0099-2399/91/1708-0396/$03.00/0 JOURNAL OF ENOOOONTICS Copyright 9 1991 by The American Association of Endodontists
Printed in U.S.A.
VOL. 17, NO. 8, AUGUST 1991
CASE REPORT Cavitational Bone Defect: A Diagnostic Challenge Ronald O. Segall, DMD, MS, and Carlos E. del Rio, DDS
A patient with a history of trauma to the maxillary left anterior region presented with chronic pain of unknown etiology. Root canal therapy and periradicular surgery failed to resolve the persistent pain. A second surgical procedure revealed a bone cavity superior and distopalatally to the apex of the maxillary left lateral incisor. The suspected etiology was necrotic bone removed from the bone cavity.
bites, and smoke. She was presently taking Ovral for birth control, Dimetapp for a nonspecific rhinitis, and Gantrasin for an urinary infection. The patient's dental history disclosed a fall in the bathtub 1 yr previously which traumatized the maxillary central and lateral incisors. The patient saw her dentist for evaluation, but no treatment was provided. A follow-up examination did not reveal any sequelae. The present complaint was of sporadic pain for several months which slowly developed into continuous pain in the area of the left maxillary incisors. Clinical examination revealed the maxillary left central incisor to be sensitive to palpation and percussion with normal mobility, but elongated 1.5 mm. The pain appeared to be radiating from the left maxillary central incisor. Pulpal vitality tests showed that the central incisor overreacted to cold and gave an electric pulp test (Burton Vitalometer, Van Nuys, CA) reading of 2, which was in the normal range for this patient. The maxillary left lateral incisor was rotated with the mesiat side showing. The left lateral incisor was completely asymptomatic and responded to the electric pulp test with a reading of 2.5. Radiographic survey showed no osseous changes (Fig. I). Due to extreme pain, history of trauma, and localization of pain to the left maxillary central incisor, it was decided to initiate root canal treatment. The periradicular area of the tooth was anesthetized and the pain subsided. Upon extirpation of the pulp, it was noted that it appeared to be normal. Instrumentation was completed and the tooth was medicated with metacresylacetate (Cresatin; Union Broach, New York, NY). The patient returned the following day with pain. The tooth was irrigated, dried, medicated, and closed with Cresatin. The pain returned immediately after closure of the access cavity. The access was reopened and the symptoms subsided. Although there was no fluid present in the root canal, it was decided to leave the tooth open. During a 1-month period, three attempts were made at closure of the tooth. Pain returned after each attempt. Finally, the patient was scheduled for periradicular surgery. The root canal was obturated with gutta-percha and periradicular surgery was performed. The cortical plate was intact and no lesion was present at the apex. The apex was beveled, the apical area was curetted, and the surgical procedure was completed (Fig. 2). The patient returned the day after surgery with malaise and a temperature of 98.4"F. Due to the presence of malaise, the patient was
Most cases requiring root canal treatment are uncomplicated to diagnose and treat. Occasionally, one comes up against a diagnostic dilemma. When pulp vitality tests are not definitive, osseous changes are not apparent on radiographs, and the patient's pain does not resolve after treatment, the practitioner must use all his knowledge and past experiences in an attempt to arrive at an accurate diagnosis and treatment plan. Ratner et al. (1, 2), Roberts et al. (3) and Roberts and Person (4) documented several cases of jawbone cavities with atypical facial neuralgias. These authors found that painful phenomena were almost always associated with bone cavities at previous tooth extraction sites. In most cases, they were unable to detect the bone cavities radiographically. Many of the patients had been through root canal treatment, apical surgeries, and extractions in attempts to eradicate their pain. The following case report coincides with most of the characteristics described in the literature (1-4). However, there were no missing teeth in the area of the painful stimulus and the bone cavity was set apart from the apex of the natural dentition. CASE R E P O R T A 21-yr-old white female was referred to one of the authors (R. S.) for evaluation and treatment. The patient's occupation was that of a flutist in the U.S. Army Band. Her medical history showed a functional heart murmur for which medication was not indicated. She bad a medical history of a stomach ulcer 7 yr previously, bilateral ovarian cyst surgery 1 yr previously, and allergies to opium derivatives, insect
396
Voh 17, No. 8, August 1991
Bone Defect
397
F~G 1. Diagnostic radiograph indicating normal bone pattern and rotation of left lateral incisor.
