**Osteomyelitis** <sup>22</sup> Osteomyelitis is an infection of the bone that can be caused by a variety of microbial agents, typically resulting in inflammation and bone destruction. ```markdown Osteomyelitis 22 <img src="https://i.imgur.com/placeholder.png" alt="Presentation slide with a right-click context menu showing options like Next, Previous, Zoom In, Show Presenter View, Start Subtitles, Help, Pause, End Show. The slide title is 'Osteomyelitis' in cyan text on a maroon background. The slide number '22' is in yellow at the bottom right." /> ```  Osteomyelitis A screenshot of a presentation software interface showing a right-click context menu with options like 'Next', 'Previous', 'Zoom In', and 'Show Presenter View'. The slide title 'Osteomyelitis' is visible in cyan text on a maroon background, and the slide number '22' is in the bottom right corner. Osteomyelitis Osteomyelitis # Osteomyelitis - **Definition**: inflammatory condition of the bone, which begins as an infection of the medullary cavity, rapidly involves the haversian systems, and extends to involve the periosteum of the affected area - Only 2 out of every 10,000 people get osteomyelitis. #### Definition of Osteomyelitis Osteomyelitis is an inflammatory condition of the bone that begins as an infection of the medullary cavity. It rapidly involves the Haversian systems and extends to involve the periosteum of the affected area. - **Prevalence**: Approximately 2 out of every 10,000 people develop osteomyelitis. ```markdown ## Predisposing factors - **Diabetes** (most cases of osteomyelitis stem from diabetes) - Sickle cell disease - **HIV** or **AIDS** - **Rheumatoid arthritis** - Intravenous drug use - **Alcoholism** - Long-term use of **steroids** - Hemodialysis - Poor **blood** supply - Recent injury 24 ```  #### Predisposing Factors Various systemic conditions and lifestyle factors can increase the risk of developing osteomyelitis: - **Diabetes**: The primary cause in most cases of osteomyelitis. - **Immune System Deficiencies**: HIV or AIDS, and long-term use of steroids. - **Chronic Conditions**: Rheumatoid arthritis, sickle cell disease, and hemodialysis. - **Lifestyle and Substance Use**: Alcoholism and intravenous drug use. - **Local Factors**: Poor blood supply and recent injury. A bulleted list titled 'Predisposing factors' on a dark background, listing medical conditions and risk factors such as diabetes, sickle cell disease, HIV or AIDS, rheumatoid arthritis, intravenous drug use, alcoholism, long-term steroid use, hemodialysis, poor blood supply, and recent injury. The text is highlighted in yellow and purple, with the number 24 at the bottom right corner. # Osteomyelitis of the Jaws - The potential source of infection is 1. Periapical infection 2. Periodontal pocket's 3. Acute gingivitis 4. Penetrating and contaminated injuries 5. Tooth extraction 25 #### Potential Sources of Infection Infection in the jaws typically originates from the following sources: 1. Periapical infection 2. Periodontal pockets 3. Acute gingivitis 4. Penetrating and contaminated injuries 5. Tooth extraction # Signs and symptoms - Fever, irritability, **fatigue** - **Nausea** - Tenderness, redness, and warmth in the area of the infection - Swelling around the affected bone - Lost range of motion #### Signs and Symptoms Clinical presentation of osteomyelitis often includes: - **Systemic Symptoms**: Fever, irritability, fatigue, and nausea. - **Local Inflammation**: Tenderness, redness, and warmth in the area of infection. - **Physical Changes**: Swelling around the affected bone and lost range of motion. ```markdown # Classification - Acute osteomyelitis is mainly in children (acute process occurs up to one month after the onset of symptoms) - Chronic osteomyelitis (mainly adults) - primary chronic osteomyelitis (PCO) is defined as chronic non-suppurative osteomyelitis; when PCO occurs in children and adolescents it is termed 'Garré's osteomyelitis'. - secondary chronic osteomyelitis (SCO), which is chronic osteomyelitis with suppuration, abscess/fistula formation, and sequestration at some stage of the disease due to a defined, infectious aetiology. ``` #### Clinical Classification Osteomyelitis is classified based on the duration and nature of the inflammatory process: - **Acute Osteomyelitis**: Primarily affects children; the acute process occurs up to one month after the onset of symptoms. - **Chronic Osteomyelitis**: Primarily affects adults and is subdivided into: - **Primary Chronic Osteomyelitis (PCO)**: Defined as chronic non-suppurative osteomyelitis. When occurring in children and adolescents, it is termed "Garré's osteomyelitis." - **Secondary Chronic Osteomyelitis (SCO)**: Chronic osteomyelitis characterized by suppuration, abscess or fistula formation, and sequestration, resulting from a defined infectious etiology. | Reference | Classification | Classification criteria | | --- | --- | --- | | Hjorting-Hansen E<br>Decortication in treatment of osteomyelitis of the mandible.<br>Oral Surg Oral Med Oral Pathol 1970<br>May;29(5):641-55 | I. Acute/subacute osteomyelitis<br>II. Secondary chronic osteomyelitis<br>III. Primary chronic osteomyelitis | Classification based on clinical picture and radiology | | Marx RE<br>Chronic Osteomyelitis of the Jaws<br>Oral and Maxillofacial Surgery Clinics of North America, Vol 3, No 2, May 91, 367-81<br>Mercuri LG<br>Acute Osteomyelitis of the Jaws<br>Oral and Maxillofacial Surgery Clinics of North America, Vol 3, No 2, May 91, 355-65 | I. Acute osteomyelitis<br>1. Associated with Hematogenous spread*<br>2. Associated with intrinsic bone pathology or peripheral vascular disease*<br>3. Associated with odontogenic and nonodontogenic local processes*<br>II. Chronic osteomyelitis<br>1. Chronic recurrent multifocal osteomyelitis of children<br>2. Garre's osteomyelitis<br>3. Chronic suppurative osteomyelitis<br>– Foreign body related<br>– Systemic disease related<br>– Related to persistent or resistant organisms<br>4. True chronic diffuse sclerosing osteomyelitis | Classification based on clinical picture and radiology, etiology, and pathophysiology<br>Classification of acute osteomyelitis by Mercuri, classification of chronic osteomyelitis by Marx. The arbitrary time limit of one month is used to differ acute from chronic osteomyelitis<br>* From Waldvogel and Medoff 1970 | | Panders AK, Hadders HN<br>Chronic sclerosing inflammations of the jaw. Osteomyelitis sicca (Garre), chronic sclerosing osteomyelitis with fine-meshed trabecular structure, and very dense sclerosing osteomyelitis.<br>Oral Surg Oral Med Oral Pathol 1970<br>Sep;30(3):396-412 | I. Primarily chronic jaw inflammation<br>1. Osteomyelitis sicca (synonymous osteomyelitis of Garre, chronic sclerosing nonsuppurative osteomyelitis of Garre, periostitis ossificans)<br>2. Chronic sclerosing osteomyelitis with fine-meshed trabecular structure<br>3. Local and more extensive very dense sclerosing osteomyelitis<br>II. Secondary chronic jaw inflammation<br>III. Chronic specific jaw inflammations<br>– Tuberculosis<br>– Syphilis<br>– Lepra<br>– Actinomycosis | Classification based on clinical picture and radiology<br>Classification of chronic osteomyelitis forms only |  #### Historical Classification Systems | Reference | Classification Categories | Criteria and Notes | | :--- | :--- | :--- | | **Hjorting-Hansen (1970)** | I. Acute/subacute<br>II. Secondary chronic<br>III. Primary chronic | Based on clinical picture and radiology. | | **Marx & Mercuri (1991)** | **I. Acute**: Hematogenous spread, intrinsic bone pathology/vascular disease, or odontogenic/nonodontogenic processes.<br>**II. Chronic**: Recurrent multifocal (children), Garre's, Suppurative (foreign body, systemic, or resistant organisms), and True chronic diffuse sclerosing. | Based on clinical picture, radiology, etiology, and pathophysiology. Uses a one-month threshold to differentiate acute from chronic. | | **Panders & Hadders (1970)** | **I. Primarily chronic**: Osteomyelitis sicca (Garre's), fine-meshed trabecular structure, or dense sclerosing.<br>**II. Secondary chronic**.<br>**III. Chronic specific**: Tuberculosis, Syphilis, Lepra, Actinomycosis. | Focuses on chronic forms based on clinical and radiological presentation. | The image contains a table comparing different classifications of osteomyelitis based on clinical picture and radiology, with references to studies by Hjorting-Hansen, Marx, Mercuri, and Panders & Hadders. The table is organized into three columns: Reference, Classification, and Classification criteria, detailing various types of acute and chronic osteomyelitis, including their etiological and pathological classifications. ```html <table> <tr> <td> <img src="https://i.imgur.com/1QZjKqL.png" alt="A timeline diagram showing the onset of disease and acute osteomyelitis over time (t). The onset is marked with a yellow arrow pointing to a box describing 'Onset of disease: Deep bacterial invasion into medullary & cortical bone'. The point labeled 'Acute osteomyelitis' is shown further along the timeline."> </td> </tr> </table> ```  #### Disease Progression Timeline The progression of the condition follows a specific sequence: 1. **Onset of Disease**: Deep bacterial invasion into the medullary and cortical bone. 2. **Acute Osteomyelitis**: Clinical manifestation following the initial invasion. A timeline diagram illustrating the progression of acute osteomyelitis over time (t). The diagram shows the onset of disease marked by a yellow arrow pointing to 'Onset of disease: Deep bacterial invasion into medullary & cortical bone', with acute osteomyelitis occurring later along the timeline. ```html <table border="1" cellpadding="5" cellspacing="0" style="border-collapse: collapse; width: 100%;"><tr><td style="text-align: left; vertical-align: top;"><img src="https://i.imgur.com/8mXq9JL.png" alt="Diagram of mandibular osteomyelitis pathogenesis" /></td><td style="text-align: left; vertical-align: top;"><img src="https://i.imgur.com/8mXq9JL.png" alt="Clinical image of mandibular osteomyelitis" /></td></tr></table> ```   #### Pathogenesis of Mandibular Osteomyelitis The pathogenesis involves the spread of infection through the medullary spaces of the mandible, leading to inflammation and potential bone necrosis. Clinical presentation often shows significant swelling and intraoral or extraoral involvement. A diagram illustrating the pathogenesis of mandibular osteomyelitis, showing inflammation causing thrombosis of vessels in the marrow, peri-osteal stripping due to pus accumulation, necrosis of bone and marrow, and possible restricted arterial supply in aging. The diagram highlights key anatomical structures such as the nerve and the progression of infection leading to bone resorption. A clinical photograph showing a case of mandibular osteomyelitis, with visible inflammation and tissue damage in the oral cavity. The image depicts an open wound with exposed bone and surrounding soft tissue involvement, indicating advanced infection and necrosis. ```markdown # Alveolar osteitis (Dry socket) - Localized inflammation of bone following either failure of blood clot to form in socket, or premature loss or disintegration of clot. Unpredictable complication of tooth extraction (~1-3%). <img src="https://i.imgur.com/placeholder.jpg" alt="Image of alveolar osteitis (Dry socket) showing an empty socket with exposed bone."> <img src="https://i.imgur.com/placeholder.jpg" alt="Image of alveolar osteitis (Dry socket) showing a dental instrument examining the socket with visible bone exposure."