DISEASES OF THE JAWS I

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1 DISEASES OF THE JAWS I

2 ODONTOGENIC AND PERIODONTAL INFECTIONS

3 ODONTOGENIC INFECTIONS PERIAPICAL GRANULOMA PERIAPICAL ABSCESS APICAL PERIODONTAL CYST PHOENIX ABSCESS FISTULA, DRAINING SINUS SPACE INFECTIONS CAVERNOUS SINUS THROMBOSIS OSTEOMYELITIS ACUTE, SUBACUTE, CHRONIC SCLEROSING FORMS

4 JAW INFECTIONS ODONTOGENIC APICAL PERIODONTITIS PERIODONTITIS OSTEOMYELITIS CHRONIC SCLEROSING OSTEOMYELITIS ACTINOMYCOSIS OSTEORADIONECROSIS GRANULOMATOUS DISEASE

5 Odontogenic Infections Bacterial infections that occur as a consequence of: Dental caries, progressing into the pulp Coronal fracture that extends into pulp chamber Tooth trauma with loss of vitality and secondary infection, probably anachoretic Pulpitis may be acute or chronic that eventuates in pulpal necrosis with microbial extention to the periapical periodontal ligament Spread of periapical inflammatory disease into surrounding bone, soft tissues, tissue spaces, maxillary sinus, cavernous sinus

6 Pulpal Inflammation Pulpal Hyperemia Pulpal insult witihout inflammation, reversible Acute Pulpitis Spontaneous pain, lingering pain upon cold stimulation. Pulpal tissues infiltrated with neutrophils Subacute Pulpitis Same as acute. Pulpal tissues infiltrated by neutrophils and mononuclear leukocytes Chronic Pulpitis Dull pain or asymptomatic. Pulp is infiltrated by mononuclear leukocytes Hyperplastic Pulpitis (Pulp Polyp) Carious loss of coronal enamel and dentin with a nodular hyperplasitic fibrous mass protruding from the pulp chamber.

7 Pulpitis Hyperplastic Pulpitis (Pulp Polyp) Carious Lesions with bacteria extending into the pulp

8 Spread of Infection from Pulp to Periapex of Periodontium One of three lesions are commonly encountered:

9 PERIAPICAL GRANULOMA NonVital Tooth (Pulpal Necrosis) Low virulence microorganisms Low level ache or no symptoms Apical radiolucency, yet may be lateral as a consequence from infection within accessory canals. In deciduous teeth the radiolucency is typically located in the furcation region due to the many accessory canals in this area. Micro: Granulation tissue with mononuclear cell infiltration May surround a focal abscess (i.e. granulation tissue walls off the abscess)

10 Chronic Apical Periodontitis Periapical Granuloma

11 Chronic Apical Periodontitis Periapical Granuloma S/P endodontic therapy Foreign material

12 Periapical Granuloma, Complications Endo/Perio Antral Polyp

13 Periapical Abscess

14 Apical Abscess, Actinomycetes

15 Periapical Actinomycosis PAS Stain

16 Apical Periodontal (Radicular) Cyst NonVital Tooth (Pulpal Necrosis) Low virulence microorganisms Low level ache or no symptoms Apical radiolucency, yet may be lateral as a consequence from infection within accessory canals. In deciduous teeth the radiolucency is typically located in the furcation region due to the many accessory canals in this area. Micro: Nonkeratinizing stratified squamous epithelial lining, often hyperplastic. The cyst wall is fibrous with granulation tissue and mononuclear cell infiltration

17 Apical Periodontal (Radicular) Cyst Laterally displaced, accessory canal

18 Apical Periodontal Cyst

19 Apical Periodontal Cyst Periodontal bone loss

20 Spread of Infection from Endodontic Sources Fistula (Parulis) Sinusitis Cellulitis Space Infections Submental Submasseteric Sublingual Ludwig s Angina Osteomyelitis

