Lec # 1 feb/2009/23

Sorry…I could not get the slides so u will get headache while reading the
lecture …so prepare some medications before u begin ;P

THE INFECTION OF JAWS & PERIOSTEAL REACTION

Today our topic will be about the infection of jaws & the osteal
reactions,,,of course we will talk only about the radiological aspects of
infections of the jaws & next time we will talk about resorbtion ….

Most of the common causes of the infection in the jaws is due to the
necrosis of the pulp , so infection is mostly odontogenic in origin….

Necrosis of the pulp will result either in osteitis & u remember that we
were using the term rarefying osteitis as closing osteitis which is the
localized infection of the jaw or actually the inflammation of part of the
bone ,
or it could be osteomyelitis which is the spit out of the inflammation of
the bone , of course osteomyelitis can be presented on radiographs by
rarefaction which is lose of the calcified material which is in the
beginning lose of the trabeculation or actually filling of the trabeculation
then the lost of most of the trabeculations which can be called
destruction of the bone &/or in combination with sclerosis which is
deposition of new bone which starts as thickening of the trabeculations &
obliteration of these bone marrow spaces.

Osteomyelitis can also result in periosteal reaction or inflammation of

(periosteitis) which covers the surface of the bone & sometime
(mucositis) if the mucus membrane is also adjacent to that bone , as the
mucositis that happens in the maxillary sinus if the inflammation happens
in the maxillary jaw,,,

This does not mean that osteitis can't cause rarefaction , so we call it
rarefying osteitis or sclerosing osteitis but it's localized , & also osteitis
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can result in periosteitis & mucositis as we will see in the end of the
lecture.

The radiographic appearance of osteitis can be either rarefaction or

sclerosis , hypercementosis (which is thickening of the apex of the root
due to laying down of more cementum) or root resorbtion (we will talk
about it in the next lecture) , or periosteitis & mucositis…

Osteitis also if it persist & is affected by the virulence of organisms &

the host defense of the patient can also be converted to osteomyelitis &
also to rarefaction which is also due to osteitis & osteomyelitis which can
lead to sequestrum which is the isolation of a piece of bone devitalization
from blood supply so it leads to dead bone which is called sequestrum.

Periosteitis when it occurs it causes bone formation at the inner part of

the periosteal tissue & this new bone is called involucrum .

Now we will see illustrations which will show all of these changes as we
said the most common cause of inflammation of the bone is due to pulpul
necrosis & the most common cause of pulpul necrosis is due to
caries(destructive caries ) & this has resulted in osteitis localized
inflammation at the apex of this tooth,so the lamina dura is lost & we can
call this rarefaction because trabeculation has been lost, it could be
rarefaction with sclerosis or sclerosis alone.

Sclerosis may make u think that it's more of a chronic condition than
rarefaction, it may also result in root resorbtion just as a combination
with sclerosis & rarefaction or hypercementosis the apex shape is like a
drum stick with a swelling .

That localized infection or inflammation which we call osteitis may spread

through direct spread which means the adjacent bone will be involved
until it reaches the surface of the bone where u have the periosteum
there where the periosteal reaction happens (laying down of new bone
which is the involucrum) , involucrum formation is pronounced in children
more than in adults & in the mandible more than in the maxilla.

To had been converted to osteomyelitis it has to be spread more than to

localized, the method of spread to the adjacent bone to involve wider
area can be through direct spread (as we said direct in this direction &
this ) or the cause can be as in the previous radiograph when it reaches
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the pus & supurative material through volcmans' canals which are present
in the surface of the bone it may also go to the surrounding bone.

So two types of spread either direct spread or through the surface of

the bone through volcmans' canals,,,this is more of a wide spread
infection, there is rarefaction which is in orange color (of course there
are no colors on the slide & also i don't have a copy of them my reference
is only the record … so sorry) & we have dead bone which shows more
radioopaque, & we also could have in association with osteomyelitis
periosteal reactions & laying down of new bone which is called
involucrum(involucrum is a kind of a reaction of periosteum which aids the
patient to prevent pathological fracture , it holds the pieces of bone
together, so that if pathological fracture has to occur it will keep the
bone together.

During surgical treatment of osteomyelitis u have to remove sequestrum ,

but involucrum u do only smoothening, but u don't remove the whole
involucrum because if u remove it, it will cause weakening to the bone &
pathological fracture, so it's a kind of defense that GOD created for
bone to be held together.

