Malignant Diseases of the Jaws

Differences to benign :
locally invasive
greater degree of cellular anaplasia
ability to metastasize regionally to lymph nodes and distantly to other sites

2 types : Primary and Secondary (metastatic)

Causes :
viruses
significant radiation exposure
genetic defects
exposure to carcinogenic chemicals . eg : tobacco

General Features of Malignant disease:

Clinical features displaced teeth , loosened teeth over a short time , foul smell , ulceration , indurated or rolled
border , exposure of underlying bone , sensory or motor neural deficit , lymph-adenopathy ,
weight loss ,dysgeusia ,dysphagia , dysphonia , hemorrhage , lack of normal healing after surgery
, pain , rapid swelling
Radiographic Important for :
examination i. Initial diagnosis and staging
ii. Determine anatomic spread for excision and radiation
iii. Determine any presence of osseous involvement from soft tissue tumor
iv. Management of cancer survivor

Modalities : Intraoral radiographs , Panoramic , CT scan , Positron emission tomographic (PET)

scan , MR
The following features may suggest presence of malignant tumour :
Location occur anywhere
Primary carcinomas > common in tongue , floor of mouth , tonsillar area,
lip , soft palate , gingiva and may invade jaws from any of the sites
Sarcomas > common in mandible and posterior regions of both jaws
Metastatic > common in posterior mandible and maxilla. May grow at
teeth apex of follicles of developing tooth.
Periphery and Shape ill defined border with bone destruction
destruction of cortical boundary with adjacent soft tissue mass
lack cortication
non - encapsulated
Internal Structure Usually radiolucent. no bone production nor stimulate reactive bone
formation.
Occasionally , residual islands of bone are present
Metastatic breast and prostate lesions -> induce bone formation
Osteogenic sarcomas -> sclerotic radiopaque as it produce abnormal
bone
Effects on destroy supporting alveolar bone giving appearance of teeth 'floating in
surrounding space'
structures root resorption is more common in sarcomas
destroy internal trabecular bone and even cortical boundaries . eg: sinus
floor, inf. border of mandible
irregular widening of lamina dura , widening of mandibular canal
Types of Cortical bone and Periosteal reaction ->
cortical destruction without periosteal reaction
laminated periosteal reaction with destruction of cortical bone
and new periosteal bone
destruction of cortical bone with periosteal reaction at periphery (
codmans triangle )
sunray type periosteal reaction
Book divide malignant diseases into 4 main categories :

1. Carcinomas
Squamous cell carcinoma arising in soft tissue
squamous cell carcinoma originating in bone
squamous cell carcinoma originating in cyst
central mucoepidermoid carcinoma
malignant ameloblastoma and ameloblastic carcinoma
2. Metastatic

3. Sarcomas
Osteosarcoma
Chondrosarcoma
Ewing's sarcoma
Fibrosarcoma

4. Malignancies of hematopoietic system

Multiple myeloma
Non -Hodgkins lymphoma
Burkitt's lymphoma
Leukemia
1. CARCINOMAS
1.1 Squamous cell carcinoma arising in soft tissue
Synonym : Epidermoid carcinoma
most common oral malignancy
originating from surface epithelium
invasion of epithelial cell -> underlying connective tissue -> deep soft tissue -> bone occasionally . ultimately , metastasis .
Clinical Features
Radiographic features
the anterior floor of the nasal fossa has
Male > female
> 50 years old
initially : white or red in colour , irregular patchy lesion
with time : ulceration , rolled indurated border , palpable infiltration to adj. muscle , bone
variable pain
regional lympadenopathy , hard lymph nodes
shows typical features of malignancy eg : paresthesia , foul smell , etc..
fatal if untreated
Location commonly, lateral border of tongue
thus, bone lesion commonly on posterior lingual of mandible
lesion of lip and floorof mouth will invade anterior mandible
also seen in tonsils, soft palate, buccal vestibule
uncommon in hard palate
Periphery and polymorphous radiolucency , irregular outline
shape ill defined , non-corticated border
extensive bone involvement -> 'finger-like' extensions periphery
been destroyed (note lack of anterior if with 2nd inflammatory disease associates with surface erosions ->
nasal spine.
sclerosis
Internal totally radiolucent
structure occasionally , small islands of residual normal trabecular bone are
visible within central radiolucency
The supporting alveolar bone has been
Effects on widening of PDL space ( early sign )
destroyed from around surrounding loss of lamina dura ( early sign )
the teeth. structure 'floating teeth'
displaced teeth
widening of inferior neurovascular canal
destruction of cortical boundary eg : nose,sinus
There is destruction of the right pathologic fracture
alveolar process and floor of maxillary
sinus and the soft tissue mass (arrow).

bone destruction similar to periodontal

disease around the lateral incisor from
a SCC originating in the soft tissues of
the alveolar process. Note the lack of a
sclerotic bone reaction at the
periphery.

