisphosphonate therapy. Osteopetrosis: (Courtesy of Dr. Molly Rosebush, LSUHSC School of Dentistry) Osteopetrosis is a rare disorder characterized by increased bone density due to abnormal osteoclast function. The increased bone density results in lack of bone marrow, thus patients have hematologic problems and brittle bones. The more severe types are usually diagnosed at birth

or in the first decade of life. The most common type, autosomal dominant adult type, has the best prognosis. Bone pain is present in less than half of affected patients. A radiograph of an affected jaw would reveal diffuse and generalized increase in radiodensity of the bone. While the bone is more dense, it is also brittle and can be susceptible to fracture or infection. Osteomyelitis (See case 1): Osteomyelitis is an acute or chronic infection of bone. Radiographically, it can be radiolucent to mixed radiolucent/radiopaque and has been described as having a “ratty” appearance. Osteomyelitis more commonly affects the mandible due to the increased bone density and decreased vascular supply compared to the maxilla. It can be localized or diffuse and can resemble malignancy in some cases. Treatment of this condition involves biopsy for definitive diagnosis followed by removal of all diseased tissue, including the source. Fibrous dysplasia: Fibrous dysplasia is a diffuse, benign, fibro-osseous process that can result in painless swelling, asymmetry, or less commonly severe disfigurement. The majority of fibrous dysplasia patients have the monostotic type (one affected bone). In the jaws, a predilection for the maxilla is seen. Radiographically, this lesion is described as having a “ground glass” or “orange peel” appearance with poorly defined margins. In most cases, treatment does not extend beyond periodic follow up and conservative management. In cases that result in functional deficits or cosmetic problems, surgery may be warranted. In review, generalized radiographic changes may suggest an underlying systemic problem. In general, ill-defined localized changes suggest infectious etiology or malignancy whereas well-defined localized changes suggest a benign process. When generalized changes are noted, age of patient and location can be helpful in reaching diagnosis. Fibrous dysplasia and Paget disease are more common in the maxilla, and florid cement-osseous dysplasia, osteomyelitis, and metastasis to the jaws are more common in the mandible. While fibrous dysplasia can

radiographically and clinically resemble Paget disease, fibrous dysplasia is typically seen in a younger population whereas Paget disease presents over age 40.

REFERENCES AND RESOURCES

1. Neville B., Damm D., Allen C., & Chi, A. (2016). Oral and Maxillofacial Pathology (4th ed.). Elsevier. 2. Mortazavi H, Baharvand M, Rahmani D, Jafari S, Parvaei P. Radiolucent rim as a possible diagnostic aid for differentiating jaw lesions. Imaging Sci Dent. 2015 Dec; 45(4): 253–261. 3. Woo SB, Central cement-ossifying fibroma: primary odontogenic or osseous neoplasm? J Oral Maxillofac Surg. 2015 Dec;73(12 Suppl):S87-93 4. Delai D, Bernardi A, Felippe GS, da Silveira Teixeira C, Felippe WT, Santos Felippe MC. Florid cement-osseous dysplasia: a case of misdiagnosis. J Endod. 2015 Nov;41(11):1923-6 5. Mufeed A, Mangalath U, George A, Hafiz A. Infected florid osseous dysplasia: clinical imaging and follow-up. BMJ Case Rep. 2015 Mar 9;2015

EDUCATIONAL LINKS

1. http://www.oooojournal.net/ 2. http://www.joomr.org/

ASHLEIGH BRIODY GRADUATED FROM LOUISIANA STATE UNIVERSITY SCHOOL OF DENTISTRY IN NEW ORLEANS,

LOUISIANA. SHE IS CURRENTLY A SECOND YEAR RESIDENT IN THE ORAL AND MAXILLOFACIAL PATHOLOGY PROGRAM AT THE OHIO STATE UNIVERSITY COLLEGE OF DENTISTRY. HER FUTURE

CAREER PLANS INCLUDE SUPPORTING A BIOPSY SERVICE AS WELL AS TREATING AND MANAGING PATIENTS WITH ORAL

DISEASE.

DR. BRIODY CAN BE REACHED AT [email protected]

NEITHER I NOR MY IMMEDIATE FAMILY HAVE ANY FINANCIAL INTERESTS THAT WOULD CREATE A CONFLICT OF INTEREST OR RESTRICT MY JUDGEMENT WITH REGARD TO THE

CONTENT OF THIS COURSE

ABOUT THE AUTHOR

ASHLEIGH BRIODY, DDS

post-test instructions - answer each question ONLINE - press “submit” - record your confirmation id - deadline is June 6, 2016 (3:30 PM EST)

d i r e c t o r john r. kalmar, dmd, phd

[email protected]

program manager ross white, bs

[email protected]

channel coordinator jon strasbourg, ba

strasbourg,[email protected]

1 T F Paget disease is more common in young patients whereas fibrous dysplasia is more common in older patients.

2 T F You take a perioapical radiograph (PA) and notice a periapical radiolucency associated with a lower incisor. The next step would be to start endodontic therapy.

3 T F Condensing osteitis occurs in association with nonvital teeth whereas cemento-osseous dysplasia occurs in association with vital teeth

4 T F In early stages, cementoblastoma can appear radiographically similar to hypercementosis.

5 T F Generalized hypercementosis can be seen in patients with fibrous dysplasia

6 T F Malignancy will typically appear ill-defined on a radiograph whereas osteomyelitis will be well-defined

7 T F Patients with fibrous dysplasia can have blood disorders as a result of the increased density in the affected bone.

8 T F The clinical significance of recognizing a patient with Gardner's syndrome is risk for colon cancer.

2016 self-study two course - College of Dentistry · further treatment). Lesions above the inferior...

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