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Idiopathic bone cavity associated with a necrotic pulp and facial cellulitis
0099-2399-83/0908-0332/$02.00/0 JOURNAL OF ENDODONTIGS Copyright @ 1983 by the American Association of Endedontists
Printed in U.S.A. VOL. 9, NO. 8, AUGUST 1983
CASE REPORT Idiopathic Bone Cavity Associated with a Necrotic Pulp and Facial Cellulitis William J. Rome, DMD, Richard H. Swan, DMD, MSD, and Mark E. Beehner, DDS
restoration was removed from the first molar. Extensive caries of leathery consistency was evident under the restoration, which extended to a necrotic pulp. The canals were instrumented to a size 40, but no drainage could be established through the canals. The preparation was temporized. An incision was then made in the buccal vestibule over the most fluctuant area of swelling, and subperiosteal dissection was accomplished in an attempt to establish drainage. No suppuration was found, but a culture was obtained of the bloody exudate. The patient was placed on 500 mg of penicillin every 6 h and given an appointment to return to the clinic in 3 days. Upon return the swelling was greatly reduced and the patient was free of pain. The endodontic therapy was then completed using gutta-percha. An onlay amalgam restoration was also placed. The radiolucency was then reevaluated. Although the radiolucency was closely associated with the roots of the pulpally involved molar and the lamina dura at the apices was missing, the lesion's large size and unusual shape were not totally consistent with what one would expect from a typical radiolucency produced by a necrotic pulp. It was concluded that two pathological entities were present in the same anatomical area. The lesion had many features consistent with an idiopathic bone cavity (traumatic bone cyst) due to its location, size, and the typical scalloping or spiking of the radiolucency between the roots of the teeth. The age and sex of the patient were also consistent for an idiopathic bone cavity. Therefore, the patient was referred to the oral and maxillofacial surgery service for further evaluation of the radiolucency. The oral surgery evaluation noted a slight expansion of the mandibular left buccal cortex in addition to the findings already mentioned above. The patient wa.s scheduled for surgical exploration of the lesion. An aspirate consisting of a watery serosanguineous fluid was first obtained prior to surgically entering the area. A window was then made in the buccal cortical plate,
When several pathological entities occur in the same anatomical location, diagnosis can sometimes be confusing or incomplete. A case report is documented in which a patient presented with a large periapical radiolucency and facial cellulitis which was at first thought to be the result of a carious nonvital mandibular molar. However, after more careful evaluation, the radiolucency was found to be consistent with an idiopathic bone cavity and not the result of the necrotic tooth.
CASE REPORT On January 12, 1982, a 15-yr-old Caucasian male reported to sick call complaining of severe constant pain and rapid swelling of the left facial area (Fig. 1). The symptoms began the day before with intermittent discomfort located in the left mandibular area. The patient was asymptomatic prior to that time, and there was no past history of odontogenic pain. Clinical examination revealed swelling of the left facial area with associated lymphadenitis and a temperature of 100~ Trismus was evident with a limited mandibular opening. A periodontal evaluation was within normal limits with normal sulcular depths. All teeth in the mandibular left quadrant were nonmobile and responded normally to pulp testing except for the mandibular first molar, which was unresponsive to thermal and electrical pulp testing and had a class three mobility. Radiographic evaluation revealed a large radiolucency associated with the roots of the mandibular first and second molars. The lamina dura along the mesial root surface of the second molar and at the apices of the nonvital first molar was absent. Caries was noted over the mesial pulp horns of the first molar (Figs. 2 and 3). With this evidence a preliminary diagnosis of a buccal space cellulitis from a necrotic mandibular first molar and an associated undiagnosed radiolucency was made. The patient's pain was relieved with an injection of 3% mepivacaine, and the clinically intact amalgam
332
Vol. 9, No. 8, August 1983
Idiopathic Bone Cavity
333
exposing a bone cavity (Fig. 4). The walls of the bony cavity were curetted and the scrapings submitted for histopathological examination. The pathology report noted chronically inflamed granulation tissue, fibrous
FtG 4. Surgical site showing the empty bone cavity.
FIG 1. Facial cellulitis, mandibular left.
FtG 5. Six-month endodontic recall showing regeneration of bone,
FIG 2. Large radiolucency associated with the mandibular first molar. Note evidence of caries over the mesial pulp horns and the loss of lamina dura about the apices of the first molar.
connective tissue, and viable bone consistent with an idiopathic bone cavity. The patient had an uneventful postoperative course, and a follow-up radiograph at 6 months revealed advanced bone regeneration (Fig. 5). DISCUSSION
FIG 3. Panograph showing the extent of the lesion, distinct scalloping between the roots of the teeth, indistinct borders, and thinning of the inferior border of the mandible.
