Clinical approach to osteolytic lesions

OBJECTIVES The objective of this Module is to in-troduce the clinician to the correct ap-proach for the diagnostic manage-ment of osteolytic lesions both of the maxilla and mandible. It is true that only histologic examination provides a certain diagnosis. However, the clini-cian must always have in mind a diag-nostic hypothesis based on the clinical and radiographic exam. Therefore, in order to guide therapeutic decisions, caution must be taken during the ex-tra-oral and intra-oral examination that will be carried out pre-operatively. To aid the diagnostic process, the cli-nician will follow a specific list of ra-diographic criteria in order to identify the benign or malignant nature of the lesion. MATERIALS AND METHODS The most recent available international literature, has been taken into consid-eration. Articles have been found through the main research databases (PubMed, Medline, Scopus, Google Scholar and Cochrane Library), all combined with decades of academic clinical experience of the authors. RESULTS Exclusion criteria are based on a com-prehensive patient anamnesis com-bined with clinical and radiographic data. These three selection methods have been staged to establish when a surgery is preferred to a monitor ap-proach. Firstly, the anamnesis allows the iden-tification of osteolytic lesions related to Gorlin-Goltz or Marfan syndrome as well as analysis of past dental surger-ies (i.e. apicectomy or history of ex-tractions). Secondly, clinical informa-tion about signs and symptoms, a full perio chart including bleeding on prob-ing, suppuration and/or mobility allow the clinician to direct the diagnosis to-wards a more or less aggressive le-sion. Finally, radiographic information allows to assess the extension of the lesion and its relation to adjacent structures (i.e. dental elements, corti-cal bone, adjacent vascular-nervous bundles, etc). DISCUSSION Osteolytic non-cancerous lesions do not cause symptoms unless they are large expansive lesions. These are generally late diagnosis cases that result in pain and sense of tension on the soft tissues. Radiographically, to note that large non-cancerous le-sions may lead to cortical erosion without causing dysesthesia and/or parestesia. In contrast, when cancer lesions en-croach adjacent structures, they can become symptomatic with possible involvement of nerve bundles. From a radiographic point of view, cancer le-sions show a rapid expansive growth and can erode the cortical bone. It is also possible that they are associated with rhizolysis of the dental elements involved in the lesion. CONCLUSIONS Among the osteolytic lesions, the den-tal surgeon must be able to discrimi-nate the benign from the malignant ones through an in-depth anamnestic knowledge and careful clinical and ra-diographic investigation. This approach allows to determine the lesions that re-quire an observational approach versus an interventional one on the base of the histo-pathologic outcome. CLINICAL SIGNIFICANCE Adequate anamnestic clinical and ra-diographic evaluation of an osteolytic lesion becomes critical for diagnostic purposes to ensure predictable thera-peutic management and to establish prognosis.