Differential diagnosis 1) Osteomyelitis

both are destructive, leaving islands of osseous structure that appear to be consistent
with sequestra
 SCC doesnt produce periosteal reaction
SCC more invasive and more profound bone destruction

2) Periodontal disease
bone loss is similar
SCC has no sclerotic bone reaction at its periphery
extracted site : in SCC the socket enlarges instead of healing
presence of intraoral soft tissue lesion in SCC
Management Surgery and radiation therapy with chemotherapy as adjunct

1.2 Squamous cell carcinoma originating in Bone

Synonym : Primary intraosseous carcinoma , intra alveolar carcinoma , primary intra -alveolar epidermoid carcinoma ,
primary epithelial tumor of the jaw , central squamous cell carcinoma , primary odontogenic carcinoma , intramandibular
carcinoma , central mandibular carcinoma .
Arises in jaw from intra osseous remnants of odontogenic epithelium
Has NO original connection with surface epithelium

Clinical features Male > Female

Radiographic features
4th - 8th decade of life
rare
remain silent until enlarged
pain , pathologic fracture , paraesthesia , lymphadenopathy
surface epithelium is normal
Location mandible > maxilla

This primary intraosseous
carcinoma in the left mandible
exhibits no internal structure, a
poorly defi ned periphery, and
thinning of the overlying
mandibular bone.
Differential diagnosis
Management
> molar region
less frequent anteriorly
originates ONLY in tooth bearing parts of the jaw (odontogenic)
Periphery and Shape ill defined
often rounded , irregular in shape
border shows osseous destruction and varying extensions at
periphery . More ragged, more aggressive .
big -> pathologic fractures , thin cortical border , soft tissue mass
Internal structure totally radiolucent
very little residual bone left, if any
if small -> overlying buccal or lingual plate may cast a shadow ,
mimicking internal trabeculae bone
Effects on destructive to antral or nasal floors
surrounding loss of cortical outline of mandibular canal
loss of lamina dura
root resorption is unusual
teeth floating in space
1) Periapical cyst or granuloma
when not aggressive , smooth border, radiolucent area
2) Odontogenic cyst or tumors
when not centered about the apex of tooth
3) metastatic lesions, multiple myeloma ,fibrosarcoma, carcinoma from dental cyst
when border obviously infiltrative , extensive bone destruction
excision with surrounding osseous structure ' en bloc resection '
radiation , chemotherapy
 1.3 Squamous cell carcinoma in a cyst
Synonym : Epidermoid cell carcinoma , Carcinoma ex odontogenic cyst
uncommon
may arise from infl. periapical, residual , dentigerous , OKC .
the lining sq. epithelium of cyst -> malignant

Clinical features dull , several months duration pain ( most common )

occasionally with swelling
pathologic fracture
fistula
regional lymphadenopathy
Radiographic features Location anywhere an odontogenic cyst is found , namely tooth bearing
area
> mandible
few in maxilla
Periphery and as arises from cyst, often round or ovoid
shape if small in cyst wall -> well defined and even corticated
advanced -> ill defined , infiltrative periphery , lacks cortication ,
less 'hydraulic' looking, more diffuse
Internal totally radiolucent. Uncapable to produce bone even more than
structure surface carcinoma
Effects on thinning and destroys lamina dura of adjacent teeth
Carcinoma arising in a preexisting surrounding destroys cortical boundaries
dentigerous cyst related to the mandibular
left third molar shows absence of a cyst complete destruction of alveolar process
cortex , invasion into adjacent bone , and ill-
defined borders.

Differential diagnosis 1) infected dental cyst

loss of cortical border, ragged periphery
inf. dental cyst shows reactive peripheral sclerosis unlike SCC from cyst.
2) solitary multiple myeloma
3) metastatic lesion
lesion commonly multifocal unlike SCC from cyst
Management excision with surrounding osseous structure ' en bloc resection '
radiation , chemotherapy

1.4 Central Muco-epidermoid carcinoma

Mucoepidermoid carcinoma
Epithelial tumor arising in bone . Originates from pluripotential odontogenic epithelium or from a cyst lining . (Theory that
odontogenic epithelium is capable of giving rise to mucous secretory cells which may undergo neoplastic transformation to
mucoepidermoid carcinoma)
Diagnosis criteria : Intact cortical plates , r/graphic evidence of bone destruction , histopathologic findings.