It would be tempting for the practitioner to assume that the periapical radiolucency in this case was the result of the pulpal pathology because of the close association of the radiolucency with the apices of the tooth and the loss of the lamina dura. However, the lesion was larger than one would expect with no history of previous discomfort from the area, and the scalloping between the roots were also unusual for a lesion of pulpal origin. The idiopathic bone cavity or traumatic bone cyst occurs most frequently in young individuals, with males being affected somewhat more often than females (1). Radiographically, they are found most commonly in the posterior portion of the mandible and
334
R o m e et al.
J o u r n a l of E n d o d o n U c s
show a distinct scalloping or spiking between the roots of the associated teeth. The bony cavity may contain a small amount of straw-colored fluid, a thin connective tissue lining, or nothing other than bare bone (2). The etiology is unknown; however, in the past, the most widely accepted theory was one of intramedullary hemorrhage following trauma with subsequent degeneration of the clot and formation of an empty cavity within the bone (3). Numerous other theories have been suggested (4). Although most idiopathic bone cavities will eventually heal spontaneously, surgical intervention provides a definitive diagnosis and a stimulus for healing. Endodontics, in this case, was performed to eliminate the necrotic pulp and associated cellulitis; however, it is possible that endodontics alone may have provided the necessary stimulus to initiate a healing response in the associated bone cavity. Factors in this case that depart from the normal findings are the loss of the lamina dura, the nonvital pulp, and the resultant cellulitis. In the majority of cases of idiopathic bone cavity, the lamina dura appears to be intact (5). This was not the case in our patient, which made diagnosis difficult and causative association with the necrotic pulp tempting. Also, the idiopathic bone cavity is usually associated with vital teeth. Hansen and co-workers (2), in a review of 50 cases, reported only five nonvital teeth associated with the bone cavity. Other reports (6, 7), reviewing a total of 39 lesions, reported no association with nonvital teeth. Association of the idiopathic bone cavity with infection or cellulitis is also a rare finding (2, 7). The rapid onset of symptoms and facial swelling in our case can be explained by the loss of bone associated with the idiopathic bone cavity which resulted in little
resistance to the spread of inflammation to the soft tissues. SUMMARY A case report has been presented documenting an infected idiopathic bone cavity associated with a necrotic pulp and an acute odontogenic facial cellulitis. The diagnostic dilemma which can occur when several pathological entities present in the same anatomical area and interact with one another was discussed. Dentists must be cautious in assuming a causative relationship between necrotic pulp tissue and all associated periapical radiolucencies. The opinions or conclusions contained in this article are those of the authors and are not to be construed as official or reflecting the views of the United States Air Force. Dr. Rome is a Lt. Colonel and OIC, endodontics, United States Air Force Clinic, Randolph Air Force Base, TX. Dr. Swan is a Lt. Colonel and assistant chief, periodontal section, Department of general dentistry, Wilford Hall Medical Center, Lackland Air Force Base, TX. Dr. Beehner is a Captain and resident, oral and maxiUofacial surgery, Wilford Hall Medical Center, Lackland Air Force Base, TX. Address requests for reprints to Dr. William J. Rome, 16622 Front Royal, San Antonio, TX 78247.
References 1. Huebner GR, Turlington EG. So-called traumatic (hemorrhagic) bone cysts of the jaws. Oral Surg 1971 ;31:354-65. 2. Hansen LS, Sapone J, Sproat RC. Traumatic bone cysts of jaws. Oral Surg 1974;37:899-910. 3. Olech E, Sicher H, Weinmann JP. Traumatic mandibular bone cysts. Oral Surg 1951 ;4:1160-72. 4. Whinery JG. Progressive bone cavities of the mandible. Oral Surg 1955;8:903-16. 5. Khosla VM. Hemorrhagic bone cyst of mandible. Oral Surg 1970;30:723-9. 6. Choukas NC, Romano J. Idiopathic bone cavities. J Oral Surg 1978;36:33-5. 7. Beasley JD. Traumatic cyst of the jaws: report of 30 cases. J Am Dent Assoc 1976;92:145-52.