> ```   #### Definition and Overview Alveolar osteitis, commonly known as "Dry Socket," is a localized inflammation of the bone. It occurs following the failure of a blood clot to form in the extraction socket, or the premature loss/disintegration of that clot. - **Incidence**: It is an unpredictable complication occurring in approximately 1–3% of tooth extractions. Clinical photograph showing a dry socket with exposed bone in the alveolar socket following tooth extraction, illustrating the localized inflammation characteristic of alveolar osteitis. Close-up clinical photograph of a dry socket with visible exposed bone and a dental instrument examining the area, highlighting the typical appearance of alveolar osteitis after tooth extraction. # Alveolar osteitis (Dry socket) ## Etiology: 1. Failure of blood clot formation due to Poor blood supply as in: - Paget’s disease. - Osteopetrosis. - Following radiotherapy. - Excessive use of vasoconstrictor in local anesthesia. 2. Premature loss of blood clot may be due to: - Excessive mouth rinsing. - Fibrinolysis by proteolytic bacteria. #### Etiological Factors 1. **Failure of Blood Clot Formation**: Often due to poor blood supply associated with: - Paget’s disease - Osteopetrosis - History of radiotherapy - Excessive use of vasoconstrictors in local anesthesia 2. **Premature Loss of Blood Clot**: May be caused by: - Excessive mouth rinsing - Fibrinolysis triggered by proteolytic bacteria ```markdown **Alveolar osteitis (Dry socket)** **Clinical picture :** 1. Intense pain. 2. Most frequently seen in : * 3rd molar extraction * Difficult extraction with trauma * Smoker. 3. tooth socket appears empty and dry 4. jaw bone is visible in the tooth socket 5. Bad breath and Unpleasant taste. 6. Swollen of regional lymph node. <img src="https://i.imgur.com/9VzJzJz.png" alt="Illustration of a person holding their cheek with a red lightning bolt indicating pain, with a red dot marking the jaw area." /> ```  #### Clinical Features - **Pain**: Intense, localized pain. - **Risk Groups**: Most frequently observed in 3rd molar extractions, difficult/traumatic extractions, and smokers. - **Physical Appearance**: The tooth socket appears empty and dry; the underlying jaw bone is often visible. - **Associated Symptoms**: Bad breath (halitosis), unpleasant taste, and swelling of regional lymph nodes. Illustration of a person holding their cheek with a red lightning bolt indicating pain, with a red dot marking the jaw area. The image is related to the clinical picture of alveolar osteitis (dry socket), showing symptoms like intense pain and visible jaw bone in the tooth socket. ```markdown Alveolar osteitis (Dry socket) **Histopathology:** Histological section of socket wall reveal formation of necrotic bone containing empty lacunae <img src="https://i.imgur.com/placeholder.jpg" alt="Image of alveolar osteitis (Dry socket) showing an exposed socket with inflamed tissue and a red dot indicating the affected area."> ```  #### Histological Characteristics Histological sections of the socket wall in alveolar osteitis reveal the formation of necrotic bone. A key diagnostic feature is the presence of empty lacunae within the bone tissue. A close-up photograph of a dry socket, showing an exposed alveolar socket with inflamed tissue and a red dot indicating the affected area. The image is part of a presentation on alveolar osteitis, with text describing the histopathology of necrotic bone containing empty lacunae. ```markdown # Osteonecrosis - Osteoradionecrosis - Osteochemonecrosis (corticosteroids and other cancer and antineoplastic drugs) - MRONJ (medication-induced osteonecrosis) - BRONJ (bisphosphonate-induced osteonecrosis) - Phosphorous necrosis of the jaw (exposure to white phosphorous) 36 ```  #### Types of Osteonecrosis - **Osteoradionecrosis**: Bone death resulting from radiation therapy. - **Osteochemonecrosis**: Induced by corticosteroids and other antineoplastic drugs. - **MRONJ**: Medication-related osteonecrosis of the jaw. - **BRONJ**: Bisphosphonate-induced osteonecrosis of the jaw. - **Phosphorous Necrosis**: Also known as "phossy jaw," caused by exposure to white phosphorous. The image displays a slide titled 'Osteonecrosis' with a hierarchical list of related conditions. It includes osteoradionecrosis, osteochemonecrosis (caused by corticosteroids and other cancer and antineoplastic drugs), MRONJ (medication-induced osteonecrosis), BRONJ (bisphosphonate-induced osteonecrosis), and phosphorous necrosis of the jaw (due to exposure to white phosphorus). The text is organized in a bullet-point format with yellow and white text on a dark purple background. # Osteoradionecrosis and Radioosteomyelitis - Radiotherapy in HNSCC - Osteoradionecrosis was once considered an infection initiated by bacteria, which invaded the radiation-damaged bone - The term “radiation-induced osteomyelitis” or radioosteomyelitis was commonly used. Marx (1983) 37 #### Pathological Concepts - **Radiation Context**: Primarily associated with radiotherapy for Head and Neck Squamous Cell Carcinoma (HNSCC). - **Historical View**: Historically viewed as an infection initiated by bacteria invading radiation-damaged bone. - **Terminology**: The term "radiation-induced osteomyelitis" or "radioosteomyelitis" was commonly utilized (Marx, 1983). ```html <table border="1" cellpadding="5" cellspacing="0" style="border-collapse: collapse; width: 100%;"><tr><td style="text-align: center; vertical-align: middle; font-weight: bold; background-color: #00c8a0; color: #ffd700;">HNSCC</td><td style="text-align: left; vertical-align: top; background-color: #f4f400;">• Radiation</td></tr><tr><td style="text-align: center; vertical-align: middle; font-weight: bold; background-color: #00c8a0; color: #ffd700;">Bone</td><td style="text-align: left; vertical-align: top; background-color: #f4f400;">• Hypoxia<br>• Hypocellular<br>• hypovascular</td></tr><tr><td style="text-align: center; vertical-align: middle; font-weight: bold; background-color: #00c8a0; color: #ffd700;">Trauma</td><td style="text-align: left; vertical-align: top; background-color: #f4f400;">• Chronic nonhealing wound<br>• Susceptible to superinfection</td></tr></table> ```  #### Pathogenesis Factors - **HNSCC Treatment**: Radiation exposure. - **Bone Changes**: Development of hypoxia, hypocellularity, and hypovascularity. - **Trauma**: Leads to chronic non-healing wounds that are highly susceptible to superinfection. The diagram illustrates a hierarchical structure with three main categories: HNSCC, Bone, and Trauma. Each category is represented by a green arrow pointing downward, connected to a yellow box containing bullet points. HNSCC is associated with 'Radiation,' Bone with 'Hypoxia,' 'Hypocellular,' and 'hypovascular,' and Trauma with 'Chronic nonhealing wound' and 'Susceptible to superinfection.' The layout suggests a progression or relationship between these medical conditions and their characteristics. **BRONJ** - Bisphosphonate: - Osteoporosis - Multiple myeloma - Metastatic cancer 39 #### Bisphosphonate-Related Osteonecrosis (BRONJ) Bisphosphonates are commonly prescribed for the management of: - Osteoporosis - Multiple myeloma - Metastatic cancer # Biologic Action of Bisphosphonates - Osteoclastic toxicity - Apoptosis - Inhibited release of bone induction proteins - BMP, ILG1, ILG2 - Reduced bone turnover, resorption - Reduced serum calcium* - Hypermineralization* - "sclerotic" changes in lamina dura of alveolar bone - * = goal of medicinal use --- <figure> <img src="https://i.imgur.com/9fzJzJz.png" alt="Diagram showing the mechanism of bisphosphonates on osteoclasts, including proton pump, carbonic anhydrase-II, chloride channel-7, and HCl release."> <figcaption>Diagram showing the mechanism of bisphosphonates on osteoclasts, including proton pump, carbonic anhydrase-II, chloride channel-7, and HCl release.</figcaption> </figure> --- <figure> <img src="https://i.imgur.com/8v8V8v8.png" alt="Diagram illustrating the biological action of bisphosphonates, showing mesenchymal stem cells, osteoblasts, osteoid, actively resorbing osteoclasts, and the release of BMP, ILG1, ILG2, which chemo-attract stem cells and promote differentiation into osteoblasts."> <figcaption>Diagram illustrating the biological action of bisphosphonates, showing mesenchymal stem cells, osteoblasts, osteoid, actively resorbing osteoclasts, and the release of BMP, ILG1, ILG2, which chemo-attract stem cells and promote differentiation into osteoblasts.</figcaption> </figure>   #### Mechanisms of Action Bisphosphonates exert their effects through osteoclastic toxicity and altered bone dynamics: - **Osteoclast Impact**: Induction of apoptosis and inhibition of the release of bone induction proteins (BMP, ILG1, ILG2). - **Bone Turnover**: Reduced resorption and overall turnover. - **Mineralization Effects**: - Reduced serum calcium (therapeutic goal). - Hypermineralization, leading to "sclerotic" changes in the lamina dura of alveolar bone. #### Cellular Interaction The biological action involves the inhibition of osteoclasts (affecting proton pumps and HCl release), which disrupts the normal chemo-attraction of mesenchymal stem cells and their differentiation into osteoblasts. Diagram showing the mechanism of bisphosphonates on osteoclasts, including proton pump, carbonic anhydrase-II, chloride channel-7, and HCl release, illustrating how bisphosphonates inhibit bone resorption by disrupting acidification. Diagram illustrating the biological action of bisphosphonates, showing mesenchymal stem cells, osteoblasts, osteoid, actively resorbing osteoclasts, and the release of BMP, ILG1, ILG2, which chemo-attract stem cells and promote differentiation into osteoblasts, highlighting the indirect bone-forming effects. <img>Severe gingival necrosis and discoloration<img>  #### Clinical Manifestations Severe cases may present with gingival necrosis and significant tissue discoloration. A close-up photograph of a patient's mouth showing severe gingival necrosis and discoloration, with dark, sloughed tissue on the lower gums and visible bleeding. The image is taken during a dental examination, with a dental retractor holding the mouth open and a dental mirror reflecting the affected area. <figure> <img src="https://i.imgur.com/5QzJzQl.png" alt="Panoramic X-ray of the jaw showing teeth and a red dot indicating a specific area of interest." /> <figcaption>Panoramic X-ray of the jaw showing teeth and a red dot indicating a specific area of interest.</figcaption> </figure>  #### Radiographic Presentation Panoramic imaging may reveal localized areas of bone density changes or sequestration in the affected jaw regions. Panoramic X-ray of the jaw showing teeth and a red dot indicating a specific area of interest. The image displays the dental structure, including the mandible and maxilla, with a highlighted region suggesting a point of clinical concern. <img src="https://i.imgur.com/5QzZ9dE.png" alt="Microscopic histological section stained with hematoxylin and eosin, showing areas of dense pink tissue interspersed with lighter, cellular regions." />  #### Microscopic Findings Histological examination typically shows dense bone tissue with irregular cellular regions, consistent with the suppression of normal bone remodeling. Microscopic histological section stained with hematoxylin and eosin, showing areas of dense pink tissue interspersed with lighter, cellular regions. The image displays a complex pattern of tissue architecture with varying cellular density and structural organization. ```markdown Position Paper saving faces | changing lives* American Association of Oral and Maxillofacial Surgeons Medication-Related Osteonecrosis of the Jaw—2014 Update **Special Committee on Medication-Related Osteonecrosis of the Jaws:** Salvatore L. Ruggiero, DMD, MD, Clinical Professor, Division of Oral and Maxillofacial Surgery, Stony Brook School of Dental Medicine, Hofstra North Shore-LIJ School of Medicine, New York Center for Orthognathic and Maxillofacial Surgery, Lake Success, NY Thomas B. Dodson, DMD, MPH, Professor and Chair, Associate Dean for Hospital Affairs, University of Washington School of Dentistry, Department of Oral and Maxillofacial Surgery, Seattle, WA John Fantasia, DDS, Chief, Division of Oral Pathology, Hofstra North Shore-LIJ School of Medicine, New Hyde Park, NY Reginald Goodday, Professor, Department of Oral and Maxillofacial Sciences, Dalhousie University, Halifax, NS Tara Aghaloo DDS, MD, PhD, Associate Professor, Oral and Maxillofacial Surgery, Assistant Dean for Clinical Research, UCLA School of Dentistry, Los Angeles, CA **Introduction** The Special Committee recommends changing the nomenclature of bisphosphonate-related osteonecrosis of the jaw (BRONJ). The Special Committee favors the term **medication-related osteonecrosis of the jaw (MRONJ)**. The change is justified to accommodate the growing number of osteonecrosis cases involving the maxilla and mandible associated with other antiresorptive (denosumab) and antiangiogenic therapies. MRONJ adversely affects the quality of life, producing significant morbidity. Strategies for management of patients with, or at risk for, MRONJ were set forth in the American Association of Oral and Maxillofacial Surgeons (AAOMS) updated *Position Paper on Bisphosphonate-Related Osteonecrosis of the Jaws* and approved by the Board of Trustees in 2009.