DEFINITIVE DEFINITIONS

DEFINITIVE DEFINITIONS OF TERMS

Rarefying osteitis : this is a term that is used in radiology , it's only used
in radiology although it's a good term to describe inflammation on
radiographs ,so it's a radiographic interpretation not a diagnosis , & it's
related to a localized inflammatory response , actually inflammatory
response could be apical periodontitis ,chronic apical periodontitis ,
periapical granuloma or radicular cyst , all of which are inflammatory , all
of which are radiolucent , so that's why because I don't know the
definitive diagnosis i use the term rarefying osteitis , & the diagnosis of
rarefying will be either abscess , cyst , or granuloma .

This is an example of rarefying osteitis , when u see rarefying osteitis

the tooth is non-vital & endodontic treatment is required if the prognosis
of the tooth is good , but if it does not worth doing then extraction is
required so the tooth has to be removed & it will heal by itself because
the focus of the infection which is the tooth has been removed so it will
heal by the host defense.
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The difference between osteitis & osteomyelitis is the clinical picture &
also the radiological picture is different,,
In osteitis the patient will have localized pain , he does not have fever ,
malaise & he does not require antibiotic treatment , so it needs only
localized treatment ,as it is localized u have only to remove the cause of
that infection ,

While in osteomyelitis the patient may have other symptoms as we said &
the ESR of him will be high , & he requires for sure systemic antibiotic &
also the radiological picture of osteomyelitis may not be evident in cases
of acute osteomyelitis before 8- 10 days from the onset of the disease ,
cause removal of bone to be evident on radiograph requires the removal
of 30 – 60 % of the calcific material to be seen on the radiograph.

In this radiograph we can see rarefying osteitis & it's not a must to be on
the apex , it could be on the lateral part of the tooth ,,,
& u have also in this case to rule out other types of pathology , we can say
lateral periodontal cyst which is not inflammatory & this case u have to
do vitality test, so if it's vital we exclude rarefying & if it's non-vital it
could be rarefying.

Sclerosis may present around the periphery of rarefying or by itself

without rarefaction.
We have an example on sclerosing osteitis by itself (alone) without
rarefaction, & another one with a little bit rarefaction surrounded by
sclerosis,,

So these terms u have to know by sure & u have to know what they mean&
how would they look on radiographs.

So when we say rarefaction we also mean rarefying osteitis, & sclerosis is

the same as sclerosing osteitis, sequestrum can be seen as single
sequestrum or plural (more sequestrum) which is dead bone,,, periosteitis
(when u have periosteitis u have to look for involucrum,,, tumor we don't
mean by it neoplasm we only mean swelling which is a soft tissue mass.

This is a part of an occlusal radiograph of the mandible, & shows that

normally we can't see the periosteum cause it's adherent to the surface
of the bone, but in cases of inflammation it will be pealed off , & evident
of new bone is there so we call it periosteitis or periosteal reaction, we
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are talking in this lecture about periosteal reaction which is due to

inflammation , which is due to osteitis or osteomyelitis , in the end of the
lecture we will talk that periosteal reaction may also occur due to other
causes other than inflammation.

When u look at radiographs of course u should have a picture of what

normally the bone looks like this is the most important as the doctor
said ,,,how would trabeculae look like ?? how thin or thick they should
be??

If u can see in this radiograph the trabeculation looks wet & as they are
wiped with a tissue , so this blurry & fuzzy appearance should bring ur
attention that there is something abnormal there , & what u should think
of specially that it's spread out (not localized) u should think about
osteomyelitis after u connect this with the clinical picture of the
patient,,, this patient after 3 weeks follow up there will be wiping out of
all the trabeculations & there are some areas of deprived bone.

Another case also in the mandible & this is what the surface of the
mandible should look like & in this area we have new bone formation which
is called involucrum,other areas are not so clear because we always take
the occlusal aspect to see the 3rd dimension which is the periosteal
reaction, if we want to see what's inside the dentoalveolar process we
have to take an OPG or periapical radiograph .