FIG 2. Two-month postsurgical radiograph of the maxillary left central incisor.
given a prescription for Penicillin VK (500 mg four times a day for 10 days). Sutures were removed 1 wk later and healing was progressing uneventfully. At this time, the left maxillary lateral incisor was tested. The electric pulp test (Burton Vitalometer) reading was 4 on a scale of 14, a normal response. The tooth was slightly sensitive to percussion. Two months later, the patient returned with recurrent pain in the maxillary anterior region. At this time, the pain was radiating from the left maxillary lateral incisor which was sensitive to percussion. Although the electric pulp test was in the normal range (3.5 on a scale of 14), based on the origin of the pain and the history of trauma, root canal therapy was started in the maxillary left lateral incisor. Access was achieved and the canal was fully instrumented. The tooth was medicated with formocresol and sealed with Cavit (Premier, Norristown, PA). The extirpated pulp appeared to be normal, as had been the pulp of the maxillary left central incisor. Although the patient experienced relief, adequate anesthesia was not obtained during the procedure. Six days later, the tooth was asymptomatic and the canal was obturated. After 3 months, the patient returned complaining of continuous pain with muscle spasms and radiating headaches. The patient described headaches as starting in the left maxillary central and lateral incisors and radiating to the left eye. There were no radiological changes in the periradicular area. The patient was referred to a periodontist for evaluation of possible TMJ dysfunction which was causing muscle spasms. After the diagnosis by the periodontist of TMJ dysfunction
and in conjunction with the periodontist, it was decided to treat the patient with a bite guard making certain the maxillary left central and lateral incisors were not in occlusion. The patient was asked to refrain from playing the flute. There was improvement in the TMJ dysfunction. However, there was no improvement in the pain in the maxillary left incisor area. The pain seemed to subside for short periods of time but tended to reappear. During the following year, there were episodes of exacerbation alternating with painless periods. The patient conservatively increased the time she was playing the flute. Also, during this 1-yr period, the periodontist continued to treat the patient for TMJ dysfunction. Various occlusal adjustments were made and a frenectomy was performed. One month after the yearly evaluation the patient called to report an increase in pain. The maxillary central and lateral incisors were sensitive to palpation and percussion. Radiographs still did not show any osseous changes (Fig. 3). The mucobuccal fold on the left side appeared to be more hyperemic than the fight mucobuccal fold. Due to the continuous pattern of exacerbations, it was decided to perform exploratory periradicular surgery on the left maxillary lateral incisor. The area was anesthetized and a full mucoperiosteal flap was elevated. The cortical plate over the central and lateral incisors was intact (Fig. 4). During the making of the surgical window in the apical area of the lateral incisor, a bone cavity was discovered superior and distopalatally to the apex of the lateral incisor. The cavity was separated from the apex by approxi-
398
Segall and del Rio
Journal of Endodontics
FIG 5. Bone cavity (,) uncovered superior and distopalatally to the apex (arrowhead) of the maxillary left lateral incisor.
FtG 3. Radiograph of the bone appearance of the maxillary left central and lateral incisors just prior to apical surgery on the lateral.
Fte 4. Clinical appearance of the intact cortical plate over the maxillary left central and lateral incisors.
FIG 6. Immediate postoperative radiograph after apical surgery of the maxillary left lateral incisor. There is an apical amalgam in the apex of the lateral.
mately 2 to 3 m m of normal bone (Fig. 5). Tissue, fibrotic in consistency and containing osseous spicules, was curetted from the osseous cavity for biopsy. An apical amalgam was placed in the lateral incisor (Fig. 6). The flap was coapted and sutured. The patient was placed prophylactically on 250 mg of Penicillin VK for 10 days and postoperative instructions were given. The sutures were removed 1 wk later and healing was progressing uneventfully. There had been no pain since
the day of the apical surgery. Shortly after the operation, the patient resumed her musical career, playing the flute for 2 h daily. The biopsy report indicated there was sequestered osseous tissue with necrosis and loose connective tissue containing a few scattered chronic round inflammatory cells. There was a small section of fibrous connective tissue rimming the larger bone fragment (Fig. 7).
Bone Defect
Vol. 17, No. 8, August 1991
The patient has been periodically followed. She has had no discomfort or pain in the left maxillary incisor area for a period of l0 yr (Fig. 8).