Clinical features Females > Males

Radiographic features
Mimic a benign tumor or cyst
Painless swelling ( most common )
Swelling may present for months or years causing facial asymmetry
'Denture no longer fit' or 'Teeth have been moved feeling'
Parasthesia , spreading to regional lymph node
Location > mandible 2:1
The multilocular radiolucency in this
radiograph is characteristic of central
mucoepidermoid carcinoma; this lesion
has displaced the mandibular canal and
destroyed the superior crest of the
alveolar process and the distal
supporting bone of the second molar
The multilocular radiolucency in this
radiograph is characteristic of central
mucoepidermoid carcinoma; this lesion
has displaced the mandibular canal and
destroyed the superior crest of the
alveolar process and the distal
supporting bone of the second molar
Differential diagnosis
Management
premolar molar region
above mandibular canal , similar to odontogenic tumors
Periphery and unilocular or multilocular expansile mass
Shape well defined , well corticated border
often crenated (scalloped) and undulating in nature ; similar to benign
odon. tumors
cortication may be impressively thick ; mispresenting its malignant
nature
Internal 'soap bubble' or 'honeycomb' appearance like ameloblastoma
structure
Effects on expansion of bony walls
Surrounding Usually intact but thinned buccal and lingual cortical plates, inferior
border of mandible, alveolar crest
mandibular canal is displaced inferiorly , laterally , or medially
Teeth unaffected . Adjacent lamina dura may be lost
1) Ameloblastoma
Chief d/d
2) Glandular odontogenic cyst
3) Odontogenic myxoma
4) Central giant cell granuloma
excision with surrounding osseous structure ' en bloc resection '
neck dissection and post-operative radiation to control spread to lymph nodes
 1.5 Malignant Ameloblastoma (MA) and Ameloblastic carcinoma (AC)
MA : benign ameloblastoma deemed malignant because of its biologic behavior ; metastasis
AC : ameloblastoma with histologic criteria of a malignant neoplasm

Clinical features Males > Females

Radiographic features
1st - 6th decades of life
hard expansile mass of the jaw
displaced , loosened teeth
Metastatic spread may be to cervical lymph nodes, lung, spine
Location > mandible
premolar molar region
Periphery and similar to ameloblastoma
shape well defined border with cortication
crenated , scalloping border
AC : may show loss or breaching of the cortical boundary invading into
surrounding soft tissue
Internal structure unilocular or multilocular
honeycomb or soap bubble appearance
septa are robust and thick
Effects on teeth may be moved bodily
surrounding root resorption
loss of lamina dura
destruct bony borders (AC)
displaced floor of nose , sinus
displaced or eroded mandibular canal
Differential diagnosis 1) benign ameloblastoma
2) OKC
3) Odontogenic myxoma
4) Central muco epidermoid tumor
5) Carcinoma arising in dental cyst
if invasive radiographically
(6) Central Giant cell Granuloma
if patient is young
if lesion occur anterior to premolar
Management en bloc surgical resection
2. METASTATIC TUMORS
Synonym : secondary malignancy
new foci from distant malignant tumor
lesions in jaws usually arise from sites inferior to clavicle
jaw involvement : 1%
> commonly, tumor is of carcinoma
Clinical features
Radiographical features
Metastatic breast carcinoma surrounding
the apical half of the
second and third molar roots and extending
inferiorly .It has destroyed the inferior
border of the mandible
5th - 7th decade of life
pain , numbness, parasthesia
haemorrhage
pathologic fractures
Location > mandible posteriorly
maxillary sinus comes second
usually bilateral
may be in PDL space or root apex , mimicking periodontal infl disease ,
or in developing tooth
Periphery moderately well demarcate
and shape no cortication, no capsule
may have ill defined invasive margin
usually polymorphous in shape
by time, small lesions coalesce into larger size ; enlarges the jaw
Prostate and Breast lesions -> stimulate bone formation -> sclerotic
Internal radiolucent , except prostate and breast (patchy sclerosis)
structure
prostate metastatic lesions involving
the body and ramus of the body; note the sclerotic bone
reaction
 metastatic lesion of breast carcinoma; note the irregular
widening of the periodontal membrane spaces and patchy
sclerotic bone reaction, especially around the roots of the
molars.