This is the clinical picture in a patient, it's dead bone( a chronic case of
osteomyelitis),,, on radiographs u can see that it has been caused by
extraction of a tooth may be the six, & has resulted in sequestrum
formation which is the inter radicular bone & it has lost vitalization (lost
blood supply) & resulted in sequestrum formation which acts also as a
foreign body, so it has to be removed, unless it has been removed the
inflammation will persist there.

An occlusal radiograph of the same case shows rarefaction of the area ,

it was taken to see if there is any periosteal reaction & there is not.

Another case where osteomyelitis has caused pathological fracture , u

can notice that the periphery of all these lesions are ill defined in
comparison to other conditions like cysts or begnin tumors where the
periphery will be very well defined ,,, so that when it is ill defined u
should think about more of a serious condition like malignancies , but the
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clinical picture , the onset & the period of the disease will aid u to
exclude or include malignancy.

Another case…also u can see the ill defined bone destruction & also it's
separated by normal bone ( two lesions are separated by normal bone in
the radiograph & it's not uncommon)

In this case there is a sequestrum & sclerosis in the trabeculations

occurred , we said that sclerosis can occur with rarefaction or separate
from it in case of osteomyelitis.

Radiograph ,,, another case of osteomyelitis & there is sequestrum

Now we will talk about the density of sequestrum,,, usually it has been
normal bone before & now it's devitalized & that means that it has lost
blood supply to remove any calcific material or calcium from it, so it
preserve it's calcium material so the radioopacity will remain the nearly
the same, the sequestrum will be covered on the surrounding by
granulation tissue, granulation tissue can cause resorbtion on the
periphery , but inside it may become smaller with time , but the
radioopacity will remain the same , in comparison the normal bone which
surround it (the vital bone) will have lose in calcium material &
rarefaction , so it may happen in some cases that sequestrum will look a
little bit denser than the surrounding bone, but it has not gained new
bone formation ( only relative to the surrounding bone it looks a little bit
denser).

Sequestrum is non-vital so the amount of calcium material will be the

same & the surrounding bone is vital but it is inflamed so rarefaction will
occur (lose of calcium material) so it will appear after a while more
radiolucent.

Sever case of osteomyelitis that has resulted in pathological fracture,

actually in sever cases may be the whole bone (for example the whole
mandible) may be lost due to osteomyelitis & only may be the condyles
have been preserved, & it depends on the host defense upon the recovery
of the bone ,,, either it's recovered by soft tissue that requires grapht
from somewhere else or it can regenerate & we will have a new mandible ,
but it will not have the same morphology of the previous one , but at least
there is new bone formation.
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This is a lateral oblique radiograph that shows also extensive

osteomyelitis in the ramus area causes pathological fracture &
sequestrum formation.

Now during treatment (surgical treatment) u have to decide which pieces

are sequestrum or which pieces are still vital, so actually u have to decide
from radiographic examination after antibiotics have been given to the
patient u have to wait for 3 weeks to take another radiograph s to see
the density & size of the sequestrum , if its size is different & the
density remains the same then the sequestrum has to be removed .

This is the same case which shows rarefaction & lose of the surface of
the bone.

This was all due to pulpul necrosis , but we said that inflammation can also
be due to chemical insult.

CHEMICAL INSULT

Most common was the arsenic use , now it's rarely or never been used,
but this was a case that resulted from the use of arsenic which causes
necrosis of bone ,arsenic reaches the bone from the tooth then to the
pulp until it reaches the bone.

OSTEORADIONECROSIS
RADIOOSTEONECROSIS

Osteoradionecrosis is mostly used in books, but it's somehow wrong , so

radioosteonecrosis is a better term to be used, so necrosis of the bone is
due to radiation , & not radiation from diagnostic radiology ,,, but from
therapeutic radiation where the patient or the bone will be exposed to
high amount of ionizing radiation which result in devitalization of bone &
lose of blood supply that will result in osteomyelitis.

In this patient these radioopaque materials are implanted materials that

give radiation (localized radiation in the area),,,
So these two illustrations show that the patient has osteomyeitis &
periosteitis…usually which one will u believe the one on the right or the
one on the left?? The one on the left cause the tooth is non-vital.
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We've talked about the most common cause of periosteal reaction which
is necrosis of the pulp or inflammation of the bone….