¹ The *Position Paper* was developed by a Special Committee appointed by the Board and composed of clinicians with extensive experience in caring for these patients and basic science researchers. The knowledge base and experience in addressing MRONJ has expanded, necessitating modifications and refinements to the previous *Position Paper*. This Special Committee met in September 2013 to appraise the current literature and revise the guidelines as indicated to reflect current knowledge in this field. This update contains revisions to ``` #### AAOMS Position Paper Update In the 2014 update, the American Association of Oral and Maxillofacial Surgeons (AAOMS) Special Committee recommended a change in nomenclature from Bisphosphonate-Related Osteonecrosis of the Jaw (BRONJ) to **Medication-Related Osteonecrosis of the Jaw (MRONJ)**. - **Rationale**: The change accounts for the increasing number of cases associated with other antiresorptive therapies (such as denosumab) and antiangiogenic therapies. - **Impact**: MRONJ significantly affects quality of life and produces substantial morbidity. - **Guidelines**: The update reflects expanded knowledge and refinements to the 2009 guidelines for managing patients at risk. ```html <table border="1" cellpadding="5" cellspacing="0" style="border-collapse: collapse; width: 100%;"><tr><td style="text-align: left; vertical-align: top;"><strong>Format:</strong> Abstract</td><td style="text-align: right; vertical-align: top;"><strong>Send to</strong> ▼</td></tr></table> <p><em>Oral Surg Oral Med Oral Pathol Oral Radiol. 2015 Aug;120(2):207-26. doi: 10.1016/j.oooo.2015.03.001. Epub 2015 Mar 11.</em></p> <h2>World Workshop on Oral Medicine VI: Controversies regarding dental management of medically complex patients: assessment of current recommendations.</h2> <p><em>Napeñas JJ<sup>1</sup>, Kujan O<sup>2</sup>, Arduino PG<sup>3</sup>, Sukumar S<sup>4</sup>, Galvin S<sup>5</sup>, Baričević M<sup>6</sup>, Costella J<sup>7</sup>, Czerninski R<sup>8</sup>, Peterson DE<sup>9</sup>, Lockhart PB<sup>10</sup>.</em></p> <p>Author information</p> <h3>Abstract</h3> <p><strong>OBJECTIVES:</strong> Current recommendations for safe and effective dental management are less than optimal for some medical conditions because of limited evidence, conflicting conclusions, or both. This review (1) compiled and evaluated dental management recommendations for select medical conditions; (2) summarized recommendations and their assigned levels of evidence; (3) identified areas of conflict, ambiguity, or both; and (4) identified issues that warrant future research, enhanced consensus statements, or both.</p> <p><strong>STUDY DESIGN:</strong> Systematic literature searches were performed for guideline publications, systematic and narrative reviews, and opinion documents containing recommendations for (1) medication-related osteonecrosis of the jaw (MRONJ); (2) cardiovascular diseases (CVDs); (3) prosthetic joints (PJs); and (4) systemic steroid therapy (SST).</p> <p><strong>RESULTS:</strong> The search yielded the following numbers of publications that met the inclusion criteria: MRONJ - 116; CVDs - 54; prosthetic joints - 39; and systemic steroids - 12.</p> <p><strong>CONCLUSIONS:</strong> Very few of the compiled recommendations were assigned or linked to levels of evidence by their authors. Key conclusions include the following: MRONJ-expert recommendations trend toward proceeding with dental treatment with little to no modification in osteoporotic patients on bisphosphonates; CVDs-current recommendations are primarily directed to general surgery and applied to dentistry; PJs-routine antibiotic prophylaxis is not indicated for dental treatment; and SST-steroid supplementation is not indicated for most patients undergoing dental procedures under local anesthesia.</p> <p>Copyright © 2015 Elsevier Inc. All rights reserved.</p> ``` #### World Workshop on Oral Medicine VI A systematic review was conducted to assess dental management recommendations for medically complex patients, specifically focusing on MRONJ, cardiovascular diseases, prosthetic joints, and systemic steroid therapy. - **MRONJ Findings**: Expert recommendations generally trend toward proceeding with dental treatment with little to no modification for osteoporotic patients taking bisphosphonates. - **General Conclusions**: - Routine antibiotic prophylaxis is not indicated for dental treatment in patients with prosthetic joints. - Steroid supplementation is not required for most patients on systemic steroids undergoing procedures under local anesthesia. ```html <table border="1" cellpadding="5" cellspacing="0" style="border-collapse: collapse; width: 100%;"> <thead> <tr> <th colspan="2">Table III. Key recommendations from guideline statements and systematic reviews: dental management of patients receiving bisphosphonates for osteoporosis (none of the publications assigned levels of evidence for any of the recommendations)</th> <th rowspan="2">Level of evidence<sup>*</sup></th> <th rowspan="2">Class of recommendation<sup>†</sup></th> </tr> <tr> <th>Recommendations</th> <th></th> </tr> </thead> <tbody> <tr> <td colspan="2"><strong>In all patients, clinicians should discuss:</strong></td> <td></td> <td></td> </tr> <tr> <td>• Importance of maintaining good oral hygiene<sup>19</sup></td> <td></td> <td>NA</td> <td></td> </tr> <tr> <td>• Lifestyle changes, such as smoking cessation for those at high risk for MRONJ<sup>19</sup></td> <td></td> <td>NA</td> <td></td> </tr> <tr> <td>• Very rare occurrence of MRONJ<sup>19</sup></td> <td></td> <td>NA</td> <td></td> </tr> <tr> <td colspan="2"><strong>Risk assessment and treatment planning - Potential risk factors for MRONJ:</strong></td> <td></td> <td></td> </tr> <tr> <td colspan="2"><strong>Oral risk factors:</strong></td> <td></td> <td></td> </tr> <tr> <td>• Recent dentoalveolar trauma<sup>91-93</sup></td> <td></td> <td>NA</td> <td></td> </tr> <tr> <td>• Dental extraction<sup>90,91</sup></td> <td></td> <td>NA</td> <td></td> </tr> <tr> <td>• Dentoalveolar surgery<sup>91</sup></td> <td></td> <td>NA</td> <td></td> </tr> <tr> <td>• Poor oral hygiene<sup>91</sup></td> <td></td> <td>NA</td> <td></td> </tr> <tr> <td>• Oral infections<sup>91</sup></td> <td></td> <td>NA</td> <td></td> </tr> <tr> <td>• Periodontal disease<sup>91</sup></td> <td></td> <td>NA</td> <td></td> </tr> <tr> <td colspan="2"><strong>Systemic risk factors:</strong></td> <td></td> <td></td> </tr> <tr> <td>• Greater frequency of administration<sup>91</sup></td> <td></td> <td>NA</td> <td></td> </tr> <tr> <td>• Larger BP dose<sup>91</sup></td> <td></td> <td>NA</td> <td></td> </tr> <tr> <td>• Longer treatment regimens<sup>91</sup></td> <td></td> <td>NA</td> <td></td> </tr> <tr> <td>• Radiation therapy<sup>91</sup></td> <td></td> <td>NA</td> <td></td> </tr> <tr> <td>• Infectious disease<sup>91</sup></td> <td></td> <td>NA</td> <td></td> </tr> <tr> <td>• Concomitant therapy with corticosteroids<sup>90,92</sup></td> <td></td> <td>NA</td> <td></td> </tr> <tr> <td>• Compromised immune status or immunodeficiency<sup>92</sup></td> <td></td> <td>NA</td> <td></td> </tr> <tr> <td>• Advanced age<sup>92</sup></td> <td></td> <td>NA</td> <td></td> </tr> <tr> <td>• Chronic diseases<sup>92</sup></td> <td></td> <td>NA</td> <td></td> </tr> </tbody> </table> ```  #### Management Recommendations for Osteoporotic Patients **General Patient Communication:** - Emphasize the importance of maintaining excellent oral hygiene. - Discuss lifestyle modifications, such as smoking cessation. - Inform patients of the very rare occurrence of MRONJ. **Risk Factors for MRONJ:** - **Oral Risk Factors**: - Recent dentoalveolar trauma - Dental extractions or surgery - Poor oral hygiene and oral infections - Periodontal disease - **Systemic Risk Factors**: - High frequency of drug administration and larger doses - Longer duration of treatment regimens - History of radiation therapy - Concomitant corticosteroid therapy - Immunodeficiency or compromised immune status - Advanced age and chronic systemic diseases Table III presenting key recommendations from guideline statements and systematic reviews regarding dental management of patients receiving bisphosphonates for osteoporosis. The table lists recommendations under categories such as patient discussion, risk assessment, and treatment planning, with corresponding levels of evidence (NA) and classes of recommendation. It includes oral risk factors like recent dentoalveolar trauma and dental extraction, and systemic risk factors such as greater frequency of administration and longer treatment regimens. Central Giant Cell Granuloma Central Giant Cell Granuloma is a localized benign, but sometimes aggressive, osteolytic proliferation of the jaws. <figure> <img src="https://i.imgur.com/placeholder.jpg" alt="Dental X-ray showing teeth with a red dot highlighting a specific area."> </figure>  Radiographic examination of the affected dental arches often reveals localized areas of bone alteration, frequently appearing as radiolucent lesions in the mandible or maxilla. Dental X-ray showing teeth with a red dot highlighting a specific area. The image is a grayscale radiograph with a red marker indicating a point of interest, likely for diagnostic purposes. The surrounding text context suggests this is part of a medical or dental report.  The lesion is characterized by its unique cellular composition and its tendency to occur in specific demographic groups, often presenting as an asymptomatic swelling. A black and white radiographic image showing a medical scan, likely an X-ray of a body part, with a red dot highlighting a specific area of interest. The image appears to be a diagnostic medical photograph, possibly related to a surgical or anatomical study.  Clinical evaluation is essential to distinguish this reactive process from other more aggressive neoplastic conditions of the bone. Microscopic image of tissue showing a dense population of cells with purple and pink staining, likely indicating a histological section. The image displays a high cellular density with scattered small nuclei and some larger cells, possibly representing a pathological condition such as a tumor or inflammatory infiltrate. A red dot is visible near the center, possibly highlighting a specific area of interest.  