Bilateral metastatic lesions from the lung Effects on periosteal reaction in prostate and neuroblastome-> spiculated pattern
destroying the mandibular rami surrounding

widening of PDL space

loss of lamina dura
floating teeth
fail to heal pf extraction socket
rare teeth resorption
destruction of cortical bone
can extends into soft tissue -> intraoral mass
Differential diagnosis (1) multiple myeloma
border of MM is better circumscribed
(2) Periapical infl lesion
if initially starts within PDL space
in periapical infl lesion, it is centred at the apex
Metastatic has irregular widening , may extend up to the side of root
(3) 2nd infected Odontogenic cyst

Management poor prognosis , usually die in 1-2 years

refer quickly to oncologist
3. SARCOMAS

3.1 Osteosarcoma
synonym : Osteogenic sarcoma
Oteoid is produced directly by malignant stroma
3 major histologic type : chondroblastic , osteoblastic , fibroblastic
cause unknown. may be genetic mutation or viral
known to occur in fibrous dysplasia and paget's disease after therapeutic irradiation

Clinical features rare in jaw ( 7% of all osteosarcomas )

Radiographic features
resected mandible of a 25-year-old
Males > Females
4th decade
rapid swelling for as long as 6 months before diagnosed
pain, tenderness, ulceration of overlying mucosa, loose teeth , epistaxis ,hemorrage , nasal
obstruction , exophthalmus , trimus ,blindness
Location > mandible
> posterior , tooth bearing region , angle , vertical ramus
in maxilla , > alveolar ridge , sinus , palate
may cross midline
Periphery and ill defined borders
shape no sclerosis , no capsule
sunray spicule or 'hair on end' trabeculae in periosteum
man with osteosarcoma, showing sometimes, Codman's triangle
sunray spicules.
Internal structure totally radiolucent or mixed or quite radiopaque
can be granular or sclerotic bone, cotton balls , wisps, or honeycombed
normal trabecular structure is always lost
Effects on widening of PDL space
surrounding loss of lamina dura
loss of bony cortices

osteosarcoma occupying the body

of the right mandible. Note the
widened ligament spaces
(arrows) and that the density of
the mandible in the first molar
region is greater than normal due
to abnormal bone formation

Differential Diagnosis (1) Fibrosarcoma chief d/d

(2) Metastatic carcinoma
(3) Chondrosarcoma - if osseous structure is visible
(4) Prostate and Breast metastasize - if spiculated periosteal new bone is present
(5) Ossifying fibroma - OF more uniform internal structure
(6) Ewing sarcoma
(7) solitary plasmacytoma
(8) osteomyelitis
Management resection with large border of adj normal bone
radiation and chemotherapy
 3.2 Chondrosarcoma
synonym : Chondrogenic sarcoma
malignant tumor of cartilaginous origin
4 histo subtype : clear cell, dedifferentiated , myxoid , mesenchymal forms
may occur intraoseous , periphery of bone , or less commonly soft tissue

Clinical features > males

Radiographic features
Chondrosarcoma of the anterior
maxilla, with irregular calcification
in the internal structure of the
tumor (arrows).
> adults . mean age 47 years old
firm , hard mass for long duration
enlargement cause headache , pain , deformity
trimus if near to TMJ
Location equal frequency in mandible and maxilla
maxilla : more anteriorly
mandible : more to coronoid process, condylar head and neck .
Periphery and slow growing tumors
Shape misled as benign
round , ovoid , or lobulated
usually well defined , at times corticated
occasionally , sun ray appearance
Internal structure some calcification within center -> mixed appearance
'moth eaten 'bone
central radiopaque structure : 'flocculent' or snow like
ground glass appearance
careful examination of flocculence, may reveal central radiolucent
nidus , the cartilage surrounded by calcifications .
 Effects on expand cortical boundary rather than destruction (slow growing) eg :
surrounding inferior border, sinus
root resorption and tooth displacement
widening of PDL space
Differential diagnosis 1) Osteosarcoma (chief)
typical calcification in Chondrosarcoma is absent in osteosarcoma
2) Fibrous dysplasia
similar internal features
periphery of f. dysplasia is better defined
f. dysplasia alters bone including the lamina dura resulting in thin PDL space
Management surgical , radiation , chemo
good 5 year survival rate
poor 10 year survival rate

