Bacterial & Fungal Infections

Syphilis - Congenital

Hutchinson's Triad:

1. Mulberry molars & peg-shaped incisors
2. VIII nerve deafness
3. Interstitial keratitis

Higoumenaki Sign: Thickened sternoclavicular joint

Rhinoscleroma

• Also Called: Hebra nose

Sarcoidosis

• Diagnostic Test: Kveim–Siltzbach
• Histology: Schaumann bodies

Candidiasis

• Id Reaction: Hypersensitivity to Candida antigen
• Chairside Diagnosis: Wet smear in 10% KOH

Chronic Osteomyelitis

• As soon as pus drains intra or extraorally, condition ceases to spread and chronic phase commences.
• Infection is localized but persistent as bacteria are able to grow in dead bone inaccessible to body’s defenses.

Clinical features

• Primary – insidious in onset , slight pain , gradual increase in jaw size.
• Secondary - Pain is deep pain and intermittent, temperature fluctuations , pyrexia , cellulitis eventually leading to abscess
• New bone formation leads to thickening causing facial asymmetry.
• Thickened or “wooden” character of bone in cr sec osteomyelitis.
• Eventually cures itself as the last sequestra is discharged.

Radiographic Features

• Trabeculae in the involved area become thin or appear fuzzy & then lose their continuity.
• After some time “moth eaten” appearance is seen
• Sequestra appear denser on radiographs.
• Where the subperiosteal new bone formation , the new bone is superimposed upon that of jaw, “fingerprint” or “orange peel” appearance is seen
• Cloacae seen as dark shadows passing through opacity.

Histologic features

• Areas of acute and subacute inflammation in the cancellous spaces of the necrotic bone.
• Foci of acute inflammation
• Active osteoclastic resorption of bone noted in peripheral portions

Chronic Subperiosteal Osteomyelitis

• Cortical plate deprived of its blood supply undergoes necrosis, underlying medullary bone  is slightly affected.
• Multiple small sequestra form, eventually discharged through sinuses with pus.
• Following extrusion of sequestra, healing occurs.
• Spontaneous drainage poor in submassetric area.
• Much of  body of mandible is lost due to poor central blood supply of the region.

D/D

• Paget’s disease – particularly wen periosteal bone is involved
• Fibrous dysplasia
• Osteosarcoma

Chronic sclerosing osteomyelitis

– focal

- diffuse

Focal Sclerosing Osteomyelitis

Clinical features

• Most commonly in children and young adults, rarely in older individuals.
• Tooth most commonly involved is the mandibular third molar presenting with a large carious lesion.
• No signs or symptoms other than mild pain associated with infected pulp.

Radiographic features

• Entire root outline always visible with intact lamina dura.
• Periodontal ligament space widened.
• Border smooth & distinct appearing to blend into surrounding bone

D/D for focal sclerosing osteomyelitis

• Local bone sclerosis
• Sclerosing cementoma
• Gigantiform cementoma

Treatment & prognosis

• Affected tooth may be treated endodontically or extracted.
• Sclerotic bone  not attached to tooth and remains behind after tooth is removed.
• This dense area may not get remodeled.
• Recognizable on bone years later and is referred as bone scar.

Diffuse Sclerosing Osteomyelitis

• May occur at any age, most common in older persons, esp in edentulous mandibles
• vague pain, unpleasant taste.
• Many times spontaneous formation of fistula seen opening onto mucosal surface to establish drainage
• Slowly progressive, not particularly dangerous since it is non destructive & seldom produces complications

Radiographic features

• Diffuse patchy, sclerosis of bone – “cotton wool” appearance
• Radiopacity may be extensive and bilateral.
• Due to diffuse nature, border between sclerosis & normal bone is often indistinct

D/D for DIFFUSE sclerosing osteomyelitis

FLORID OSSEOUS DYSPLASIA

SCLEROTIC CEMENTAL MASSES

TRUE CHR DIFFUSE SCLEROSING OSTEOMYELITIS

FIBROUS DYSPLASIA

Treatment & Prognosis

• Resolution of adjacent foci of chronic infection often leads to improvement.
• Usually too extensive to be removed surgically,
• Acute episodes treated with antibiotics.

Mnemonics Flashcards

Paget's Disease

• Chief Complaint: Denture tightening (due to arch expansion)
• Fractures: Chalk-stick fractures
• Facial Feature: Leontiasis ossea (lion-like facies)
• Radiology: Cotton wool appearance
• Histology: Jigsaw puzzle pattern
• Clinical: Bone warm to touch (↑ vascularity)
• Laboratory: ↑ Alkaline phosphatase (>250 Bodansky units)
• Other Signs: Osteoporosis circumscripta, platybasia
• Memory Aid: "Paget's Patients Prefer Tight Dentures"

Osteopetrosis

• Radiographic Sign: Rugger Jersey Spine (classic)
• Fractures: Chalk-stick fractures

Fibrous Dysplasia

• Facial Feature: Leontiasis ossea
• Histology: Chinese script pattern
• Radiology:
  • Ground glass appearance
  • Rind sign, orange peel appearance
• Bone Deformity: Hockey stick/Shepherd's crook deformity (femur)
• Key Feature: Lesional bone fused with normal bone (vs COF)
• Memory Aid: "Fibrous Faces Feel Funny"

Cemento-Ossifying Fibroma (COF)

• Histology: Chinese script pattern
• Facial Feature: Leontiasis ossea
• Difference: NOT fused with normal bone (vs Fibrous Dysplasia)

Hyperparathyroidism

• Radiology: Ground glass appearance (brown tumor)
• Histology: Numerous giant cells, vascular stroma, hemosiderin deposits

Cherubism & Central Giant Cell Granuloma

• Histology: Same as hyperparathyroidism (giant cells + vascular stroma + hemosiderin)
• Note: Cherubism previously called "Familial fibrous dysplasia"
• Memory Aid: "Giant Cells Have Three Homes" (Hyperparathyroidism, Cherubism, CGCG)

Juvenile Ossifying Fibroma

• Aggressiveness: More aggressive than Cemento-ossifying fibroma
• Types:
  • Trabecular type: Common in jaws
  • Psammomatoid type: Involves base of skull

• Cheiloscopy: The examination of lip prints.

• Gustafson's Method for Age Estimation: Includes assessment of:

  • Amount of occlusal attrition

  • Secondary dentine deposition (coronal)

  • Periodontal attachment loss

  • Cementum apposition at root apex

  • Root resorption at apex

  • Dentine translucency

• Café au Lait Spots:

  • "Coast of California": Associated with Neurofibromatosis (Type 1).

  • "Coast of Maine": Associated with Fibrous Dysplasia.

• Carpet Tack Lesions: Characteristic of Discoid Lupus Erythematosus.

• Cerebriform Tongue: Seen in Pemphigus Vegetans.

• Charcot's Triad: Seen in Multiple Sclerosis, characterized by:

  • Intention tremor

  • Nystagmus

  • Dysarthria

• Chipmunk Facies: Seen in Thalassemia.

• Chvostek's Sign: Indicative of Hypoparathyroidism (facial muscle twitching upon tapping the facial nerve).

• Buffalo Hump: A characteristic clinical sign of Cushing's Syndrome (fat pad on the upper back).