Management strategies vary based on the clinical behavior of the lesion, ranging from conservative surgical intervention to medical therapies. microscopic view of tissue stained with hematoxylin and eosin, showing cellular structures with purple nuclei and pink cytoplasm, likely from a histological sample. the image includes a red dot indicating a specific area of interest, possibly a tumor or abnormal cell cluster. # Central Giant Cell Granuloma - **Etiology**: non-neoplastic – reactive lesion - **Age**: wide range (60% < 30 years of age) - **Gender**: female > male - **Site**: anterior mandible (70%) - **Symptoms**: painless expansion - **Radiograph**: - unilocular to multilocular radiolucency - 0.5 – 10.0 cm #### Clinical Characteristics - **Etiology**: Non-neoplastic – reactive lesion - **Age**: Wide range (60% occur in patients under 30 years of age) - **Gender**: Higher prevalence in females than males - **Site**: Predominantly found in the anterior mandible (70% of cases) - **Symptoms**: Typically presents as a painless expansion of the bone #### Radiographic Presentation - Appearance ranges from unilocular to multilocular radiolucency - Size varies significantly, typically between 0.5 cm and 10.0 cm # Central Giant Cell Granuloma Histology: - Multinucleated giant cells - Spindled stroma - Erythrocyte extravasation - Hemosiderin deposits - Fibrosis - Osteoid formation #### Microscopic Findings - Presence of multinucleated giant cells - Spindled mesenchymal stroma - Erythrocyte extravasation (bleeding into the tissue) - Hemosiderin deposits - Areas of fibrosis - Evidence of osteoid formation # Central Giant Cell Granuloma - **Treatment:** - curettage - intra-lesional steroids - calcitonin - interferon alpha 2a - resection - **Prognosis:** - non-aggressive - aggressive - recurrence (15-20%) #### Treatment Modalities - Surgical curettage - Intra-lesional steroid injections - Calcitonin therapy - Interferon alpha 2a - Surgical resection for more extensive cases #### Prognosis and Behavior - **Clinical Behavior**: Categorized as either non-aggressive or aggressive - **Recurrence**: Observed in approximately 15-20% of cases ```markdown Central Giant Cell Lesion Differential Diagnosis: - Central giant cell granuloma - Brown tumor – hyperparathyroidism - Aneurysmal bone cyst - Cherubism - Giant cell tumor - Benign fibro-osseous lesion ```  #### Differential Diagnosis for Giant Cell Lesions - Central giant cell granuloma - Brown tumor associated with hyperparathyroidism - Aneurysmal bone cyst - Cherubism - Giant cell tumor - Benign fibro-osseous lesion A bulleted list under the heading "Central Giant Cell Lesion Differential Diagnosis" outlines various conditions including central giant cell granuloma, brown tumor - hyperparathyroidism, aneurysmal bone cyst, cherubism, giant cell tumor, and benign fibro-osseous lesion. The text is presented in yellow font on a dark purple background. ```markdown Hyperparathyroidism Brown tumour (osteitis fibrosa cystica) 58 ```  #### Hyperparathyroidism and Bone Involvement - **Brown Tumor**: Also known as osteitis fibrosa cystica, this lesion is a bone manifestation of hyperparathyroidism and is histologically indistinguishable from central giant cell granuloma. The image contains a small red circular figure, which appears to be a graphical representation or marker related to the text 'Brown tumour (osteitis fibrosa cystica)'. This figure is likely a visual aid to highlight a specific point in the context of hyperparathyroidism. <figure> <img src="https://i.imgur.com/1234567.png" alt="Five dental X-ray images labeled A through E, showing different stages or views of teeth and jaw structures. Image A has a red circle highlighting a specific area. Image E shows teeth with orthodontic brackets."> </figure>  Radiographic series illustrating various presentations of giant cell-related bone lesions, including those affecting the alveolar bone and those occurring in patients undergoing orthodontic treatment. Five dental X-ray images labeled A through E, showing different stages or views of teeth and jaw structures. Image A has a red circle highlighting a specific area, and Image E shows teeth with orthodontic brackets. ```markdown Cysts of the jaws ``` ```html <table> <tr> <td>62</td> </tr> </table> ```  Cysts of the jaws represent a significant category of oral and maxillofacial pathology, often requiring detailed clinical and radiographic assessment for proper diagnosis and management. The image contains a table with the number '62' displayed, which appears to be a page number. The table is small and located at the bottom right corner of the page. Cyst Lining Cyst Wall  #### Structural Components of a Cyst - **Cyst Lining**: The inner epithelial layer that characterizes the type of cyst and regulates the passage of fluids. - **Cyst Wall**: The outer connective tissue capsule that provides structural integrity and contains the blood supply. A diagram illustrating the structure of a cyst, showing the cyst lining and cyst wall. The diagram highlights different layers and components within the cyst, with labels pointing to specific areas such as the cyst lining and cyst wall. # Aetiology and pathogenesis - Epithelial proliferation - Hydrostatic or osmotic factors - Keratin formation - Bone resorbing factors (prostaglandins, collagenase) #### Mechanisms of Development The growth and expansion of jaw cysts involve several integrated processes: - **Epithelial proliferation**: The active multiplication of the epithelial lining. - **Hydrostatic or osmotic factors**: Pressure gradients that contribute to the expansion of the cyst lumen. - **Keratin formation**: Accumulation of keratinized debris in specific cyst types. - **Bone resorbing factors**: The release of substances such as prostaglandins and collagenase that facilitate bone destruction to accommodate cyst growth. # Clinical features - Noticeable swelling - Discharge into the mouth - Pain due to secondary infection #### Presentation and Symptoms Cysts of the jaws may present with various clinical signs, including: - Noticeable swelling of the jaw or soft tissues. - Discharge of cystic contents into the oral cavity. - Pain, typically occurring as a result of secondary infection. ```markdown CYSTS ├── EPITHELIAL │ ├── ODONTogenic │ │ ├── INFLAMMATORY │ │ │ ├── Radicular │ │ │ ├── Apical │ │ │ ├── Lateral │ │ │ └── Residual │ │ └── PARADENTAL │ │ └── Paradental │ │ └── DEVELOPMENTAL │ │ └── Dentigerous │ │ └── Eruption │ │ └── Odontogenic keratocyst │ │ └── Lateral periodontal │ │ └── Gingival - infants │ │ └── Gingival - adults │ └── NON-ODONTogenic │ └── Nasopalatine duct │ └── Nasolabial └── NON-EPITHELIAL (PRIMARY BONE) └── Aneurysmal └── Solitary ```  #### Classification Hierarchy 1. **Epithelial Cysts** - **Odontogenic Cysts** - **Inflammatory** - Radicular (Apical, Lateral, Residual) - **Paradental** - Paradental cyst - **Developmental** - Dentigerous - Eruption - Odontogenic keratocyst - Lateral periodontal - Gingival (infants and adults) - **Non-Odontogenic Cysts** - Nasopalatine duct - Nasolabial 2. **Non-Epithelial (Primary Bone) Cysts** - Aneurysmal bone cyst - Solitary bone cyst A hierarchical classification diagram of cysts, starting with 'CYSTS' at the top, branching into 'EPITHELIAL' and 'NON-EPITHELIAL (PRIMARY BONE)'. The 'EPITHELIAL' category further divides into 'ODONTGENIC' and 'NON-ODONTGENIC', with 'ODONTGENIC' subdivided into 'INFLAMMATORY' and 'DEVELOPMENTAL'. The diagram lists specific cyst types such as radicular, apical, lateral, residual, paradental, dentigerous, eruption, odontogenic keratocyst, lateral periodontal, gingival (infants and adults), nasopalatine duct, nasolabial, aneurysmal, and solitary. ```html <table border="1" cellpadding="5" cellspacing="0" style="border-collapse: collapse; width: 100%; font-family: Arial, sans-serif; font-size: 14pt; color: #ffffff; background-color: #5a0030;"> <thead> <tr> <th style="background-color: #5a0030; color: #ffffff; text-align: left; font-weight: bold;">Odontogenic (90%)</th> <th style="background-color: #5a0030; color: #ffffff; text-align: left; font-weight: bold;">Non-odontogenic (10%)</th> </tr> </thead> <tbody> <tr> <td style="background-color: #5a0030; color: #ffffff; text-align: left;"><strong>Radicular</strong> 60-75%</td> <td style="background-color: #5a0030; color: #ffffff; text-align: left;">Nasopalatine 5-10%</td> </tr> <tr> <td style="background-color: #5a0030; color: #ffffff; text-align: left;"><strong>Dentigerous</strong> 10-15%</td> <td style="background-color: #5a0030; color: #ffffff; text-align: left;">Others 1%</td> </tr> <tr> <td style="background-color: #5a0030; color: #ffffff; text-align: left;">Keratocyst 5-10%</td> <td style="background-color: #5a0030; color: #ffffff; text-align: left;"></td> </tr> <tr> <td style="background-color: #5a0030; color: #ffffff; text-align: left;"><strong>Paradental</strong> 3-5%</td> <td style="background-color: #5a0030; color: #ffffff; text-align: left;"></td> </tr> <tr> <td style="background-color: #5a0030; color: #ffffff; text-align: left;">Gingival < 1%</td> <td style="background-color: #5a0030; color: #ffffff; text-align: left;"></td> </tr> <tr> <td style="background-color: #5a0030; color: #ffffff; text-align: left;">Lateral periodontal < 1%</td> <td style="background-color: #5a0030; color: #ffffff; text-align: left;"></td> </tr> </tbody> </table> ```  #### Relative Incidence and Frequency **Odontogenic Cysts (90% of total)** - **Radicular**: 60–75% - **Dentigerous**: 10–15% - **Keratocyst**: 5–10% - **Paradental**: 3–5% - **Gingival**: < 1% - **Lateral periodontal**: < 1% **Non-odontogenic Cysts (10% of total)** - **Nasopalatine**: 5–10% - **Others**: 1% A table titled 'Relative frequency' comparing the prevalence of odontogenic (90%) and non-odontogenic (10%) conditions. The table lists specific types under each category with their corresponding frequency percentages, such as Radicular (60-75%) and Nasopalatine (5-10%). ```markdown # Inflammatory Odontogenic Cysts - Radicular (dental) cyst - periapical - lateral - residual - Paradental cyst ```  #### Classification of Inflammatory Odontogenic Cysts - Radicular (dental) cyst - Periapical - Lateral - Residual - Paradental cyst A hierarchical diagram showing the classification of radicular (dental) cysts, with branches for periapical, lateral, and residual types, all stemming from the main category. ```markdown # RADICULAR CYSTS ## Clinical Features - 60-75% of all jaw cysts (Most Common) - Peak in 4th and 5th decades - Non-vital tooth - Upper lateral incisor - most common tooth - Rare in deciduous teeth - Asymptomatic or expansion → springy → egg-shell crackling → fluctuation - Infection → pain ``` #### Clinical Features - **Prevalence:** Accounts for 60-75% of all jaw cysts (the most common type). - **Demographics:** Peak incidence occurs in the 4th and 5th decades of life. - **Associated Tooth:** - Always associated with a non-vital tooth. - The upper lateral incisor is the most commonly affected tooth. - Rare in deciduous teeth. - **Symptoms and Progression:** - Often asymptomatic. - Expansion can lead to a "springy" sensation, followed by egg-shell crackling, and eventually fluctuation. - Secondary infection will result in pain. # Radicular Cyst <img src="https://i.imgur.com/9zKfZQl.png" alt="Three diagrams illustrating different types of radicular cysts: Apical, Lateral, and Residual." /> - **Apical**: A cyst located at the root apex of the tooth. - **Lateral**: A cyst developing on the side of the root. - **Residual**: A cyst that remains after the removal of the tooth, often indicated by a red dot in the diagram.  #### Anatomical Variations - **Apical:** A cyst located at the root apex of the tooth. - **Lateral:** A cyst developing on the side of the root. - **Residual:** A cyst that remains in the jaw after the removal of the associated tooth. Three diagrams illustrating different types of radicular cysts: Apical, Lateral, and Residual. The Apical cyst is located at the root apex of the tooth, the Lateral cyst develops on the side of the root, and the Residual cyst remains after the removal of the tooth, indicated by a red dot in the diagram. ```html <table> <tr> <td> <img src="https://i.imgur.com/5JZzQ.png" alt="Close-up view of oral cavity showing a radicular cyst near the root of a tooth, indicated by a red dot."