Odontogenous Osteitis of the Mandible Periapical Abscess

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Inflammation or infection about the dental root apex is one of the most common conditions in the mandible that manifests as intense tracer uptake. The condition is also important clinically since it occasionally progresses to alveolar abscess, apical granuloma, and cyst formation. The process may be either sterile or septic with a septic source usually in the infected dental pulp.

Dental Pulp

Fig. 7.14A, B Early radiation-induced osteitis in the mandible (2 months after 65 Gy irradiation with 6 MeV gamma-ray for right submandibular malignant lymphoma). A T1-weighted gadolinium DTPA-enhanced coronal MRI section through the premolar zone of the mandible in a 47-year-old woman with mandibular irradiation shows a modest volume decrease of the irradiated marrow with suppressed enhancement and regional cortical thickening, indicating marrow depletion with shrinkage and osteitis, respectively (arrow). B Anterior pinhole scintigraph shows diffusely increased uptake in the irradiated area due to an osseous reaction (arrowheads)

Fig. 7.13A, B Odontogenous osteitis related to periapical inflammation in the mandible. A Slightly tilted lateral radiograph of the right mandible in a 59-year-old man with mandibular dental pain shows bone resorption about the second molar roots (arrow) and in the extracted third molar alveolus and diffuse sclerosis (arrowheads), denoting the periapical abscess, erosions, and reactive eburnation, respectively. B Lateral pinhole scintigraph shows very intense tracer uptake focally in the molar alveolar bones (arrow) and less intense uptake around it (arrowheads). The presence of more intense tracer uptake in the periapical bone may represent infection, but infection is not a prerequisite to nonspecific, intense, mandibular tracer uptake. Indeed, frequently the painless. nonin-fective bone resorption is attended by intense tracer accumulation

Fig. 7.14A, B Early radiation-induced osteitis in the mandible (2 months after 65 Gy irradiation with 6 MeV gamma-ray for right submandibular malignant lymphoma). A T1-weighted gadolinium DTPA-enhanced coronal MRI section through the premolar zone of the mandible in a 47-year-old woman with mandibular irradiation shows a modest volume decrease of the irradiated marrow with suppressed enhancement and regional cortical thickening, indicating marrow depletion with shrinkage and osteitis, respectively (arrow). B Anterior pinhole scintigraph shows diffusely increased uptake in the irradiated area due to an osseous reaction (arrowheads)

Osteitis Mandible

Fig. 7.15A, B Chronic radiation osteitis in the innominate bone (18 months after 47.50 Gy irradiation with 6 MeV gamma-ray for breast cancer metastasis). A Anteroposterior radiograph of the left hip in a 43-year-old woman with known breast cancer metastasis reveals irregular bone thickening with interspersed streaky and cystic lu-cencies in the irradiated left innominate bone (arrow). The femoral head was shielded, hence saved, preserving a normal trabecular pattern. B Anterior pinhole scan shows moderately increased, irregular tracer uptake roughly corresponding to radiographically sclerotic areas (arrows). Observe the normal tracer uptake in the shielded femoral head

Fig. 7.15A, B Chronic radiation osteitis in the innominate bone (18 months after 47.50 Gy irradiation with 6 MeV gamma-ray for breast cancer metastasis). A Anteroposterior radiograph of the left hip in a 43-year-old woman with known breast cancer metastasis reveals irregular bone thickening with interspersed streaky and cystic lu-cencies in the irradiated left innominate bone (arrow). The femoral head was shielded, hence saved, preserving a normal trabecular pattern. B Anterior pinhole scan shows moderately increased, irregular tracer uptake roughly corresponding to radiographically sclerotic areas (arrows). Observe the normal tracer uptake in the shielded femoral head

Radiographically, the nonspecific chronic bone inflammation is represented by diffuse reactive osteosclerosis, whereas periapical abscess is represented by focal bone destruction (Fig. 7.13A). The characteristic pinhole scintigraphic feature of nonspecific sterile osteitis in the mandible is an ill-defined area of homogeneous tracer uptake in the molar and premolar regions, whereas the tracer uptake in periapical abscess is very intense, and usually surrounded by less intense, reactive uptake (Fig. 7.13B).

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