Condensing osteitis: etiology, anatomy, clinical presentation and treatment

Condensing osteitis (focal sclerosing osteomyelitis, focal sclerosing osteitis) is a localized area of increased bone formation around the apex of the tooth root that forms in response to prolonged exposure to a bacterial irritant.

Etiology

The development of condensing osteitis is thought to be due to a prolonged inflammatory process associated with the activity of low-virulent microflora in the root canal system of a tooth with irreversible pulpitis, pulp necrosis, or chronic apical periodontitis. In this condition, instead of resorption, osteoblasts are stimulated by growth factors/cytokines and trabecular or cancellous bone grows around the apex of the tooth root. It is more common in childhood and young adulthood in the mandibular premolars or molars, but can occur in any tooth.

Process outcome

Healing after endodontic treatment, remodeling of excess bone tissue to normal may occur.

Anatomy

The lesion is usually found around the root tips of the molar or premolar roots of the mandible.

The affected tooth may be observed in the affected tooth:

• A carious cavity that penetrates the pulp of a tooth;
• A tooth restoration close to the pulp chamber or directly adjacent to the pulp tissue;
• Restoration of a tooth with signs of impaired seal (defects, cracks in the restoration, pigmentation on the margin, secondary caries);
• Signs of trauma (cracks, chipped enamel, dentin).

The pulp of the tooth is represented by whitish dense coarse-fibered scar tissue, or necrotic and has a yellowish-gray or gray-black color. The space of the periodontal ligament may be widened. In the periapical area there is a concentric deposition of bone substance infiltrated with a small number of lymphocytes, without bone destruction.

As the medullary spaces shrink and obliterate, the bone takes on the appearance of compact bone with reduced lacunae, many of which do not contain osteocytes.

Diagnosis of condensing osteitis

• Collection of complaints and history;
• Clinical methods: visual inspection, percussion, palpation along the transitional fold;
• Thermoprobe, electroodontodiagnostics;
• Radiography (intraoral contact radiography, radiovisiography, orthopantomography, cone beam computed tomography): carious cavity, restoration or traumatic defect penetrating into the pulp chamber, expansion of the periodontal ligament may be detected. A well-defined or faintly visible concentrically oriented radio-contrast formation without a radiopaque rim in the region of the root apex. The compact lamina around the root apex is usually without visible pathologic changes.

Clinical manifestations

The process is usually asymptomatic or the patient may present complaints characteristic of chronic irreversible pulpitis (prolonged pain due to thermal, chemical stimuli). Depending on the cause, a deep carious cavity, restoration or traumatic defect penetrating into the pulp chamber is visually identified in the tooth.

Percussion is usually painless, palpation of the transitional fold is painless. The thermal test may be positive in the presence of a vital pulp in a state of irreversible inflammation, or there may be no response to a thermal stimulus in the case of pulp necrosis. The causative tooth does not respond to the electrical stimulus or has a higher electrical stimulation threshold than healthy teeth.

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Treatment of condensing osteitis

Endodontic treatment of the tooth is carried out: pulp removal, instrumentation and medication of root canals, then their obturation with subsequent restoration of the tooth.

If the prognosis of endodontic treatment is unsatisfactory, the tooth should be extracted.