> </td> <td> <p><strong>Radicu lar Cyst</strong></p> </td> </tr> </table> ```  Radicular cysts typically present near the root of the involved tooth. Close-up view of the oral cavity showing a radicular cyst near the root of a tooth, indicated by a red dot. The image displays the upper teeth and surrounding gum tissue with a visible lesion. ```html <table border="1" cellpadding="5" cellspacing="0" style="border-collapse: collapse; width: 100%;"><tr><td style="text-align: center; font-size: 24pt; color: #FFD700; font-weight: bold;">Radicul<br>Cyst</td></tr></table> ``` ```html <img src="https://i.imgur.com/1234567.jpg" alt="Radicul Cyst" /> ``` ```html <img src="https://i.imgur.com/7654321.jpg" alt="Radicul Cyst" /> ```   Visual documentation of radicular cyst presentations. Close-up photograph of a radicular cyst in the oral cavity, showing a swollen gum area with visible teeth and surrounding tissue inflammation. Another photograph of a radicular cyst, highlighting the affected area on the palate with a red dot marking the cyst location, surrounded by inflamed tissue. ```html <table> <tr> <td>Shape:</td> <td>Monolocular</td> </tr> <tr> <td>Outline:</td> <td>Well defined</td> </tr> <tr> <td></td> <td>Well corticated</td> </tr> <tr> <td>Radiodensity:</td> <td>Uniformly radiolucent</td> </tr> </table> ``` ```html <img src="https://i.imgur.com/7XQzJzL.png" alt="Radicuclar cyst X-ray image with annotations"/> ``` ```markdown Radicuclar cyst ```   #### Radiographic Characteristics - **Shape:** Monolocular - **Outline:** Well defined and well corticated - **Radiodensity:** Uniformly radiolucent A radiographic image showing a radicular cyst, characterized by a well-defined, monolocular lesion with a well-corticated outline and uniformly radiolucent radiodensity. The cyst is located at the apex of a tooth, indicated by a red dot. A table listing the characteristics of a radicular cyst, including its shape as monolocular, outline as well-defined and well-corticated, and radiodensity as uniformly radiolucent. ```html <table> <tr> <td><img src="https://i.imgur.com/9ZQJz.png" alt="Radicularr cyst"></td> <td><img src="https://i.imgur.com/9ZQJz.png" alt="Radicularr cyst"></td> </tr> <tr> <td colspan="2"><strong>Radicularr cyst</strong></td> </tr> <tr> <td colspan="2"><strong>Shape:</strong> Monolocular</td> </tr> <tr> <td colspan="2"><strong>Outline:</strong> Well defined<br>Well corticated</td> </tr> <tr> <td colspan="2"><strong>Radiodensity:</strong> Uniformly radiolucent</td> </tr> </table> ```    #### Radiographic Features Summary - **Shape:** Monolocular - **Outline:** Well defined and well corticated - **Radiodensity:** Uniformly radiolucent A radiographic image showing a radicular cyst, characterized by a well-defined, monolocular lesion with a uniformly radiolucent appearance. The cyst is located at the apex of a tooth, with surrounding bone structure visible. A second radiographic image displaying a radicular cyst, highlighting its monolocular shape, well-defined outline, and well-corticated borders. The lesion appears uniformly radiolucent, consistent with the description of a radicular cyst. A table summarizing the characteristics of a radicular cyst, including its shape (monolocular), outline (well-defined, well-corticated), and radiodensity (uniformly radiolucent). The table is presented in yellow text on a dark background. ```html <table> <tr> <td> <img src="https://i.imgur.com/1.png" alt="Radiculare cyst X-ray image with red dot highlighting a specific area"/> </td> <td> <img src="https://i.imgur.com/2.png" alt="Radiculare cyst X-ray image showing a large radiolucent lesion"/> </td> </tr> <tr> <td> <img src="https://i.imgur.com/3.png" alt="Radiculare cyst X-ray image showing a large radiolucent lesion with multiple teeth"/> </td> <td> <p><strong>Shape:</strong> Monolocular</p> <p><strong>Outline:</strong> Well defined<br>Well corticated</p> <p><strong>Radiodensity:</strong> Uniformly radiolucent</p> </td> </tr> </table> <p><em>Radicular cyst</em></p> ```     #### Radiographic Presentation - **Shape:** Monolocular - **Outline:** Well defined and well corticated - **Radiodensity:** Uniformly radiolucent Radiographs often show a large radiolucent lesion involving one or multiple teeth. X-ray image showing a radicular cyst with a red dot highlighting a specific area, indicating the lesion's location near the root of a tooth. X-ray image displaying a large radiolucent lesion associated with the root of a tooth, characteristic of a radicular cyst. X-ray image of a radicular cyst showing a large radiolucent lesion with multiple teeth, illustrating the cyst's impact on surrounding dental structures. Text-based table summarizing the characteristics of a radicular cyst, including its monolocular shape, well-defined and well-corticated outline, and uniformly radiolucent radiodensity.  A dental X-ray image showing a panoramic view of the jaw, including teeth, roots, and surrounding bone structure. The image highlights the presence of dental implants and fillings, with a noticeable dark area on the left side indicating a potential abnormality or lesion. **Radiculär Cyst** <img src="https://i.imgur.com/1234567.jpg" alt="Radiculär Cyst">   Clinical imaging of a radicular cyst. A dental radiograph showing a radicular cyst, indicated by a red dot, located at the apex of a tooth root with a dark, circular lesion suggesting bone loss. A macroscopic photograph of a removed tooth with a radicular cyst, displaying a pale, irregular mass attached to the root, illustrating the physical manifestation of the cyst. **Radicul**ar Cyst <img src="https://i.imgur.com/1234567.jpg" alt="Radicul**ar Cyst" /> <img src="https://i.imgur.com/7654321.jpg" alt="Radicul**ar Cyst" />   Clinical imaging of a radicular cyst. A photo showing a radicular cyst attached to a tooth, with a darkened area indicating the cyst's location and a red dot highlighting a specific point of interest. A photo displaying a radicular cyst that has been split open, revealing its internal structure with a white center and brownish outer layer.   X-ray image showing a dental scan with a highlighted area indicating a dental implant or surgical site, with a white line pointing to the lower jaw region. Close-up photo of a surgical site with visible sutures, red wound dressing, and a small red dot indicating a specific point of interest on the skin. ```markdown # RADICULAR CYST ## Pathogenesis ### INITIATION - Cell rest of Malassez activated - Activated by products of necrotic pulp ### CYST FORMATION - Degeneration and death of central cells leads to cavitation ```  #### Initiation and Formation 1. **Initiation** - Cell rests of Malassez are activated. - Activation is triggered by products of necrotic pulp. 2. **Cyst Formation** - Degeneration and death of central cells leads to cavitation. Two microscopic images showing histological sections of a radicular cyst. The top image displays a cross-section with cellular structures and a dark boundary, while the bottom image shows a magnified view of tissue with cellular degeneration, illustrating the pathogenesis stages described in the text. # RADICULAR CYST ## Pathogenesis - **CYST ENLARGEMENT** - increased osmolality due to breakdown products becoming smaller and more osmotically active - wall acts as semi-permeable membrane <img src="https://i.imgur.com/8Qz7X7l.png" alt="Illustration of radicular cyst enlargement stages"/>  #### Cyst Enlargement - **Osmotic Pressure:** Enlargement is driven by increased osmolality. This occurs because breakdown products become smaller and more osmotically active. - **Mechanism:** The cyst wall acts as a semi-permeable membrane. A diagram illustrating the stages of radicular cyst enlargement, showing a tooth with a cyst that progressively increases in size, accompanied by text explaining increased osmolality and the semi-permeable nature of the cyst wall. ```markdown # RADICULAR CYST ## Cysts Contents - Breakdown products of cells - Serum proteins - Water and electrolytes - Cholesterol crystals <img src="https://i.imgur.com/7QZJZ.png" alt="Microscopic images of radicular cyst contents"/> ```  #### Cystic Contents - Breakdown products of cells - Serum proteins - Water and electrolytes - Cholesterol crystals Microscopic images showing the contents of a radicular cyst, including cholesterol crystals and other cellular debris. The top image displays flat, crystalline structures, while the bottom image shows a larger, irregularly shaped crystal with smaller particles nearby. ```markdown # RADICULAR CYST ## Histopathology - Periapical granuloma with epithelial proliferation - polymorphs in epithelium - Cyst lined by irregular, non-keratinised stratified squamous epithelium - Foam cells, lymphocytes, plasma cells, cholesterol clefts, surrounding fibrosis - Lining becomes thinner and less inflamed - 10% contain hyaline (Rushton) bodies ``` #### Microscopic Features - **Epithelium:** - The cyst is lined by irregular, non-keratinized stratified squamous epithelium. - Epithelial proliferation is often seen in association with periapical granuloma. - Polymorphs may be present within the epithelium. - **Cyst Wall and Lining:** - The lining may become thinner and less inflamed over time. - Approximately 10% of cases contain hyaline (Rushton) bodies. - **Connective Tissue Features:** - Presence of foam cells, lymphocytes, and plasma cells. - Cholesterol clefts and surrounding fibrosis are common.  microscopic image of a tissue section stained with hematoxylin and eosin, showing a circular structure with a central lumen surrounded by dense cellular material, likely a glandular or ductal formation, with a red dot indicating a specific point of interest.  A histological slide showing a tissue section stained with hematoxylin and eosin, displaying pink and purple hues. The image reveals cellular structures with a prominent branching network of white lines, likely representing blood vessels or ducts, and a red dot indicating a specific point of interest within the tissue.   Microscopic image of tissue showing glandular structures with varying shapes and sizes, stained in pink and purple, likely representing a histological section of epithelial tissue. Microscopic image of tissue with glandular formations and surrounding stroma, stained in pink and purple, highlighting cellular architecture and potential pathological features.  microscopic view of a tissue section stained in pink and white, showing cellular structures with a red dot highlighting a specific area of interest.  The image displays three dental X-ray images side by side, showing a tooth with a dental implant and surrounding bone structure. The leftmost image shows a standard X-ray of the tooth and implant, the middle image highlights the implant with a white outline, and the rightmost image shows a panoramic view with a red dot indicating a specific area of interest, possibly a lesion or abnormality.    