A 22-year-old male visited a general dentist for his annual checkup. Radiographic examination revealed a radiopaque area surrounding the distal root of tooth #19.
Joen Iannucci Haring, DDS, MS
History
The patient was unaware of the lesion in the left mandible and denied any recent history of pain in the involved molar region. In addition, the patient denied any sensitivity to hot or cold in the area of the affected tooth.
At the time of the dental visit, the patient appeared to be in a general good state of health. His past medical history included routine childhood diseases, a tonsillectomy, and broken bones as a result of an automobile accident.
No medications were being taken by the patient at the time of the dental examination. The patient`s past dental history included regular dental examinations and routine dental treatment.
Examinations
The patient`s vital signs were all found to be within normal limits. A physical examination of the head and neck region revealed no enlarged or palpable lymph nodes. No abnormal extraoral findings were identified.
After a thorough intraoral examination, a panoramic radiograph and selected periapical radiographs were ordered and exposed. Examination of the panoramic radiograph revealed a solitary well-defined radiopacity in the left mandible. In order to view the area more closely, a periapical radiograph of the left mandibular molar area was exposed (see radiograph). The radiopacity appeared well-defined and was located below the apex of the distal root of tooth #19.
Subsequent to the identification of the radiopacity, the soft tissues of the left mandibular quadrant were examined and the bone was evaluated for expansion. No bony or soft tissue abnormalities were identified. The teeth in the lower left quadrant were all pulp tested for vitality; tooth #19 tested non-vital. Further examination of the oral cavity revealed no unusual or abnormal findings.
Clinical Diagnosis
Based on the clinical and radiographic information presented, which of the following is the most likely clinical diagnosis?
- osteoma
- condensing osteitis
- ossifying fibroma
- benign cementoblastoma
- periapical cemental dysplasia
Diagnosis
__ condensing osteitis
Discussion
Condensing osteitis (also known as focal sclerosing osteomyelitis) is the most common tooth-associated radiopacity viewed on dental radiographs. Condensing osteitis is believed to represent a focal bony reaction to a low-grade inflammatory stimulus resulting from a tooth with a non-vital pulp.
Clinical Features
Condensing osteitis is most often seen in young adults, although it can occur at any age. There is no sex predilection. Condensing osteitis occurs most frequently in the mandible, with most cases appearing in the premolar/molar region. The mandibular first molar is most commonly involved.
Condensing osteitis is asymptomatic and is typically discovered during radiographic examination. No symptoms or bony expansion are present. This lesion is always associated with pulpal death and necrosis and consequently, the involved tooth is always non-vital.
Radiographic Features
Condensing osteitis appears as a solitary radiopacity with fairly well-defined borders and uniform radiodensity. The lesion is seen extending below the roots of the involved tooth. The lesion size is variable; generally, condensing osteitis will measure less than one centimeter in diameter.
The surrounding lamina dura and periodontal ligament space of the involved root appears obliterated. In addition, the lesion does not exhibit a radiolucent rim surrounding the radiopacity, as seen with the benign cementoblastoma.
Differential Diagnosis
Condensing osteitis is typically diagnosed based on the clinical presentation and radiographic appearance: an asymptomatic, well-defined radiopacity surrounding the apex of a non-vital tooth is characteristic for condensing osteitis. Other lesions that may resemble condensing osteitis on a dental radiograph include periapical cemental dysplasia (RDH March 1990), the osteoma (RDH February 1995), and the benign cementoblastoma (RDH August 1992).
Diagnosis and Treatment
The treatment for condensing osteitis involves treating the offending tooth that is the source of inflammation. Treatment options include extraction or endodontic therapy. Following treatment, approximately 85% of cases will exhibit partial or complete resolution; the resolution of the lesion is associated with the normalization of the periodontal ligament.
Periodic post-treatment radiographs can be used to evaluate the lesion as it resolves. In the majority of cases, the lesion eventually exhibits a normal bony appearance on follow-up radiographs.
lesion size is variable; generally, condensing osteitis will measure less than one centimeter in diameter.
The surrounding lamina dura and periodontal ligament space of the involved root appears obliterated. In addition, the lesion does not exhibit a radiolucent rim surrounding the radiopacity, as seen with the benign cementoblastoma.
Differential Diagnosis
Condensing osteitis is typically diagnosed based on the clinical presentation and radiographic appearance: an asymptomatic, well-defined radiopacity surrounding the apex of a non-vital tooth is characteristic for condensing osteitis. Other lesions that may resemble condensing osteitis on a dental radiograph include periapical cemental dysplasia (RDH March 1990), the osteoma (RDH February 1995), and the benign cementoblastoma (RDH August 1992).
Diagnosis and Treatment
The treatment for condensing osteitis involves treating the offending tooth that is the source of inflammation. Treatment options include extraction or endodontic therapy. Following treatment, approximately 85% of cases will exhibit partial or complete resolution; the resolution of the lesion is associated with the normalization of the periodontal ligament.
Periodic post-treatment radiographs can be used to evaluate the lesion as it resolves. In the majority of cases, the lesion eventually exhibits a normal bony appearance on follow-up radiographs.
Joen Iannucci Haring, DDS, MS, is an associate professor of clinical dentistry, Section of Diagnostic Services, The Ohio State University College of Dentistry.