& we can have periosteal reactions due to other causes …

1. firstly here inflammation of bone could be due to periapical
inflammation which is as a result of necrosis of the pulp which we
talked about, the inflammation products leak until they reach the
periosteum & periosteal reaction will occur
2. or it could be due to periodontal cause & the pulp is
preserved in this case so the inflammation can reach the
periosteum & causes periosteal reaction
3. it can be perichoronitis
4. & it could be due to hematogenic spread which is less
common
5. due to orthodontic band which is the same as periodontal
cause
6. also a fracture in the bone can lead to periosteal reaction, &
the periosteal reaction happens to hold the pieces together

HALO EFFECT

There is something called halo effect, u can hear it more in radiology

than other clinics , what do we mean by halo effect??
It is like ‫ هالة‬which is like the brightening zone around the angles' head,
this is periosteitis in the maxilla , because the maxillary sinus is
radiolucent a periosteal reaction there will cause the periosteum to be
resorbed & laying down of new bone , that means that the floor of the
sinus is there , due to inflammation the periosteum will lay down new bone
..new bone ..new bone & the older bone will be resorbed due to the
inflammation until it reaches a shape that looks like a halo effect.

PERIOSTEITIS, PERISTEITIS WITH MUCOSITIS, MUCOSITIS,

MUCUS RETENTION PSEUDOCYST

If it only appears on radiograph that bone is involved& nothing in soft

tissue we call it (periosteitis) ,sometimes the mucus membrane that lines
the sinus also gets swollen or locally swollen just above that periosteal
reaction & we call it ( periosteitis with mucositis) so it is a localized
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inflammation of the mucus membrane,,, sometimes u may get only

( mucositis ) without periosteitis , in comparison to that mucus membrane
swelling in a dome-shape which we have talked before about it , which we
call it ( mucus retention pseudocyst ) which doesn't relate to the
inflammation, only it is related to the obliteration which occurs to the
outlet of the goblet cells ,so retention for the mucus happens inside
those cells & it get swollen & gave us this dome-shape appearance, &
because it's only in one cell we call it pseudocyst,,, so u must
differentiate between periosteitis ,periosteitis with mucositis , mucositis
alone, & mucus retention pseudocyst

RADIOGRAPHS

-periosteitis
-mucus retention pseudocyst
-mucositis
-periosteitis with mucositis
-periosteitis
-periosteitis
-localized mucositis , a case of localized mucus membrane swelling due to
odontogenic inflammation

Other periosteal reactions in cysts ,begnin neoplasms, & in malignancies

…..& what differentiates it……in malignant is that the shape of the
periosteal reaction is characteristic which is called codman or sunray
speculs .

We have here in this radiograph a cyst or begnin tumor , u actually can't

differentiate between them from the radiograph , cause they are nearly
the same on radiographs we will talk about them in another lecture .

If u see this swelling at the inferior border of the mandible it's due to
periosteal reaction , it's not a balloon that is swelling , actually this
swelling is due to resorbtion & deposition, & what makes the deposition of
bone is the periosteum.
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This occlusal radiograph shows the periosteal swelling or reaction due to

the enlargement of the cyst or the begnin tumor material .

Another radiograph…it could be lateral periodontal cyst , keratocyst or

amyloblastoma

This is due to osteomyelitis …we have rarefaction , sequestrum formation

& interruption of the periosteum or pealing of the periosteum which may
later cause new bone formation.

In comparison to this…where I see something like a triangle at the

periphery which we call codman triangles these are characteristic for
osteogenic sarcoma , also this sunray appearance is another kind of
periosteal reaction in malignant cases of osteogenic sarcoma

In this radiograph for a patient we can see speculs , destruction of bone

& periosteal reaction this is also due to osteogenic sarcoma.

Another case more localized but sunray speculs are evident at the inner
surface of the mandible due to osteogenic sarcoma also .

In the last slide….. we can see osteomyelitis which lead to periosteitis …

which will give involucrum , & here healing from trauma , may be anemia
which can cause hair on end – appearance , it could be sarcoma as sunray
speculs or codman triangles also as in sarcoma.

Done by : Asmaa M. Momani

‫ كلمتان خفيفتان على‬: ‫قال رسول الله صلى الله عليه و سلم‬
‫ سبحان‬, ‫سبحان الله و بحمده‬, ‫ ثقيلتان في الميزان‬, ‫اللسان‬
‫الله العظيم‬

‫تم بحمد الله‬