FtG 7. Photomicrograph of tissue curetted from the bone cavity superior to the maxillary left lateral incisor. Note sequestered osseous tissue with necrosis (arrowhead) and fibrous connective tissue rimming part of the fragment. There is also loose connective tissue containing a few scattered chronic round inflammatory cells (,) (hematoxylin and eosin; original magnification •
399
DISCUSSION Throughout the treatment phase, there were always enough indications to perform an endodontic procedure. In retrospect, apical surgery should have been instituted much earlier on the lateral incisor. However, apical surgery of the central incisor did not provide any knowledge of the problem since there appeared to be no reason for surgery when the apex was exposed. Also, the bony cavity was found by chance. If the initial penetration in the apical area had been lower, the bony cavity would have been completely missed due to the 2 to 3 mm of intact bone over the apex. Other authors have demonstrated that both cancellous bone and cortical plate must be removed before defects can be detected radiographically (5-9). In this instance, the radiolucency that would have been so important in the diagnosis of the lesion was never apparent. Root canal treatment was done solely because of severe pain, history of trauma, and lack of a better differential diagnosis. There was never a doubt that the patient was in pain, but there was doubt that root canal treatment was necessary. The patient's occlusal disharmony and muscular pressures exerted while playing the flute were also complications in diagnosing the problem. Ratner et al. (1, 2) and Roberts and his colleagues (3, 4) have suggested that there are specific referred areas of pain from bone cavities. They have shown that local anesthesia removes all pain from the referred area when deposited over the bony cavity. However, in their case reports, their patients were missing teeth in the area of the bone cavity. This was not true in our case. The diagnosis of a bone cavity may have been considered had the articles been published prior to seeing this patient. The suspected cause of bone cavities has been postulated to be bacterial, most probably anaerobic, in nature (1-4). The source of bacteria would probably be from exposure of the extraction socket to oral fluids. In this case, it is possible there was no bacterial contamination, but just an isolated area of bone necrosis due to trauma. If bacteria were involved, it might have been due to anachoresis. A differential diagnosis of oral pain of unknown origin should include the possibility of the presence of a bone cavity as the source of pain. The probability of a bone cavity is rare. It should not be considered until all other possibilities are thoroughly investigated and discarded. Readers are urged to review previous articles (1-4) before surgically exploring for bone cavities. Exploration in the mental nerve and maxillary sinus area may cause more severe problems if the anatomical structures are not observed. It is likely that any bone cavity would be in close proximity to the apices of the teeth rather than at a large distance away. Only after a thorough diagnosis (1) should surgical exploration be considered. CONCLUSIONS
Fte 8. Ten-year follow-up radiograph of the maxillary left central and lateral incisors showing normal bone pattern.
Some significant conclusions can be reached from this case report: 1. Intact cortical bone is no indication of healthy cancellous bone. 2. Lesions in cancellous bone with an intact cortical plate cannot always be detected radiographically. 3. Bone cavities occur in the alveolar bone and may refer pain to the dentition.
400
Journal of Endodontics
Segall and del Rio
4. Extraction sites are not the only origin of bone cavities. 5. The origin of a bone cavity may be a traumatic incident to the alveolar bone. 6. Thorough documentation of a difficult diagnostic case is very important for future study. Dr. Segall is in private practice limited to endodontics in Frederick, MD. Dr. del Rio is professor and chairman, Department of Endodontics, The University of Texas Health Science Center at San Antonio, San Antonio, TX. Address requests for reprints to Dr. Ronald O. Segall, Amber Meadows Professional Bldg. 12, 198 Thomas Johnson Drive, Frederick, MD 21702.
References 1. Ratner EJ, Langer B, Evins ML. Alveolar cavitational osteopathosis. Manifestations of an infectious process and its implication in the causation of
chronic pain. J Periodonto11986;57:593-603. 2. Ratner EJ, Person P, Kleinman DJ, Shklar G, Socransky SS. Jawbone cavities and trigeminal facial neuralgias, Oral Surg 1979;48:3-20. 3. Roberts AM, Person P, Chandran NB, Hod JM. Further observations on dental parameters of trigeminal and atypical facial neuralgias. Oral Surg 1984;58:121-9. 4. Roberts AM, Person P. Etiology and treatment of idiopathic trigeminal and atypical facial neuralgias. Oral Surg 1979;48:298-308. 5. LeQuire AK, Cunningham CJ, Pelleu GB. Radiographic interpretation of experimentally produced osseous lesions of the human mandible. J Endodon 1977;3:274-6. 6. Bender IB, Seltzer S. Roentgenographic and direct observation of experimental lesions in bone. I. J Am Dent Assoc 1961 ;62:152-60. 7. Bender IB, Seltzer S. Roentgenographic and direct observation of experimental lesions in bone. II. J Am Dent Assoc 1961;62:708-16. 8. Shoha RR, Dowson J, Richards AG. Radiographic interpretation of experimentally produced bony lesions. Oral Surg 1974;38:294-302. 9. Ramadan AE, Mitchell DF. A roentgenographic study of experimental bone destruction. Oral Surg 1962;15:934-43.
