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NEET MDS Synopsis - Lecture Notes
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📖 Oral Pathology

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Acute suppurative osteomyelitis

Oral Pathology

Acute suppurative osteomyelitis

  • Serious sequela of periapical infection.
  • Leads to spread of pus through the medullary cavities of bone.
  • Depending upon the main site of involvement of bone, can be of two types-
  1. Acute intramedullary
  2. Acute subperiosteal

Acute Intramedullary Osteomyelitis

CLINICAL FEATURES:

  • Patient experiences dull , continuous pain , indurated swelling forms over the affected region of jaw involving the cheek , febrile.
  • When mandible involved, loss of sensation occurs on lower lip on affected side due to involvement of inferior alveolar nerve.
  • Teeth become loose later along with tender on percussion
  • Pus discharge , trismus , foul smell , regional lymphadenopathy , weakness

RADIOGRAPHIC FEATURES

  • Earliest radiographic change is that trabeculae in involved area are thin, of poor density & slightly blurred.
  • Subsequently multiple radiolucencies appear which become apparent on radiograph.
  • In some cases there is saucer shaped area of destruction with irregular margins.
  • Loss of continuity of lamina dura, seen in more than one tooth.

HISTOLOGIC FEATURES:

  • Dense infiltration of marrow by polymorphonuclear leukocytes.
  • Bone trabeculae in involved site (sequestrum) are devoid of cells in the lacunae.
  • separation of considerable portions of devitalized bone.

 

Acute Subperiosteal Osteomyelitis

CLINICAL FEATURES

  • Pain , febrile condition , i/o and e/o swelling , parasthesia
  • Bone involvement limited to localized areas of cortex.
  • Pus ruptures rapidly through the overlying cortex, tracks along the surface of mandible under the periosteal sheath.
  • Elevation of periosteum from cortex is followed eventually by minute cortical sequestration.

Infantile Osteomyelitis

Oral Pathology

Infantile Osteomyelitis

  • Osteomyelitis Maxillaries Neonatarum, Maxillitis of infancy
  • Osteomyelitis in the jaws of new born infants occurs almost exclusively in maxilla.

Etiology

  • Trauma – through break in mucosa cause during delivery.
  • Infection of maxillary sinus
  • Paunz & Ramon et al  believe that disease caused through infection from the nose.
  • Hematogenous spread through streptococci & pneumococci

Clinical features

  • Fever, anorexia & intestinal disturbances.
  • swelling or redness below the inner canthus of the eye in lacrimal region.
  • Followed by marked edema of the eyelids on the affected side.
  • Next, alveolus & palate in region of first deciduous molar become swollen.
  • Pus discharge from affected sites

D/D for Infantile Osteomyelitis

  • Dacrocystitis neonatarum
  • Orbital cellulitis
  • Ophthalmia neonatarum
  • Infantile cortical hyperostosis

TREATMENT

  • Intravenous antibiotics, preferably penicillin.
  • Culture & sensitivity testing
  • Incision & drainage of fluctuant areas
  • Sequestrectomy
  • Supportive therapy

Chronic Osteomyelitis

Oral Pathology

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.

Non-epithelial cysts

Oral Pathology

Non-epithelial cysts (not true cysts)

Solitary bone cyst

Radiology

The solitary bone cyst appears as a well-defined but non-corticated radiolucency. Typically, it has little effect
on adjacent structures and 'arches' up between the roots of teeth .

The inferior dental canal may not be displaced, but the cortical margins of the canal may be lost where it overlies the lesion. Expansion is rare.

Pathology

The cyst is lined by fibrovascular tissue that often includes haemosiderin and multinucleate giant cells.

Aneurysmal bone cyst

Radiology

The aneurysmal bone cyst typically presents as a fairly well-defined radiolucency. Sometimes it has a multilocular appearance because of the occurrence of internal bony septa and opacification. Marked expansion is a feature.

Pathology

The predominant feature of an aneurysmal bone cyst is the presence of blood-filled spaces of variable size lying in a stroma rich in fibroblasts, multinucleate giant cells and haemosiderin. Deposits of osteoid are also seen