New active members Rahmat Barkhordar School of Dental Medicine Department of Endodentics University of Connecticut Health Center Farmington, CT 06032 Garry L. Bey Bard Professional Bldg. Route 304 Bardonia, NY 10954
Dominic Cittadino Student Dental Service (STC) Southern Illinois University Carbondale, IL 62901 Cesar M. de Almeida Escola Superior de Medicina de Lisboa Cidade Universitaria 1600 Lisboa, Portugal
Gerald H. Hyman 49 Deepdale Parkway Roslyn Heights, NY 11577 Stetla A. Kitzenberg 229 Ward Parkway 902A Kansas City, MO 64112
Paul J. Legunn 7 D Street, #1C Pomona, NY 10970 Salim P. Sumar 7623-68th Avenue, NW Calgary, Alberta, Canada
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Printed in U.S.A. VOL. 9, NO. 8, AUGUST 1983
CASE REPORT Idiopathic Bone Cavity Associated with a Necrotic Pulp and Facial Cellulitis William J. Rome, DMD, Richard H. Swan, DMD, MSD, and Mark E. Beehner, DDS
restoration was removed from the first molar. Extensive caries of leathery consistency was evident under the restoration, which extended to a necrotic pulp. The canals were instrumented to a size 40, but no drainage could be established through the canals. The preparation was temporized. An incision was then made in the buccal vestibule over the most fluctuant area of swelling, and subperiosteal dissection was accomplished in an attempt to establish drainage. No suppuration was found, but a culture was obtained of the bloody exudate. The patient was placed on 500 mg of penicillin every 6 h and given an appointment to return to the clinic in 3 days. Upon return the swelling was greatly reduced and the patient was free of pain. The endodontic therapy was then completed using gutta-percha. An onlay amalgam restoration was also placed. The radiolucency was then reevaluated. Although the radiolucency was closely associated with the roots of the pulpally involved molar and the lamina dura at the apices was missing, the lesion's large size and unusual shape were not totally consistent with what one would expect from a typical radiolucency produced by a necrotic pulp. It was concluded that two pathological entities were present in the same anatomical area. The lesion had many features consistent with an idiopathic bone cavity (traumatic bone cyst) due to its location, size, and the typical scalloping or spiking of the radiolucency between the roots of the teeth. The age and sex of the patient were also consistent for an idiopathic bone cavity. Therefore, the patient was referred to the oral and maxillofacial surgery service for further evaluation of the radiolucency. The oral surgery evaluation noted a slight expansion of the mandibular left buccal cortex in addition to the findings already mentioned above. The patient wa.s scheduled for surgical exploration of the lesion. An aspirate consisting of a watery serosanguineous fluid was first obtained prior to surgically entering the area. A window was then made in the buccal cortical plate,
When several pathological entities occur in the same anatomical location, diagnosis can sometimes be confusing or incomplete. A case report is documented in which a patient presented with a large periapical radiolucency and facial cellulitis which was at first thought to be the result of a carious nonvital mandibular molar. However, after more careful evaluation, the radiolucency was found to be consistent with an idiopathic bone cavity and not the result of the necrotic tooth.
CASE REPORT On January 12, 1982, a 15-yr-old Caucasian male reported to sick call complaining of severe constant pain and rapid swelling of the left facial area (Fig. 1). The symptoms began the day before with intermittent discomfort located in the left mandibular area. The patient was asymptomatic prior to that time, and there was no past history of odontogenic pain. Clinical examination revealed swelling of the left facial area with associated lymphadenitis and a temperature of 100~ Trismus was evident with a limited mandibular opening. A periodontal evaluation was within normal limits with normal sulcular depths. All teeth in the mandibular left quadrant were nonmobile and responded normally to pulp testing except for the mandibular first molar, which was unresponsive to thermal and electrical pulp testing and had a class three mobility. Radiographic evaluation revealed a large radiolucency associated with the roots of the mandibular first and second molars. The lamina dura along the mesial root surface of the second molar and at the apices of the nonvital first molar was absent. Caries was noted over the mesial pulp horns of the first molar (Figs. 2 and 3). With this evidence a preliminary diagnosis of a buccal space cellulitis from a necrotic mandibular first molar and an associated undiagnosed radiolucency was made. The patient's pain was relieved with an injection of 3% mepivacaine, and the clinically intact amalgam
332
Vol. 9, No. 8, August 1983
Idiopathic Bone Cavity
333
exposing a bone cavity (Fig. 4). The walls of the bony cavity were curetted and the scrapings submitted for histopathological examination. The pathology report noted chronically inflamed granulation tissue, fibrous
FtG 4. Surgical site showing the empty bone cavity.
FIG 1. Facial cellulitis, mandibular left.
FtG 5. Six-month endodontic recall showing regeneration of bone,
FIG 2. Large radiolucency associated with the mandibular first molar. Note evidence of caries over the mesial pulp horns and the loss of lamina dura about the apices of the first molar.
connective tissue, and viable bone consistent with an idiopathic bone cavity. The patient had an uneventful postoperative course, and a follow-up radiograph at 6 months revealed advanced bone regeneration (Fig. 5). DISCUSSION
FIG 3. Panograph showing the extent of the lesion, distinct scalloping between the roots of the teeth, indistinct borders, and thinning of the inferior border of the mandible.