You Might Be Interested to Know Most endodontists have a collection of x-rays of cases referred for retreatment which show a post placed through a perforation of the side of the root and secured in the surrounding alveolar bone. Now comes a report in the British Medical Journal accompanied by an x-ray of a femur which shows the canal filled with cement and a metal post floating free in soft tissue (BMJ 6730:301). It seems a 93-year-old woman had a hip replacement at age 80. She functioned with a walker for 13 years even though the surgeons apparently placed cement in the canal and the metal prosthesis elsewhere. We dentists are apparently not the only ones who can occasionally be a bit distracted and lose orientation during treatment.
Zachariah Yeomans
Printed in U.S.A.
VOL. 17, NO. 8, AUGUST 1991
CASE REPORT Cavitational Bone Defect: A Diagnostic Challenge Ronald O. Segall, DMD, MS, and Carlos E. del Rio, DDS
A patient with a history of trauma to the maxillary left anterior region presented with chronic pain of unknown etiology. Root canal therapy and periradicular surgery failed to resolve the persistent pain. A second surgical procedure revealed a bone cavity superior and distopalatally to the apex of the maxillary left lateral incisor. The suspected etiology was necrotic bone removed from the bone cavity.
bites, and smoke. She was presently taking Ovral for birth control, Dimetapp for a nonspecific rhinitis, and Gantrasin for an urinary infection. The patient's dental history disclosed a fall in the bathtub 1 yr previously which traumatized the maxillary central and lateral incisors. The patient saw her dentist for evaluation, but no treatment was provided. A follow-up examination did not reveal any sequelae. The present complaint was of sporadic pain for several months which slowly developed into continuous pain in the area of the left maxillary incisors. Clinical examination revealed the maxillary left central incisor to be sensitive to palpation and percussion with normal mobility, but elongated 1.5 mm. The pain appeared to be radiating from the left maxillary central incisor. Pulpal vitality tests showed that the central incisor overreacted to cold and gave an electric pulp test (Burton Vitalometer, Van Nuys, CA) reading of 2, which was in the normal range for this patient. The maxillary left lateral incisor was rotated with the mesiat side showing. The left lateral incisor was completely asymptomatic and responded to the electric pulp test with a reading of 2.5. Radiographic survey showed no osseous changes (Fig. I). Due to extreme pain, history of trauma, and localization of pain to the left maxillary central incisor, it was decided to initiate root canal treatment. The periradicular area of the tooth was anesthetized and the pain subsided. Upon extirpation of the pulp, it was noted that it appeared to be normal. Instrumentation was completed and the tooth was medicated with metacresylacetate (Cresatin; Union Broach, New York, NY). The patient returned the following day with pain. The tooth was irrigated, dried, medicated, and closed with Cresatin. The pain returned immediately after closure of the access cavity. The access was reopened and the symptoms subsided. Although there was no fluid present in the root canal, it was decided to leave the tooth open. During a 1-month period, three attempts were made at closure of the tooth. Pain returned after each attempt. Finally, the patient was scheduled for periradicular surgery. The root canal was obturated with gutta-percha and periradicular surgery was performed. The cortical plate was intact and no lesion was present at the apex. The apex was beveled, the apical area was curetted, and the surgical procedure was completed (Fig. 2). The patient returned the day after surgery with malaise and a temperature of 98.4"F. Due to the presence of malaise, the patient was
Most cases requiring root canal treatment are uncomplicated to diagnose and treat. Occasionally, one comes up against a diagnostic dilemma. When pulp vitality tests are not definitive, osseous changes are not apparent on radiographs, and the patient's pain does not resolve after treatment, the practitioner must use all his knowledge and past experiences in an attempt to arrive at an accurate diagnosis and treatment plan. Ratner et al. (1, 2), Roberts et al. (3) and Roberts and Person (4) documented several cases of jawbone cavities with atypical facial neuralgias. These authors found that painful phenomena were almost always associated with bone cavities at previous tooth extraction sites. In most cases, they were unable to detect the bone cavities radiographically. Many of the patients had been through root canal treatment, apical surgeries, and extractions in attempts to eradicate their pain. The following case report coincides with most of the characteristics described in the literature (1-4). However, there were no missing teeth in the area of the painful stimulus and the bone cavity was set apart from the apex of the natural dentition. CASE R E P O R T A 21-yr-old white female was referred to one of the authors (R. S.) for evaluation and treatment. The patient's occupation was that of a flutist in the U.S. Army Band. Her medical history showed a functional heart murmur for which medication was not indicated. She bad a medical history of a stomach ulcer 7 yr previously, bilateral ovarian cyst surgery 1 yr previously, and allergies to opium derivatives, insect
396
Voh 17, No. 8, August 1991
Bone Defect
397
F~G 1. Diagnostic radiograph indicating normal bone pattern and rotation of left lateral incisor.