21 Spread from Endodontic Infections

22 Fistula(Parulis)

23 Sinusitis

24 Cellulitis

25 Cellulitis Acute inflammation between muscle fibers

26 Space Infections Bilateral Submandibular space infection: Ludwig s Angina

27 Microscopic, Space Infection Acute Inflammation

28

29 Osteomyelitis Acute Subacute Chronic Moth-eaten radiolucencies

30 Actinomycotic Osteomyelitis Radial fringe

31 Osteoradionecrosis High dose radiation to bone in the process of treating head and neck cancer Tx: Hyperbaric oxygen and antibiotics

32 Focal boney sequestration Bisphosphonates used to treat osteoporosis and as adjunctive therapy in metastatic cancer to increase bone Lingual mandible (myohyoid ridge), post intubation trauma following general anesthesia Acute or chronic trauma, especially over tori

33 Bisphosphonate Related Osteonecrosis of the Jaws BRONJ

34 BRONJ MIXED FLORA VACANT lacunae ACTINOMYCETES

35 BRONJ Osteochemonecrosis Bisphosphonate therapy to strengthen bone, oral or IV Osteoporosis Multiple Myeloma Metastatic CA to bone Necrosis, bacterial osteomyelitis, sequestration Serum Enzyme Biomarker

36 Postintubation Sequestrum

37

38 Sclerosing Forms of Osteomyelitis Low grade endodontic bacterial infections, often anaerobic, that actually stimulate osteogenesis in the periapical region Some are localized to a specific tooth, others are wide spread and diffuse Specific subtypes: Focal Sclerosing Osteomyelitis (condensing osteitis) Diffuse Sclerosing Osteomyelitis Proliferative Periostitis

39 Focal Sclerosing Osteomyelitis

40 Focal Sclerosing condensing Osteitis Root resorption

41 Focal Osteosclerosis Osteopetrotic Scar

42

43 Diffuse Sclerosing Osteomyelitis

44 Diffuse Sclerosing Osteomyelitis

45 Chronic Sclerosing Osteomyelitis

46 Proliferative Periostitis

47 Proliferative Periostitis

48 Osteomyelitis with Proliferative Periostitis

49

50 Chronic Inflammatory Periodontitis A bacterial infection of the periodontal ligament Periodontopathic bacteria in dental plaque Actinobacillus actinomycetemcomitans, Porphyromonas gingivalis, Prevotella intermedia, Fusobacterium nucleatum, Bacteroides PDL inflammation with apical migration of the epithelial attachment Sulcular epithelial hyperplasia, granulation tissue with plasma cells and lymphocytes in PDL and gingival connective tissues Loss of supporting alveolar bone, pocket formation, lossening of teeth, tooth loss

51 Chronic Periodontitis P L A Q U E M I C R O B E S Apical cyst

52 Horizontal Bone Loss

53 Periodontal Abscess An acute inflammatory response within a periodontal pocket Pyogenic bacteria Probing will elicit the exudation of pus from the sulcus Unrelated to pulpal disease Most common among diabetics with preexisting chronic periodontitis Curettage with antibiotic therapy

54 Periodontal Disease, Diabetes

55 Periodontitis, Diabetes Multiple periodontal abscesses

56 HIV Periodontitis Rapidly progressive form of periodontitis seen only in a minority of patients who are HIV infected. Skip lesions: Normal areas interposed between lesional areas of periodontium No pocket formation: Complete periodontal breakdown with loss of PDL, alveolar bone, gingival soft tissues

57 HIV Periodontal Disease HIV Gingivitis Generalized Linear Erythema Acute Necrotizing ulcerative Periodontitis

58 Juvenile Periodontitis Actinobacillus actinoacetemcommitans Progressive bone loss, deciduous and mixed dentition Classic pattern (associated with Papillon LaFevre syndrome Incisor, Molar bone loss (premolars spared) Non Classic pattern Generalized or multifocal, no specific distribution

59 Siblings Juvenile Periodontitis

60 Papillon LaFevre Syndrome Juvenile periodontitis, palmar/plantar keratosis Incisor/Molar bone loss

61 ORAL INFECTIONS AND SYSTEMIC DISEASES Correlation with: Atherosclerosis (MI, Stroke) Diabetes Birth weight Data are correlational and cause/effect Underlying mechanisms make sense yet are not by any means substantiated

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