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Infection of The Jaws and Periosteal
Reactions
Dr. Mustafa Alkhader
Assistant Professor of Oral Radiology


White & Pharoah, Oral Radiology Principles and Interpretation 6
th
.
Ed.
Ch. 20
I nflammatory Lesions
Most common pathologic conditions of the
jaws

Teeth create a direct pathway for
inflammatory agents and pathogens to
invade the bone when caries and
periodontal disease are present
General clinical features
Cardinal signs of
inflammation: Swelling,
redness, heat, pain, and loss
of function.
Acute lesions: recent and rapid onset, pronounced pain,
fever and swelling.

Chronic lesions: prolonged gradual course, mild pain,
intermittent fever, slow swelling. Symptoms may be entirely
sub-symptomatic.
General Radiographic features
Location:
Periapical: epicenter at apex of a tooth.
Periodontal lesions: at alveolar crest, furcation or even up to root
apex.
Osteomyelitis: posterior mandible, rare in maxilla.

Periphery:
ill defined.

Internal structure:
Bone resorption, formation or combination of both.
Sequestra: a radiopaque island of non-vital bone surrounded by
ill-defined radiolucency.
General Radiographic features
Effect on surrounding structures:
Bone resorption, formation or combination of
both.
Widening of PDLS.
Root resorption.
Cortical bone resorption.
Periosteal elevation and new bone formation.

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Rarefying Osteitis
A radiographic interpretation, not a diagnosis.
It refers to a localized inflammatory
response. The diagnosis of rarefying osteitis
will be abscess, cyst, or granuloma.
Infection of The Jaws and Periosteal Reactions Infection of The Jaws and Periosteal Reactions
Infection of The Jaws and Periosteal Reactions Infection of The Jaws and Periosteal Reactions
Sclerosing Osteitis
May be present around the periphery of
rarefying osteitis or by itself
Infection of The Jaws and Periosteal Reactions Infection of The Jaws and Periosteal Reactions
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Infection of The Jaws and Periosteal Reactions
Periapical Inflammatory Lesions
Caries
Periodontitis
Trauma
Necrotic Pulp Apical periodontitis
Periapical
Abscess
Periapical
Granuloma
Osteomyelitis
Periapical
cyst
Size
Epicenter
Sequestra
Infection of The Jaws and Periosteal Reactions
Periapical Inflammatory
Lesions
At least 60% demineralization must occur
before the lesion can be seen on a
radiograph. Therefore, it is inappropriate to
use a radiograph as a vitality test

Histologically, the lesion is apical
periodontitis, which is defined as
aperiapical abscess or periapical granuloma
Periapical Inflammatory
Lesions
Clinically, the symptoms may include pain,
swelling, fever, lymphadenopathy, or may
be asymptomatic

It is important to note that the clinical
presentation may not correspond with the
histopathological or radiographic findings
Radiographic features

Location:

Periphery:

Internal structure:

Effect on surrounding structures:
Periapical Inflammatory Lesions
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Halo Effect
Infection of The Jaws and Periosteal Reactions Infection of The Jaws and Periosteal Reactions


Mucositis
(Localized Mucositis)


Infection of The Jaws and Periosteal Reactions Infection of The Jaws and Periosteal Reactions
Periapical Inflammatory Lesions
Differential Diagnosis:
PCD
Enostosis
Granuloma.
Cyst.
Healing scar
Malignancies (leukemia)
Metastatic lesions.
Management:
Elimination of cause: Endo Tx / Extraction.
Antibiotics
Pericoronitis
Definition: inflammation of
tissue surrounding a partially
erupted tooth which extends to
the bone.

Clinically:
Pain and swelling
Trismus
Ulcerated oberculum.
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Pericoronitis
Radiographic features
Either no changes or
Localized rarifaction or sclerosis
Mandibular wisdom is the most commonly
affected.
Area of rarifaction that causes increase in the
width of folicular space.
Pericoronitis
Radiographic features
Normal
Pericoronitis
Enlarged follicular space
Sclerotic bone
Osteomyelitis
Inflammation of the bone
May spread to involve:
Marrow
Cortex Periosteum
Cancellous portion
Caused by pyogenic organisms from abscessed
teeth, trauma, or surgery
Source of infection can not always be identified
Bacteria and by-products stimulate an
inflammatory reaction in bone

In young patients, the periosteum is lifted by
inflammatory exudates. New bone is laid down.
This is called Garres Osteomyelitis

Presence of sequestra is a hallmark of
osteomyelitis. These can be seen in both plain
films and CT
Acute and chronic forms exist

Acute form demonstrates purulent drainage

Paresthesia of the lip may be present,
suggesting a malignancy
Location
The most common location of
osteomyelitis of the jaws is the posterior
body of the mandible

Involvement of the maxilla is rare, perhaps
due to its excellent vascularity
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Borders
The borders of these lesions are illdefined,
gradually blending into the normal
trabecular pattern
Internal architecture
Initially, there is a slight decrease in the
radiodensity of the bone, with the trabeculae
becoming less well defined

There may be scattered areas of lucency in the
area

Later, areas of sclerotic bone are seen

Sequestra are most apparent in the chronic forms
Chronic osteomyelitis may arise from the acute
form or de novo

In the chronic form, the balance tips in favor of
osteoclastic activity

Trabeculae may be completely obscured, yielding
a uniformly opaque appearance to the bone

Sequestra are generally larger in the chronic form
Effects on adjacent structures
Surrounding bone may be resorbed or laid down

May cause resorption of the cortex

In Garres osteomyelitis, the cortex is expanded
through deposition of new bone. The radiographic
appearance of these new layers of bone is termed
onion skin or proliferative periostitis
Chronic suppurative Osteomyelitis
Axial CT showing multiple
sequestra
Coronal CT showing extension
to TMJ
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DD?
Osteoradionecrosis
High radiation dose (50 Gy) lowers the bone
blood supply and reparative power of osteocytes.
A minor infection or trauma may lead to
osteoradionecrosis.

More in posterior mandible.

More in male (susceptibility of carcinomas).

Osteoradionecrosis
Clinically:
It resembles ch.supp.osteo. But it shows :
More spread
Late sequestration.
Radiographically:
Areas of RL,RO.
More spread.
No actual difference except with history of
radiation to head and neck.