3.3 Ewing's Sarcoma

Endothelial myeloma and round cell sarcoma
indetermine histogenesis
arise in medullary -> endosteal -> periosteal surface
Clinical features
Radiographic features
Ewing s sarcoma involving the left
mandibular condyle with a small
pathologic fracture
destruction of the medial cortex of
the condyle
Differential Diagnosis
Management
Males > Females
> 2nd decade of life , between 5 - 30 years old
swelling
pain , loose teeth , parasthesia , exophthalmus , ptosis ,trismus
Location > Mandible
Posteriorly in both jaws
develops in marrow first then extend to cortical plates . characteristic.
Periphery and poorly demarcated radiolucency , never corticated
shape edge destroys bone unevenly , ragged border
usually solitary
may cause pathologic fracture
generally round or ovoid
Internal structure little induction of bone formation
entirely radiolucent (course of lesion from inside-out)
Effects on Stimulate periosteal reaction -> Codman's triangle or Sunray appearance
surrounding destructive to cortical borders or plates
destroy supporting bone of teeth but doesnt cause root resorption
1) Primary malignancy of bone eg : osteosarcoma , chondrosarcoma, fibrosarcoma are difficult to
distinguish radiographically
2) Osteomyelitis
sequestra in osteomyelitis
infl lesion usually with reactive bone formation -> sclerosis internally or periphery
3) Eosinophilic granuloma
laminar periosteal reaction is seen but not in Ewing's sarcoma jaw lesion
surgery , radiation , chemo
 3.4 Fibrosarcoma
malignant fibroblast that produce collagen and elastin
unknown etiology
may arise 2nd in tissues that have received therapeutic level of radiation

Clinical features equal in males and females

Radiographic features
> 4th decade
slow to rapidly enlarging mass
arise centrally in bone or peripherally
centre : pain
peripheral or those exiting from bone : invade soft tissue , bulky obvious lesion
pathologic fracture , sensory neural abnormalities , overlying mucosa may become
ulcerated , trismus
Location > mandible premolar, molar region
Periphery and ill defined borders , ragged
shape poorly demarcated , non corticated , no capsule
tend to elongated in marrow space . grow 'along the bone '
may have sclerosis
Internal entirely radiolucent
structure if less aggresive, may have residual bone or reactive osseous reaction
Effects on destruction

fibrosarcoma involving the right maxillary
sinus has destroyed the cortical
boundaries of the sinus, zygomatic
process, hard palate and posterior
maxilla, and the alveolar process
Differential diagnosis
Management
4. MALIGNANCIES OF THE HEMATOPOIETIC SYSTEM
synonym : myeloma , plasma cell myeloma , plasmacytoma
malignant neoplasm of plasma cells
most common malignancy of bone in adult
single : plasmacytoma
multiple : multiple myeloma
Clinical features
surrounding root resorption is uncommon
displaced teeth
widening of PDL space
if involve periosteum : Codman's triangle or Sunray appearence
1) Ewing's sarcoma and radiolucent osteosarcoma . hard to distinguish
2) Grossly infected dental cyst - it shows increased peripheral sclerosis in adj bone than
fibrosarcoma
surgical with wide margin , radiation , chemo
4.1 Multiple Myeloma
Males > Females
between 35 - 70 years old
fatal
fatigue , weight loss, fever, bone pain , anemia
2nd signs : amyloidosis, hypercalcemia
 in 50% patients : Bence Jones protein in urine -> foamy
occupy cancellous first before cortical
dental pain , swelling , hemorrhage , paresthesia , or no complains
Radiographic features Location > mandible , posterior body and ramus
jaw involvement vary ( 2% - 78% )
Periphery and well defined
Shape lacks any sign of bone reaction
'punched out' appearance , lacking any cortical boundary
In skull

some oval , cystic shape

multiple aggressive areas become confluent ,giving appearance of
present through the body and multilocularity
ramus of the mandible soft tissue lesions may occur
Internal no internal structure
structure occasionally, islands of residual bone
Effects on good deal of bone mineral is lost. thus, teeth appear 'too opaque' or
surrounding 'stand out' when compare to osteopenic background
loss of cortical boundary (whole or in partly) in lamina dura, mandibular
canal
thinning of the inferior border of mandible
Solitary lesion in the condylar neck
region and a pathologic fracture
(arrow).