FIG 2. Two-month postsurgical radiograph of the maxillary left central incisor.
given a prescription for Penicillin VK (500 mg four times a day for 10 days). Sutures were removed 1 wk later and healing was progressing uneventfully. At this time, the left maxillary lateral incisor was tested. The electric pulp test (Burton Vitalometer) reading was 4 on a scale of 14, a normal response. The tooth was slightly sensitive to percussion. Two months later, the patient returned with recurrent pain in the maxillary anterior region. At this time, the pain was radiating from the left maxillary lateral incisor which was sensitive to percussion. Although the electric pulp test was in the normal range (3.5 on a scale of 14), based on the origin of the pain and the history of trauma, root canal therapy was started in the maxillary left lateral incisor. Access was achieved and the canal was fully instrumented. The tooth was medicated with formocresol and sealed with Cavit (Premier, Norristown, PA). The extirpated pulp appeared to be normal, as had been the pulp of the maxillary left central incisor. Although the patient experienced relief, adequate anesthesia was not obtained during the procedure. Six days later, the tooth was asymptomatic and the canal was obturated. After 3 months, the patient returned complaining of continuous pain with muscle spasms and radiating headaches. The patient described headaches as starting in the left maxillary central and lateral incisors and radiating to the left eye. There were no radiological changes in the periradicular area. The patient was referred to a periodontist for evaluation of possible TMJ dysfunction which was causing muscle spasms. After the diagnosis by the periodontist of TMJ dysfunction
and in conjunction with the periodontist, it was decided to treat the patient with a bite guard making certain the maxillary left central and lateral incisors were not in occlusion. The patient was asked to refrain from playing the flute. There was improvement in the TMJ dysfunction. However, there was no improvement in the pain in the maxillary left incisor area. The pain seemed to subside for short periods of time but tended to reappear. During the following year, there were episodes of exacerbation alternating with painless periods. The patient conservatively increased the time she was playing the flute. Also, during this 1-yr period, the periodontist continued to treat the patient for TMJ dysfunction. Various occlusal adjustments were made and a frenectomy was performed. One month after the yearly evaluation the patient called to report an increase in pain. The maxillary central and lateral incisors were sensitive to palpation and percussion. Radiographs still did not show any osseous changes (Fig. 3). The mucobuccal fold on the left side appeared to be more hyperemic than the fight mucobuccal fold. Due to the continuous pattern of exacerbations, it was decided to perform exploratory periradicular surgery on the left maxillary lateral incisor. The area was anesthetized and a full mucoperiosteal flap was elevated. The cortical plate over the central and lateral incisors was intact (Fig. 4). During the making of the surgical window in the apical area of the lateral incisor, a bone cavity was discovered superior and distopalatally to the apex of the lateral incisor. The cavity was separated from the apex by approxi-
398
Segall and del Rio
Journal of Endodontics
FIG 5. Bone cavity (,) uncovered superior and distopalatally to the apex (arrowhead) of the maxillary left lateral incisor.
FtG 3. Radiograph of the bone appearance of the maxillary left central and lateral incisors just prior to apical surgery on the lateral.
Fte 4. Clinical appearance of the intact cortical plate over the maxillary left central and lateral incisors.
FIG 6. Immediate postoperative radiograph after apical surgery of the maxillary left lateral incisor. There is an apical amalgam in the apex of the lateral.
mately 2 to 3 m m of normal bone (Fig. 5). Tissue, fibrotic in consistency and containing osseous spicules, was curetted from the osseous cavity for biopsy. An apical amalgam was placed in the lateral incisor (Fig. 6). The flap was coapted and sutured. The patient was placed prophylactically on 250 mg of Penicillin VK for 10 days and postoperative instructions were given. The sutures were removed 1 wk later and healing was progressing uneventfully. There had been no pain since
the day of the apical surgery. Shortly after the operation, the patient resumed her musical career, playing the flute for 2 h daily. The biopsy report indicated there was sequestered osseous tissue with necrosis and loose connective tissue containing a few scattered chronic round inflammatory cells. There was a small section of fibrous connective tissue rimming the larger bone fragment (Fig. 7).