A panoramic dental X-ray showing the jaw and teeth, with a highlighted lesion in the mandible indicated by a red dot. A close-up dental X-ray image showing a large radiolucent lesion in the mandible, with adjacent teeth and bone structures visible. Another close-up dental X-ray image of the mandible, displaying a large radiolucent lesion with surrounding bone texture and a radiographic marker. ```markdown # CLASSIFICATION ## Cysts of the jaws **EPITHELIAL CYSTS** - **Odontogenic** - Inflammatory - Developmental - **Non-odontogenic** **NON-EPITHELIAL CYSTS (Primary Bone Cysts)** - Dentigerous cyst - Eruption cyst - Odontogenic keratocyst (primordial cyst) - Gingival-infants - Gingival-adults - Lateral periodontal ```  #### Classification of Jaw Cysts **Epithelial Cysts** - **Odontogenic** - Inflammatory - Developmental - Dentigerous cyst - Eruption cyst - Odontogenic keratocyst (primordial cyst) - Gingival cyst of infants - Gingival cyst of adults - Lateral periodontal cyst - **Non-odontogenic** **Non-Epithelial Cysts (Primary Bone Cysts)** A classification diagram of cysts of the jaws, showing a hierarchical structure with two main branches: Epithelial Cysts and Non-Epithelial Cysts (Primary Bone Cysts). The Epithelial Cysts branch further into Odontogenic (subdivided into Inflammatory and Developmental) and Non-odontogenic. The Non-Epithelial Cysts branch lists specific types including Dentigerous cyst, Eruption cyst, Odontogenic keratocyst, Gingival-infants, Gingival-adults, and Lateral periodontal. # DENTIGEROUS CYST - Cyst enclosing crown of an unerupted tooth - Attached to cemento-enamel junction - Follicular cyst #### Definition and Terminology - A cyst enclosing the crown of an unerupted tooth. - Attached to the cemento-enamel junction. - Also known as a follicular cyst. # PATHOGENESIS - Intrafollicular fluid accumulates between REE and enamel - Pressure of tooth on impacted follicle - Obstruction of venous outflow - Serum transudation - Exudation #### Pathogenesis Mechanisms - Intrafollicular fluid accumulates between the reduced enamel epithelium (REE) and the enamel. - Pressure of the tooth on the impacted follicle leads to: - Obstruction of venous outflow - Serum transudation - Exudation # CLINICAL FEATURES - 10-15% of cyst - Children and young adults - Permanent teeth - Upper canine and lower 3rd molar – teeth likely to be impacted - M:F 1.6:1 - Painless enlargement – missing tooth - Tilting of tooth - Root resorption #### Clinical Presentation - Accounts for 10-15% of all jaw cysts. - Primarily affects children and young adults. - Associated with permanent teeth. - Most common sites involve teeth likely to be impacted: - Upper canine - Lower 3rd molar - Gender distribution: M:F ratio of 1.6:1. - Clinical signs include: - Painless enlargement - Missing tooth - Tilting of adjacent teeth - Root resorption **Dentigerous cyst** <img src="https://i.imgur.com/1.png" alt="Dentigerous cyst X-ray images showing radiolucency surrounding unerupted teeth"/> The image displays three X-ray views illustrating dentigerous cysts, which are radiolucent lesions associated with unerupted teeth. The top image shows a cyst adjacent to the roots of multiple teeth. The bottom-left image highlights a cyst with a tooth crown visible within the lesion, marked by a red dot. The bottom-right image presents a close-up view of a cyst with an unerupted tooth crown inside.    #### Radiographic Presentation Radiographic examination typically reveals radiolucent lesions associated with unerupted teeth. Key features include: - Radiolucency surrounding the crown of an unerupted tooth. - Potential displacement of adjacent roots. - Clear demarcation of the lesion around the tooth crown. A panoramic X-ray image showing a dentigerous cyst surrounding an unerupted tooth, with the lesion appearing as a radiolucent area adjacent to the tooth's crown. A close-up X-ray view of a dentigerous cyst with an unerupted tooth crown visible within the radiolucent lesion, marked by a red dot indicating the cyst's location. An X-ray image displaying a dentigerous cyst associated with an unerupted tooth, showing the cystic lesion as a well-defined radiolucent area around the tooth crown.   A black and white dental X-ray showing a lateral view of the jaw and teeth, with a highlighted area indicating a specific region of interest. A close-up dental X-ray with white arrows pointing to specific anatomical features and a red dot marking a particular point of interest, likely indicating a lesion or abnormality.  A close-up photograph of a tooth with a root canal procedure, showing the tooth structure with exposed root canals and surrounding tissue. The image highlights the dental anatomy, including the crown and roots, with a red dot indicating a specific point of interest, likely related to the treatment area. # PATHOLOGY - Clear yellow fluid – cholesterol - Purulent if infected - Lined by flattened, non-keratinised stratified squamous epithelium - Continuous with reduced enamel epithelium - Mucous and ciliated columnar metaplasia - Fibrous wall with variable inflammation #### Gross and Microscopic Features - **Cyst Contents**: Clear yellow fluid containing cholesterol; may become purulent if infected. - **Epithelial Lining**: - Lined by flattened, non-keratinised stratified squamous epithelium. - The lining is continuous with the reduced enamel epithelium. - May exhibit mucous and ciliated columnar metaplasia. - **Cyst Wall**: Composed of a fibrous wall with variable degrees of inflammation. <img src="dentigerous_cyst_image.png" alt="Dentigerous cyst histological section showing a cystic structure with a tooth embedded within it, stained with hematoxylin and eosin. A red dot highlights a specific area of interest on the cyst wall." /> Dentigerous cyst  #### Histological Characteristics Histological sections typically demonstrate a cystic structure with a tooth crown embedded within the lumen. The cyst wall is attached at the cemento-enamel junction, showing the relationship between the dental follicle and the developing tooth. Histological section of a dentigerous cyst showing a cystic structure with a tooth embedded within it, stained with hematoxylin and eosin. A red dot highlights a specific area of interest on the cyst wall.  microscopic image showing a histological section with pink-stained tissue and a distinct purple-stained epithelial layer along the right edge, likely representing a tissue sample under magnification. ```html <table border="0" cellpadding="0" cellspacing="0"> <tr> <td><img src="https://via.placeholder.com/150?text=Figure+of+Eruption+cyst" alt="Figure of Eruption cyst"/></td> </tr> </table> ```  The image displays a figure labeled 'Eruption cyst' with a small red dot centered below the text, indicating the location of the eruption cyst on a dark maroon background. The figure appears to be a simple diagram or illustration used for medical or anatomical representation. # ERUPTION CYST - Extra-alveolar dentigerous cyst - Deciduous tooth or permanent molar - Fluctuant bluish swelling - Haemorrhage into cyst common - Most spontaneously resolve - Marsupialise <img src="https://i.imgur.com/7YjXz9l.jpg" alt="Image of eruption cyst in mouth with arrow pointing to the cyst">  #### Clinical Characteristics and Management - Considered an extra-alveolar dentigerous cyst. - Associated with deciduous teeth or permanent molars. - Presents as a fluctuant, often bluish swelling on the alveolar ridge. - Hemorrhage into the cyst is common (sometimes called an eruption hematoma). - **Management**: - Most cases resolve spontaneously as the tooth erupts. - Surgical intervention via marsupialization may be required if eruption is impeded. A clinical photograph showing an eruption cyst in the mouth, characterized by a fluctuant bluish swelling on the gingiva near a deciduous tooth or permanent molar. The image includes a green arrow pointing to the cyst, highlighting its location and appearance as described in the surrounding text.   Close-up photo of a dental lesion on the gingiva, showing a pink, raised mass adjacent to a tooth with visible enamel and surrounding tissue. Photo of an oral cavity with a dark, possibly necrotic lesion on the gum, surrounded by inflamed tissue and teeth, with a dental instrument visible.  A histological micrograph showing a tissue section stained with hematoxylin and eosin, displaying epithelial cells at the top with a distinct layer of nuclei, transitioning to a more densely packed connective tissue below. A red dot highlights a specific area of interest within the tissue. # ODONTOGENIC KERATOCYST ## CLINICAL - 5-10% of all jaw cysts - SITE - 70-80% mandible - 50% angle/ramus - Often asymptomatic - M>F - Swelling, discharge, pain, pathological fracture, tooth displacement, rarely buccal expansion - 10% multiple - High recurrence rate #### Clinical Presentation - Comprises 5-10% of all jaw cysts - Gender predilection: Males > Females - Often asymptomatic - Common symptoms include: - Swelling - Discharge - Pain - Pathological fracture - Tooth displacement - Rarely buccal expansion - 10% of cases present as multiple cysts - Characterized by a high recurrence rate #### Common Sites - 70-80% occur in the mandible - 50% are located in the angle or ramus PATHOGENESIS * Derived from the dental lamina or it’s remnants - cell rests of Serres * Originate from enamel organ (tooth primordium) of a tooth before hard tissues develop: * normal tooth * supernumerary  #### Pathogenesis - Derived from the dental lamina or its remnants (cell rests of Serres) - Originate from the enamel organ (tooth primordium) of a tooth before hard tissues develop, involving: - Normal teeth - Supernumerary teeth A diagram illustrating the pathogenesis of dental structures, showing the dental lamina, enamel organ, and surrounding tissues. It labels key components such as the dental lamina (L), enamel organ (E), dental papilla (De), and the labial and lingual aspects of the developing tooth, with red dots indicating cell rests of Serres. ```markdown # RADIOLOGICAL APPEARANCE - Well demarcated radiolucency - Pseudolocular or multilocular, often with scalloped periphery - Root or tooth displacement ``` #### Radiographic Features - Well-demarcated radiolucency - Appearance may be pseudolocular or multilocular - Often exhibits a scalloped periphery - Associated with root or tooth displacement    X-ray image showing a lateral view of the skull with visible teeth and jaw structure, highlighting dental alignment and bone density. Close-up X-ray image of the jaw and teeth, focusing on the dental arch and surrounding bone structure, with a clear view of the molars and premolars. Panoramic X-ray image of the jaw, displaying the entire dental arch, including teeth, roots, and surrounding bone, with a red dot indicating a specific area of interest. ```html <table border="1" cellpadding="5" cellspacing="0" style="border-collapse: collapse; width: 100%;"><tr><td><img src="https://i.imgur.com/4z9Q6Vr.png" alt="Odontogenic keratocyst" /></td></tr><tr><td><i>Odontogenic keratocyst</i></td></tr></table> ```  A panoramic dental X-ray showing the jaw and teeth, with a highlighted area indicating an odontogenic keratocyst. The image includes a red marker pointing to the cyst location on the left side of the jaw. ```html <table> <tr> <td><img src="https://i.imgur.com/6ZjKz.png" alt="Odontogenic keratocyst"></td> <td><img src="https://i.imgur.com/7ZjKz.png" alt="Odontogenic keratocyst specimen"></td> </tr> </table> ```   A panoramic dental X-ray showing the jaw and teeth, with a radiolucent lesion visible in the left mandibular region, labeled as an odontogenic keratocyst. A macroscopic specimen of an odontogenic keratocyst, displaying a cystic mass with a tooth embedded in the tissue, labeled with a red dot indicating a specific feature. # HISTOPATHOLOGY - Regular stratified squamous epithelium - Thin epithelial layer (5-8 cells thick) - Palisaded basal layer - Corrugated surface which can be parakeratinised or orthokeratininsed - Thin, friable fibrous capsule - little inflammation - Satellite (daughter) cysts #### Histological Features - Regular stratified squamous epithelium - Thin epithelial layer (typically 5-8 cells thick) - Palisaded basal layer - Corrugated surface which can be parakeratinised or orthokeratinised - Thin, friable fibrous capsule with little inflammation - Presence of satellite (daughter) cysts  A histological micrograph showing a cross-section of tissue, likely epithelial with a stratified layer of cells. The image displays a curved structure with a dense, dark-staining layer of cells on the left and a lighter, fibrous connective tissue on the right. A small red dot is visible near the lower left portion of the epithelial layer, possibly indicating a point of interest or a specific cellular feature. <img src="https://i.imgur.com/5ZjK9dO.png" alt="Microscopic view of tissue section with purple-stained cells and a red dot marker."