It would be tempting for the practitioner to assume that the periapical radiolucency in this case was the result of the pulpal pathology because of the close association of the radiolucency with the apices of the tooth and the loss of the lamina dura. However, the lesion was larger than one would expect with no history of previous discomfort from the area, and the scalloping between the roots were also unusual for a lesion of pulpal origin. The idiopathic bone cavity or traumatic bone cyst occurs most frequently in young individuals, with males being affected somewhat more often than females (1). Radiographically, they are found most commonly in the posterior portion of the mandible and
334
R o m e et al.
J o u r n a l of E n d o d o n U c s
show a distinct scalloping or spiking between the roots of the associated teeth. The bony cavity may contain a small amount of straw-colored fluid, a thin connective tissue lining, or nothing other than bare bone (2). The etiology is unknown; however, in the past, the most widely accepted theory was one of intramedullary hemorrhage following trauma with subsequent degeneration of the clot and formation of an empty cavity within the bone (3). Numerous other theories have been suggested (4). Although most idiopathic bone cavities will eventually heal spontaneously, surgical intervention provides a definitive diagnosis and a stimulus for healing. Endodontics, in this case, was performed to eliminate the necrotic pulp and associated cellulitis; however, it is possible that endodontics alone may have provided the necessary stimulus to initiate a healing response in the associated bone cavity. Factors in this case that depart from the normal findings are the loss of the lamina dura, the nonvital pulp, and the resultant cellulitis. In the majority of cases of idiopathic bone cavity, the lamina dura appears to be intact (5). This was not the case in our patient, which made diagnosis difficult and causative association with the necrotic pulp tempting. Also, the idiopathic bone cavity is usually associated with vital teeth. Hansen and co-workers (2), in a review of 50 cases, reported only five nonvital teeth associated with the bone cavity. Other reports (6, 7), reviewing a total of 39 lesions, reported no association with nonvital teeth. Association of the idiopathic bone cavity with infection or cellulitis is also a rare finding (2, 7). The rapid onset of symptoms and facial swelling in our case can be explained by the loss of bone associated with the idiopathic bone cavity which resulted in little
resistance to the spread of inflammation to the soft tissues. SUMMARY A case report has been presented documenting an infected idiopathic bone cavity associated with a necrotic pulp and an acute odontogenic facial cellulitis. The diagnostic dilemma which can occur when several pathological entities present in the same anatomical area and interact with one another was discussed. Dentists must be cautious in assuming a causative relationship between necrotic pulp tissue and all associated periapical radiolucencies. The opinions or conclusions contained in this article are those of the authors and are not to be construed as official or reflecting the views of the United States Air Force. Dr. Rome is a Lt. Colonel and OIC, endodontics, United States Air Force Clinic, Randolph Air Force Base, TX. Dr. Swan is a Lt. Colonel and assistant chief, periodontal section, Department of general dentistry, Wilford Hall Medical Center, Lackland Air Force Base, TX. Dr. Beehner is a Captain and resident, oral and maxiUofacial surgery, Wilford Hall Medical Center, Lackland Air Force Base, TX. Address requests for reprints to Dr. William J. Rome, 16622 Front Royal, San Antonio, TX 78247.
References 1. Huebner GR, Turlington EG. So-called traumatic (hemorrhagic) bone cysts of the jaws. Oral Surg 1971 ;31:354-65. 2. Hansen LS, Sapone J, Sproat RC. Traumatic bone cysts of jaws. Oral Surg 1974;37:899-910. 3. Olech E, Sicher H, Weinmann JP. Traumatic mandibular bone cysts. Oral Surg 1951 ;4:1160-72. 4. Whinery JG. Progressive bone cavities of the mandible. Oral Surg 1955;8:903-16. 5. Khosla VM. Hemorrhagic bone cyst of mandible. Oral Surg 1970;30:723-9. 6. Choukas NC, Romano J. Idiopathic bone cavities. J Oral Surg 1978;36:33-5. 7. Beasley JD. Traumatic cyst of the jaws: report of 30 cases. J Am Dent Assoc 1976;92:145-52.
New active members Rahmat Barkhordar School of Dental Medicine Department of Endodentics University of Connecticut Health Center Farmington, CT 06032 Garry L. Bey Bard Professional Bldg. Route 304 Bardonia, NY 10954
Dominic Cittadino Student Dental Service (STC) Southern Illinois University Carbondale, IL 62901 Cesar M. de Almeida Escola Superior de Medicina de Lisboa Cidade Universitaria 1600 Lisboa, Portugal
Gerald H. Hyman 49 Deepdale Parkway Roslyn Heights, NY 11577 Stetla A. Kitzenberg 229 Ward Parkway 902A Kansas City, MO 64112
Paul J. Legunn 7 D Street, #1C Pomona, NY 10970 Salim P. Sumar 7623-68th Avenue, NW Calgary, Alberta, Canada
'