• Pulp Polyp (Chronic Hyperplastic Pulpitis):

  • Source of epithelium: Implantation of desquamated cells from saliva or by implantation from oral mucosa due to continuous rubbing.

  • Most common teeth: Deciduous molars and permanent first molars.

• Periapical Granuloma: Always associated with a non-vital tooth.

• Garre's Osteomyelitis: Another name for Chronic Osteomyelitis with Proliferative Periostitis.

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.

 General Features

• Caused by mutation in DSPP gene (dentin sialophosphoprotein).

• Teeth appear translucent or opalescent.

• Enamel fractures easily due to poor dentin support.

• Pulp chambers are obliterated or enlarged depending on type.

• Also called Hereditary Opalescent Dentin or Shell Teeth.

Type II DI

• Pulp chambers are normal but rapidly obliterate.

• Associated with progressive hearing loss.

Type III DI

• Pulp chambers are large and shell-like.

• Seen in Brandywine isolate population.

Gemination

• Attempted division of a single tooth germ before calcification.

• Results in two crowns (complete/incomplete) with one root and canal.

• Tooth count remains normal.

• Difficult to differentiate from fusion with a supernumerary tooth.

 Twinning

• Complete division of a single tooth germ.

• Results in one normal + one supernumerary tooth.

• Tooth count is more than normal.

Fusion

• Union of two separate tooth germs.

• If before calcification → single large tooth.

• If after calcification → roots fused, crowns may be separate.

• More common in deciduous teeth.

Concrescence

• Union by cementum only.

• Occurs after root formation.

• Common in maxillary molars.

• Inverted Pear-shaped Radiolucency: Globulomaxillary cyst.

  • Associated teeth need not be non-vital.

  • Klestadts’s cyst: Soft tissue variant of Globulomaxillary cyst.

• Tear Drop-shaped Radiolucency: Lateral Periodontal Cyst.

  • Associated teeth are vital.

• Cluster of Similar Cysts / Cluster of Grapes: Botryoid Odontogenic Cyst.

• Schilling Test: Done to identify the deficiency of either extrinsic (dietary vitamin B12) or intrinsic factor involved in Pernicious Anemia.

• Fanconi's Syndrome: Associated with Aplastic Anemia.

• "Safety-Pin" Cells: Characteristic finding in Thalassemia / Erythroblastic Anemia.

• Radiographic Features of Anemias:

  • "Salt and Pepper" effect (Intraoral Periapical Radiograph): Found in Cooley's Anemia (Thalassemia) and Sickle Cell Anemia.

  • "Hair-on-End" pattern (Skull Radiograph): Found in Thalassemia, Sickle Cell Anemia, Congenital Hemolytic Jaundice, Chronic Iron Deficiency Anemia.

• "Rh Hump" (Erythroblastosis Fetalis): Describes a ring-like defect.

• Plummer-Vinson Syndrome: Associated with Iron Deficiency Anemia.

• Chediak-Higashi Syndrome: Giant abnormal PAS positive granules found in peripheral circulating leukocytes are basically altered lysosomes.

• Philadelphia Chromosome: Translocation of chromosomal material from chromosome 22 to chromosome 9; found in Chronic Myeloid Leukemia (CML).