/>  Microscopic view of a tissue section showing a cross-section of a tubular structure with purple-stained cells lining the lumen. The red dot marker indicates a specific point of interest within the tissue, likely highlighting a feature relevant to the analysis. ```markdown **ENLARGEMENT** - Cancellous enlargement antero-posteriorly - Little or no bucco-lingual expansion → large, especially in angle and ramus of mandible ```  #### Patterns of Enlargement - Cancellous enlargement occurs in an antero-posterior direction - Characterized by little or no bucco-lingual expansion - Can become quite large, especially when located in the angle and ramus of the mandible The image contains a bullet point list describing the characteristics of mandibular enlargement, specifically noting 'Cancellous enlargement antero-posteriorly' and 'Little or no bucco-lingual expansion → large, especially in angle and ramus of mandible'. The text is presented in yellow font on a dark purple background, with a red dot above the second bullet point. ```markdown # RECURRENCE - Up to 60% - Size and infiltrative nature - Tendency to multiplicity and satellite cysts - Intrinsic growth potential - Thin, friable capsule - Genetic - multiple basal cell naevus syndrome (Gorlin-Goltz) <img src="https://i.imgur.com/placeholder.png" alt="Microscopic image of a cystic structure with a thin, friable capsule and surrounding tissue." /> ```  #### Factors Influencing Recurrence Recurrence rates are reported up to 60%. Contributing factors include: - Large size and infiltrative nature - Tendency toward multiplicity and the formation of satellite cysts - Intrinsic growth potential - Thin, friable capsule which is difficult to remove intact - Genetic predisposition, such as multiple basal cell naevus syndrome (Gorlin-Goltz) Microscopic image showing a cystic structure with a thin, friable capsule and surrounding tissue, illustrating features related to recurrence in basal cell naevus syndrome. The image highlights the infiltrative nature and intrinsic growth potential of the lesion. ```markdown # GORLIN - GOLTZ SYNDROME <img src="https://i.imgur.com/1.png" alt="A young boy with Gorlin-Goltz Syndrome, showing facial features and skin lesions." /> - Multiple keratocysts - Multiple basal cell naevi → carcinomas - Skeletal abnormalities - bifid ribs - spine defects - Frontal bossing and hypertelorism - Calcification of the falx cerebri <img src="https://i.imgur.com/2.png" alt="Close-up of skin lesions around the eye, characteristic of Gorlin-Goltz Syndrome." /> ```   #### Clinical and Systemic Features - Multiple keratocysts of the jaws - Multiple basal cell naevi, which may progress to carcinomas - Skeletal abnormalities: - Bifid ribs - Spine defects - Facial features including frontal bossing and hypertelorism - Calcification of the falx cerebri A photograph of a young boy with Gorlin-Goltz Syndrome, showing facial features such as frontal bossing and hypertelorism, along with skin lesions. The image is used to illustrate the clinical presentation of the syndrome. A close-up photograph of skin lesions around the eye, characteristic of Gorlin-Goltz Syndrome, demonstrating multiple basal cell naevi. This image highlights the dermatological manifestations associated with the condition.   A panoramic dental X-ray image showing the entire jaw, teeth, and surrounding bone structure, with visible dental implants and fillings. A lateral skull X-ray image displaying the profile of the skull, including the cranial cavity, facial bones, and teeth, with a clear view of the nasal cavity and mandible.  Close-up photograph of a person's face showing multiple skin lesions with a reddish, inflamed appearance, likely indicating a dermatological condition. The lesions are clustered around the eye and cheek area, with some exhibiting a crusty or ulcerated texture. The eye is obscured by a black rectangle for privacy. ```markdown # NON-ODONTOGENIC DEVELOPMENTAL CYSTS - Nasopalatine duct cyst - Nasolabial (naso-alveolar) cyst *Median cysts ❌ *Globulomaxillary cyst ❌ ``` #### Non-Odontogenic Developmental Cysts - Nasopalatine duct cyst - Nasolabial (naso-alveolar) cyst #### Excluded Classifications - Median cysts - Globulomaxillary cyst # NASO-PALATINE DUCT CYST - Incisive canal cyst - Remnants of nasopalatine duct - M:F 4:1 - 30-60 years - Swelling of midline of palate - Pain and discharge - Mucoid and salty - Vitality of anterior teeth <img src="https://i.imgur.com/7XQZfXl.jpg" alt="Image showing a nasal-palatine duct cyst with visible swelling and discharge in the midline of the palate."/>  #### Nasopalatine Duct Cyst (Incisive Canal Cyst) - **Etiology:** Derived from remnants of the nasopalatine duct. - **Demographics:** - Gender: Male to Female ratio of 4:1. - Age: Typically occurs between 30–60 years. - **Clinical Presentation:** - Swelling of the midline of the palate. - Pain and discharge (often described as mucoid and salty). - Anterior teeth remain vital. A clinical photograph showing a naso-palatine duct cyst with visible swelling in the midline of the palate, accompanied by a list of associated features such as incisive canal cyst, mucoid and salty discharge, and the vitality of anterior teeth. **NASO-PALATINE DUCT CYST** <img src="https://i.imgur.com/placeholder.jpg" alt="Naso-palatine duct cyst showing oral cavity with visible cystic lesion near the hard palate."/>  #### Clinical Presentation Visual evidence of a nasopalatine duct cyst presenting as a visible cystic lesion in the oral cavity near the hard palate. A close-up photograph of the oral cavity showing a naso-palatine duct cyst, with a visible lesion on the hard palate near the central incisors. The image highlights the cystic swelling and surrounding dental structures, providing a clinical view of the condition. ```html <table border="1" cellpadding="5" cellspacing="0" style="border-collapse: collapse; width: 100%;"><tr><td style="text-align: center; font-size: 24pt; font-weight: bold; color: #00FFFF;">NASO-PALATINE DUCT CYST</td></tr><tr><td style="text-align: center;"><img src="https://i.imgur.com/1Q3XJ5l.jpg" alt="Naso-palatine duct cyst" /></td></tr></table> ```  #### Diagnostic Imaging Radiographic and clinical documentation of a nasopalatine duct cyst. A close-up clinical photograph showing a naso-palatine duct cyst on the palatal mucosa, with a visible swelling located between the upper central incisors. The image is labeled 'NASO-PALATINE DUCT CYST' in turquoise text at the top.  X-ray image showing a skeletal structure, likely a skull, with a red dot highlighting a specific area of interest. The image is grayscale and appears to be a medical diagnostic scan. ```markdown **NASOLABIAL CYST** - Swelling in nasolabial fold below alae and leading to loss of fold - Sometimes bilateral - Swelling, pain, difficulty in nasal breathing ```  #### Nasolabial Cyst - **Clinical Features:** - Swelling in the nasolabial fold below the alae, leading to the loss of the fold. - Can occasionally be bilateral. - Symptoms include swelling, pain, and difficulty in nasal breathing. Close-up photo of a person's face showing a swelling in the nasolabial fold below the alae, marked with a red dot, illustrating the characteristic appearance of a nasolabial cyst. The image is used to demonstrate the clinical presentation described in the accompanying text. # Simple Bone Cyst ## Clinical: - Empty intra-osseous bone cavity - Etiology: uncertain - Trauma – intra-medullary hemorrhage - Age: 10-20 years - Gender: male > female (60%) - Site: mandibular body (molar-premolar) - Asymptomatic - painless swelling #### Clinical Features - **Description:** An empty intra-osseous bone cavity. - **Etiology:** Uncertain; possibly related to trauma causing intra-medullary hemorrhage. - **Demographics:** - Age: 10–20 years. - Gender: Predominantly male (60%). - **Location:** Mandibular body (molar-premolar region). - **Symptoms:** Asymptomatic; may present as a painless swelling. # Simple Bone Cyst ## Radiographic Findings: - Incidental finding - Radiolucency - Well to ill defined - Size: 1-10 cm - Scaloping between tooth roots - Vital teeth - No root resorption #### Radiographic Findings - Often an incidental finding. - Appears as a radiolucency, ranging from well-defined to ill-defined. - **Size:** 1–10 cm. - **Characteristics:** - Scalloping between the roots of the teeth. - Associated teeth remain vital. - No evidence of root resorption. # Simple Bone Cyst Histology: - Cortical bone cap - Bone resorption - remodeling - Membranous fibrovascular tissue - Fibrin - hemorrhage - No epithelial lining #### Histopathology - Presence of a cortical bone cap. - Evidence of bone resorption and remodeling. - Membranous fibrovascular tissue. - Presence of fibrin and hemorrhage. - Characterized by the absence of an epithelial lining.  a black and white dental X-ray image showing the lower jaw with teeth, including a red dot marking a specific area of interest, likely indicating a dental implant or lesion. the image is labeled with the number 131 in the bottom right corner. <img src="https://i.imgur.com/9QZjK9p.png" alt="Microscopic view of tissue stained with hematoxylin and eosin, showing cellular structures and a red dot marker. Page number 132 is visible in the bottom right corner."/>  #### Microscopic Analysis Microscopic view of tissue stained with hematoxylin and eosin (H&E) showing cellular structures associated with the lesion. Microscopic view of tissue stained with hematoxylin and eosin, showing cellular structures and a red dot marker. The image displays a histological section with pink and purple staining, highlighting various tissue components, and includes the page number 132 in the bottom right corner.   Two dental X-ray images showing the upper and lower teeth, with visible tooth roots and surrounding bone structure. The images are labeled with 'K2' and appear to be used for diagnostic purposes. A dental X-ray image displaying the upper teeth and surrounding structures, including the roots and jawbone. The image is labeled with 'K2' and is used for evaluating dental health. <img src="https://i.imgur.com/5ZjKz6l.png" alt="Dental X-ray showing the lower jaw with a red dot indicating a specific area of interest. The image is labeled 'R' for right side and has a handwritten note at the top reading 'Coote Ante 27.8.81 No. 7'." />  #### Radiographic Case Study Dental X-ray of the lower jaw indicating a specific area of interest in the mandible. A dental X-ray image showing the lower jaw with a red dot indicating a specific area of interest. The image is labeled 'R' for the right side and includes a handwritten note at the top reading 'COOTE ANTE 27.8.81 No. 7'. The X-ray displays the teeth, jawbone, and surrounding structures in grayscale. # Stafne cysts - Static bone cavity of the mandible or lingual salivary gland inclusion defect - middle-aged men - Estimated prevalence ranges around 0.10-0.48% 136 #### Clinical Overview - **Synonyms:** Static bone cavity of the mandible or lingual salivary gland inclusion defect. - **Demographics:** Most commonly found in middle-aged men. - **Prevalence:** Estimated to be approximately 0.10–0.48%. <image>Oral radiograph showing a dental X-ray with a red dot highlighting a region of interest, likely a Stafne cyst, in the mandible. Below the image is a reference link: https://radiopaedia.org/articles/stafne-cyst 137</image>  #### Radiographic Presentation Oral radiograph showing a highlighted region of interest in the mandible, characteristic of a Stafne cyst. Oral radiograph showing a dental X-ray with a red dot highlighting a region of interest, likely a Stafne cyst, in the mandible. The image displays the teeth and jawbone with a clear view of the mandibular structure and the highlighted area. ```html <table> <tr> <td><img src="https://i.imgur.com/5ZjQZjz.png" alt="3D CT scan of mandible with red dot indicating a lesion, labeled 'PL' on left, 'H', 'P', 'R' orientation marker, and scale '5 cm' on right."></td> </tr> </table> ```  #### Advanced Imaging 3D CT scan of the mandible indicating the location and scale of a mandibular lesion. 3D CT scan of the mandible showing a lesion indicated by a red dot, with anatomical labels 'PL' on the left and orientation markers 'H', 'P', 'R' at the bottom right. The scale bar indicates 5 cm, and the image is a medical visualization used for diagnostic purposes. <figure> <img src="https://i.imgur.com/7XJZz.png" alt="A dark maroon background with yellow text reading '???????' in the upper left, a small red dot in the center, and the number '140' in yellow at the bottom right."