Differential Diagnosis 1) radiolucent form of metastatic carcinoma

any distant malignancy elsewhere ?
2) osteomyelitis
 sign of inflammation clinically
sclerosis in adjacent bone unlike multiple myeloma
3) bilateral simple bone cyst
corticated
interdigitate between roots of teeth
younger population
4) hyperparathyroidism
check blood chemistry
Management chemotherapeutic
with or without bone marrow transplant
radiation

4.2 Non - Hodgkin's Lymphoma

synonym : malignant lymphoma , lymphosarcoma
malignant tumor of cells normally resident in lymphatic system
lymphoma is either intra-capsule or extra-capsule eg : bone , skin

Clinical features all age group but rare in 1st decade

sinus, palate , tonsillar area , bone
feel unwell,night sweats , pruritus , weight loss
palpable painless swelling , lymphadenopathy , sensorineural deficit
longer time -> pain and ulcers
mobile teeth
Radiographic features Location mostly lymph nodes
if extra-capsule : sinus , posterior mandible , maxillary regions
Periphery and take shape of host bone
shape if untreated , destructive to cortex
rounded or multiloculated
lack cortication
ill defined border
Internal structure entirely radiolucent
ill-defined bone destruction and loss
of the anterior aspect of the floor Effects on maxillary antral walls may be lost
of the maxillary antrum surrounding soft tissue mass may be visible
destroys cortex eg : mandibular canal , crypts in developing teeth->
displaces teeth occlusally and exfoliated
ill-defined
bone may grow in PDL space
destruction
and the lack
of any bone ill-defined lymphoma invading the left body of the mandible; note
reaction or the irregular widening of the periodontal ligament spaces (arrows
formation.

grow along soft tissue spaces ( fat ) and surface of bone

Differential diagnosis 1) Multiple myeloma

2) Metastatic carcinoma
3) Ewing 's sarcoma younger age group
4) Langerhan's histiocytosis
5) Squamous cell carcinoma arising in sinus
 * lesions that displace tooth occlusally : leukemia and langerhan's histiocytosis
Management radiation with or without chemotherapy

4.3 Burkitt's Lymphoma

synonym : African jaw lymphoma
high grade B cell lymphomas
2 separate form :
1. endemic African
- young children, jaw involvement
2. American
- adolescents and young adults , characterized by inv. of abdominal viscera

Clinical features Males > Females

more in children as young as 2 y.o and adults 7th decade
rapid growth , tumor doubling time of less than 24 hours (african)
facial deformity very early
blocking nasal passages
displacing orbital contents
eroding through skin
pain , parasthesia
teeth loosened rapidly
grossly distenden alveolar bone
Radiographic features
Differential diagnosis
Management
malignant tumor of hematopoietic stem cells
displace normal bone marrow constituents and spill out into peripheral blood
Location posterior part of one jaw or both
Peripheral and multiple ill defined
shape non corticated radiolucencies
expansile periphery
no specific shape
Internal structure radiolucent
doesnt produce bone or cause bone reaction in center
Effects of grossly displaced teeth
surrounding displaces tooth buds
if under developing tooth, it ceases the root development
loss of lamina dura
destroys cortical boundary
if periosteal is involved , sun ray appearance
1) Metastatic neuroblastoma
2) Ewings Sarcoma
3) Osteolytic osteosarcoma
4) Cherubism
bilateral
more internal structure
doesnt breach bony border
slower growth rate
chemotherapeutic
4.4 Leukemia
 acute and chronic
most cases, non random chromosomal abnormalities
Clinical features
Radiographic features
multifocal areas of bone destruction
and widening of portions of the
periodontal ligament space
chronic : no complain
acute : feel unwell, weakness, bone pain
pallor , spontaneous hemorrhage , hepatomegaly, splenomegaly , lymphadenopathy , fever
loose teeth , petechiae , boggy enlarged gingiva , ulceration
Location all over body
in jaw , > areas of developing teeth
may be localized around periapical . giving appearance of rarefying
osteitis
Periphery and bilaterally (systemic disease )
shape ill defined
patchy radiolucency
untreated, they coalesce to form larger areas
teeth may 'stand out' from osteopenic surrounding
Internal structure patchy areas of radiolucency
generalized radiolucency ( advanced )
Effects on does not cause bone expansion
surrounding developing teeth may be displaced occlusally before root
development
 loss of lamina dura
loss of crestal bone
Differential diagnosis 1) lymphoma
2) neuroblastoma
Management chemotherapy
bone marrow transplantation