> </figure>  #### Summary of Findings This concluding section summarizes the clinical and radiographic characteristics of jaw cysts discussed throughout the presentation. Proper identification and classification remain essential for effective diagnosis and treatment planning. A dark maroon background with yellow text reading '????????' in the upper left, a small red dot in the center, and the number '140' in yellow at the bottom right. The figure appears to be a minimalistic or abstract design, possibly representing a placeholder or a stylized visual element. End of slide show, click to exit. #### Presentation Closure End of slide show. Click to exit. [^1]: Original PDF page 1: [[L18 Bone disease 2_slides.pdf#page=1|L18 Bone disease 2 slides, p.1]] [^2]: Original PDF page 2: [[L18 Bone disease 2_slides.pdf#page=2|L18 Bone disease 2 slides, p.2]] [^3]: Original PDF page 3: [[L18 Bone disease 2_slides.pdf#page=3|L18 Bone disease 2 slides, p.3]] [^4]: Original PDF page 4: [[L18 Bone disease 2_slides.pdf#page=4|L18 Bone disease 2 slides, p.4]] [^5]: Original PDF page 5: [[L18 Bone disease 2_slides.pdf#page=5|L18 Bone disease 2 slides, p.5]] [^6]: Original PDF page 6: [[L18 Bone disease 2_slides.pdf#page=6|L18 Bone disease 2 slides, p.6]] [^7]: Original PDF page 7: [[L18 Bone disease 2_slides.pdf#page=7|L18 Bone disease 2 slides, p.7]] [^8]: Original PDF page 8: [[L18 Bone disease 2_slides.pdf#page=8|L18 Bone disease 2 slides, p.8]] [^9]: Original PDF page 9: [[L18 Bone disease 2_slides.pdf#page=9|L18 Bone disease 2 slides, p.9]] [^10]: Original PDF page 10: [[L18 Bone disease 2_slides.pdf#page=10|L18 Bone disease 2 slides, p.10]] [^11]: Original PDF page 11: [[L18 Bone disease 2_slides.pdf#page=11|L18 Bone disease 2 slides, p.11]] [^12]: Original PDF page 12: [[L18 Bone disease 2_slides.pdf#page=12|L18 Bone disease 2 slides, p.12]] [^13]: Original PDF page 13: [[L18 Bone disease 2_slides.pdf#page=13|L18 Bone disease 2 slides, p.13]] [^14]: Original PDF page 14: [[L18 Bone disease 2_slides.pdf#page=14|L18 Bone disease 2 slides, p.14]] [^15]: Original PDF page 15: [[L18 Bone disease 2_slides.pdf#page=15|L18 Bone disease 2 slides, p.15]] [^16]: Original PDF page 16: [[L18 Bone disease 2_slides.pdf#page=16|L18 Bone disease 2 slides, p.16]] [^17]: Original PDF page 17: [[L18 Bone disease 2_slides.pdf#page=17|L18 Bone disease 2 slides, p.17]] [^18]: Original PDF page 18: [[L18 Bone disease 2_slides.pdf#page=18|L18 Bone disease 2 slides, p.18]] [^19]: Original PDF page 19: [[L18 Bone disease 2_slides.pdf#page=19|L18 Bone disease 2 slides, p.19]] [^20]: Original PDF page 20: [[L18 Bone disease 2_slides.pdf#page=20|L18 Bone disease 2 slides, p.20]] [^21]: Original PDF page 21: [[L18 Bone disease 2_slides.pdf#page=21|L18 Bone disease 2 slides, p.21]] [^22]: Original PDF page 22: [[L18 Bone disease 2_slides.pdf#page=22|L18 Bone disease 2 slides, p.22]] [^23]: Original PDF page 23: [[L18 Bone disease 2_slides.pdf#page=23|L18 Bone disease 2 slides, p.23]] [^24]: Original PDF page 24: [[L18 Bone disease 2_slides.pdf#page=24|L18 Bone disease 2 slides, p.24]] [^25]: Original PDF page 25: [[L18 Bone disease 2_slides.pdf#page=25|L18 Bone disease 2 slides, p.25]] [^26]: Original PDF page 26: [[L18 Bone disease 2_slides.pdf#page=26|L18 Bone disease 2 slides, p.26]] [^27]: Original PDF page 27: [[L18 Bone disease 2_slides.pdf#page=27|L18 Bone disease 2 slides, p.27]] [^28]: Original PDF page 28: [[L18 Bone disease 2_slides.pdf#page=28|L18 Bone disease 2 slides, p.28]] [^29]: Original PDF page 29: [[L18 Bone disease 2_slides.pdf#page=29|L18 Bone disease 2 slides, p.29]] [^30]: Original PDF page 30: [[L18 Bone disease 2_slides.pdf#page=30|L18 Bone disease 2 slides, p.30]] [^31]: Original PDF page 31: [[L18 Bone disease 2_slides.pdf#page=31|L18 Bone disease 2 slides, p.31]] [^32]: Original PDF page 32: [[L18 Bone disease 2_slides.pdf#page=32|L18 Bone disease 2 slides, p.32]] [^33]: Original PDF page 33: [[L18 Bone disease 2_slides.pdf#page=33|L18 Bone disease 2 slides, p.33]] [^34]: Original PDF page 34: [[L18 Bone disease 2_slides.pdf#page=34|L18 Bone disease 2 slides, p.34]] [^35]: Original PDF page 35: [[L18 Bone disease 2_slides.pdf#page=35|L18 Bone disease 2 slides, p.35]] [^36]: Original PDF page 36: [[L18 Bone disease 2_slides.pdf#page=36|L18 Bone disease 2 slides, p.36]] [^37]: Original PDF page 37: [[L18 Bone disease 2_slides.pdf#page=37|L18 Bone disease 2 slides, p.37]] [^38]: Original PDF page 38: [[L18 Bone disease 2_slides.pdf#page=38|L18 Bone disease 2 slides, p.38]] [^39]: Original PDF page 39: [[L18 Bone disease 2_slides.pdf#page=39|L18 Bone disease 2 slides, p.39]] [^40]: Original PDF page 40: [[L18 Bone disease 2_slides.pdf#page=40|L18 Bone disease 2 slides, p.40]] [^41]: Original PDF page 41: [[L18 Bone disease 2_slides.pdf#page=41|L18 Bone disease 2 slides, p.41]] [^42]: Original PDF page 42: [[L18 Bone disease 2_slides.pdf#page=42|L18 Bone disease 2 slides, p.42]] [^43]: Original PDF page 43: [[L18 Bone disease 2_slides.pdf#page=43|L18 Bone disease 2 slides, p.43]] [^44]: Original PDF page 44: [[L18 Bone disease 2_slides.pdf#page=44|L18 Bone disease 2 slides, p.44]] [^45]: Original PDF page 45: [[L18 Bone disease 2_slides.pdf#page=45|L18 Bone disease 2 slides, p.45]] [^46]: Original PDF page 46: [[L18 Bone disease 2_slides.pdf#page=46|L18 Bone disease 2 slides, p.46]] [^47]: Original PDF page 47: [[L18 Bone disease 2_slides.pdf#page=47|L18 Bone disease 2 slides, p.47]] [^48]: Original PDF page 48: [[L18 Bone disease 2_slides.pdf#page=48|L18 Bone disease 2 slides, p.48]] [^49]: Original PDF page 49: [[L18 Bone disease 2_slides.pdf#page=49|L18 Bone disease 2 slides, p.49]] [^50]: Original PDF page 50: [[L18 Bone disease 2_slides.pdf#page=50|L18 Bone disease 2 slides, p.50]] [^51]: Original PDF page 51: [[L18 Bone disease 2_slides.pdf#page=51|L18 Bone disease 2 slides, p.51]] [^52]: Original PDF page 52: [[L18 Bone disease 2_slides.pdf#page=52|L18 Bone disease 2 slides, p.52]] [^53]: Original PDF page 53: [[L18 Bone disease 2_slides.pdf#page=53|L18 Bone disease 2 slides, p.53]] [^54]: Original PDF page 54: [[L18 Bone disease 2_slides.pdf#page=54|L18 Bone disease 2 slides, p.54]] [^55]: Original PDF page 55: [[L18 Bone disease 2_slides.pdf#page=55|L18 Bone disease 2 slides, p.55]] [^56]: Original PDF page 56: [[L18 Bone disease 2_slides.pdf#page=56|L18 Bone disease 2 slides, p.56]] [^57]: Original PDF page 57: [[L18 Bone disease 2_slides.pdf#page=57|L18 Bone disease 2 slides, p.57]] [^58]: Original PDF page 58: [[L18 Bone disease 2_slides.pdf#page=58|L18 Bone disease 2 slides, p.58]] [^59]: Original PDF page 59: [[L18 Bone disease 2_slides.pdf#page=59|L18 Bone disease 2 slides, p.59]] [^60]: Original PDF page 60: [[L18 Bone disease 2_slides.pdf#page=60|L18 Bone disease 2 slides, p.60]] [^61]: Original PDF page 61: [[L18 Bone disease 2_slides.pdf#page=61|L18 Bone disease 2 slides, p.61]] [^62]: Original PDF page 62: [[L18 Bone disease 2_slides.pdf#page=62|L18 Bone disease 2 slides, p.62]] [^63]: Original PDF page 63: [[L18 Bone disease 2_slides.pdf#page=63|L18 Bone disease 2 slides, p.63]] [^64]: Original PDF page 64: [[L18 Bone disease 2_slides.pdf#page=64|L18 Bone disease 2 slides, p.64]] [^65]: Original PDF page 65: [[L18 Bone disease 2_slides.pdf#page=65|L18 Bone disease 2 slides, p.65]] [^66]: Original PDF page 66: [[L18 Bone disease 2_slides.pdf#page=66|L18 Bone disease 2 slides, p.66]] [^67]: Original PDF page 67: [[L18 Bone disease 2_slides.pdf#page=67|L18 Bone disease 2 slides, p.67]] [^68]: Original PDF page 68: [[L18 Bone disease 2_slides.pdf#page=68|L18 Bone disease 2 slides, p.68]] [^69]: Original PDF page 69: [[L18 Bone disease 2_slides.pdf#page=69|L18 Bone disease 2 slides, p.69]] [^70]: Original PDF page 70: [[L18 Bone disease 2_slides.pdf#page=70|L18 Bone disease 2 slides, p.70]] [^71]: Original PDF page 71: [[L18 Bone disease 2_slides.pdf#page=71|L18 Bone disease 2 slides, p.71]] [^72]: Original PDF page 72: [[L18 Bone disease 2_slides.pdf#page=72|L18 Bone disease 2 slides, p.72]] [^73]: Original PDF page 73: [[L18 Bone disease 2_slides.pdf#page=73|L18 Bone disease 2 slides, p.73]] [^74]: Original PDF page 74: [[L18 Bone disease 2_slides.pdf#page=74|L18 Bone disease 2 slides, p.74]] [^75]: Original PDF page 75: [[L18 Bone disease 2_slides.pdf#page=75|L18 Bone disease 2 slides, p.75]] [^76]: Original PDF page 76: [[L18 Bone disease 2_slides.pdf#page=76|L18 Bone disease 2 slides, p.76]] [^77]: Original PDF page 77: [[L18 Bone disease 2_slides.pdf#page=77|L18 Bone disease 2 slides, p.77]] [^78]: Original PDF page 78: [[L18 Bone disease 2_slides.pdf#page=78|L18 Bone disease 2 slides, p.78]] [^79]: Original PDF page 79: [[L18 Bone disease 2_slides.pdf#page=79|L18 Bone disease 2 slides, p.79]] [^80]: Original PDF page 80: [[L18 Bone disease 2_slides.pdf#page=80|L18 Bone disease 2 slides, p.80]] [^81]: Original PDF page 81: [[L18 Bone disease 2_slides.pdf#page=81|L18 Bone disease 2 slides, p.81]] [^82]: Original PDF page 82: [[L18 Bone disease 2_slides.pdf#page=82|L18 Bone disease 2 slides, p.82]] [^83]: Original PDF page 83: [[L18 Bone disease 2_slides.pdf#page=83|L18 Bone disease 2 slides, p.83]] [^84]: Original PDF page 84: [[L18 Bone disease 2_slides.pdf#page=84|L18 Bone disease 2 slides, p.84]] [^85]: Original PDF page 85: [[L18 Bone disease 2_slides.pdf#page=85|L18 Bone disease 2 slides, p.85]] [^86]: Original PDF page 86: [[L18 Bone disease 2_slides.pdf#page=86|L18 Bone disease 2 slides, p.86]] [^87]: Original PDF page 87: [[L18 Bone disease 2_slides.pdf#page=87|L18 Bone disease 2 slides, p.87]] [^88]: Original PDF page 88: [[L18 Bone disease 2_slides.pdf#page=88|L18 Bone disease 2 slides, p.88]] [^89]: Original PDF page 89: [[L18 Bone disease 2_slides.pdf#page=89|L18 Bone disease 2 slides, p.89]] [^90]: Original PDF page 90: [[L18 Bone disease 2_slides.pdf#page=90|L18 Bone disease 2 slides, p.90]] [^91]: Original PDF page 91: [[L18 Bone disease 2_slides.pdf#page=91|L18 Bone disease 2 slides, p.91]] [^92]: Original PDF page 92: [[L18 Bone disease 2_slides.pdf#page=92|L18 Bone disease 2 slides, p.92]] [^93]: Original PDF page 93: [[L18 Bone disease 2_slides.pdf#page=93|L18 Bone disease 2 slides, p.93]] [^94]: Original PDF page 94: [[L18 Bone disease 2_slides.pdf#page=94|L18 Bone disease 2 slides, p.94]] [^95]: Original PDF page 95: [[L18 Bone disease 2_slides.pdf#page=95|L18 Bone disease 2 slides, p.95]] [^96]: Original PDF page 96: [[L18 Bone disease 2_slides.pdf#page=96|L18 Bone disease 2 slides, p.96]] [^97]: Original PDF page 97: [[L18 Bone disease 2_slides.pdf#page=97|L18 Bone disease 2 slides, p.97]] [^98]: Original PDF page 98: [[L18 Bone disease 2_slides.pdf#page=98|L18 Bone disease 2 slides, p.98]] [^99]: Original PDF page 99: [[L18 Bone disease 2_slides.pdf#page=99|L18 Bone disease 2 slides, p.99]] [^100]: Original PDF page 100: [[L18 Bone disease 2_slides.pdf#page=100|L18 Bone disease 2 slides, p.100]] [^101]: Original PDF page 101: [[L18 Bone disease 2_slides.pdf#page=101|L18 Bone disease 2 slides, p.101]] [^102]: Original PDF page 102: [[L18 Bone disease 2_slides.pdf#page=102|L18 Bone disease 2 slides, p.102]] [^103]: Original PDF page 103: [[L18 Bone disease 2_slides.pdf#page=103|L18 Bone disease 2 slides, p.103]] [^104]: Original PDF page 104: [[L18 Bone disease 2_slides.pdf#page=104|L18 Bone disease 2 slides, p.104]] [^105]: Original PDF page 105: [[L18 Bone disease 2_slides.pdf#page=105|L18 Bone disease 2 slides, p.105]] [^106]: Original PDF page 106: [[L18 Bone disease 2_slides.pdf#page=106|L18 Bone disease 2 slides, p.106]] [^107]: Original PDF page 107: [[L18 Bone disease 2_slides.pdf#page=107|L18 Bone disease 2 slides, p.107]] [^108]: Original PDF page 108: [[L18 Bone disease 2_slides.pdf#page=108|L18 Bone disease 2 slides, p.108]] [^109]: Original PDF page 109: [[L18 Bone disease 2_slides.pdf#page=109|L18 Bone disease 2 slides, p.109]] [^110]: Original PDF page 110: [[L18 Bone disease 2_slides.pdf#page=110|L18 Bone disease 2 slides, p.110]] [^111]: Original PDF page 111: [[L18 Bone disease 2_slides.pdf#page=111|L18 Bone disease 2 slides, p.111]]