Bone Defect
Vol. 17, No. 8, August 1991
The patient has been periodically followed. She has had no discomfort or pain in the left maxillary incisor area for a period of l0 yr (Fig. 8).
FtG 7. Photomicrograph of tissue curetted from the bone cavity superior to the maxillary left lateral incisor. Note sequestered osseous tissue with necrosis (arrowhead) and fibrous connective tissue rimming part of the fragment. There is also loose connective tissue containing a few scattered chronic round inflammatory cells (,) (hematoxylin and eosin; original magnification •
399
DISCUSSION Throughout the treatment phase, there were always enough indications to perform an endodontic procedure. In retrospect, apical surgery should have been instituted much earlier on the lateral incisor. However, apical surgery of the central incisor did not provide any knowledge of the problem since there appeared to be no reason for surgery when the apex was exposed. Also, the bony cavity was found by chance. If the initial penetration in the apical area had been lower, the bony cavity would have been completely missed due to the 2 to 3 mm of intact bone over the apex. Other authors have demonstrated that both cancellous bone and cortical plate must be removed before defects can be detected radiographically (5-9). In this instance, the radiolucency that would have been so important in the diagnosis of the lesion was never apparent. Root canal treatment was done solely because of severe pain, history of trauma, and lack of a better differential diagnosis. There was never a doubt that the patient was in pain, but there was doubt that root canal treatment was necessary. The patient's occlusal disharmony and muscular pressures exerted while playing the flute were also complications in diagnosing the problem. Ratner et al. (1, 2) and Roberts and his colleagues (3, 4) have suggested that there are specific referred areas of pain from bone cavities. They have shown that local anesthesia removes all pain from the referred area when deposited over the bony cavity. However, in their case reports, their patients were missing teeth in the area of the bone cavity. This was not true in our case. The diagnosis of a bone cavity may have been considered had the articles been published prior to seeing this patient. The suspected cause of bone cavities has been postulated to be bacterial, most probably anaerobic, in nature (1-4). The source of bacteria would probably be from exposure of the extraction socket to oral fluids. In this case, it is possible there was no bacterial contamination, but just an isolated area of bone necrosis due to trauma. If bacteria were involved, it might have been due to anachoresis. A differential diagnosis of oral pain of unknown origin should include the possibility of the presence of a bone cavity as the source of pain. The probability of a bone cavity is rare. It should not be considered until all other possibilities are thoroughly investigated and discarded. Readers are urged to review previous articles (1-4) before surgically exploring for bone cavities. Exploration in the mental nerve and maxillary sinus area may cause more severe problems if the anatomical structures are not observed. It is likely that any bone cavity would be in close proximity to the apices of the teeth rather than at a large distance away. Only after a thorough diagnosis (1) should surgical exploration be considered. CONCLUSIONS
Fte 8. Ten-year follow-up radiograph of the maxillary left central and lateral incisors showing normal bone pattern.
Some significant conclusions can be reached from this case report: 1. Intact cortical bone is no indication of healthy cancellous bone. 2. Lesions in cancellous bone with an intact cortical plate cannot always be detected radiographically. 3. Bone cavities occur in the alveolar bone and may refer pain to the dentition.
400
Journal of Endodontics
Segall and del Rio
4. Extraction sites are not the only origin of bone cavities. 5. The origin of a bone cavity may be a traumatic incident to the alveolar bone. 6. Thorough documentation of a difficult diagnostic case is very important for future study. Dr. Segall is in private practice limited to endodontics in Frederick, MD. Dr. del Rio is professor and chairman, Department of Endodontics, The University of Texas Health Science Center at San Antonio, San Antonio, TX. Address requests for reprints to Dr. Ronald O. Segall, Amber Meadows Professional Bldg. 12, 198 Thomas Johnson Drive, Frederick, MD 21702.
References 1. Ratner EJ, Langer B, Evins ML. Alveolar cavitational osteopathosis. Manifestations of an infectious process and its implication in the causation of
chronic pain. J Periodonto11986;57:593-603. 2. Ratner EJ, Person P, Kleinman DJ, Shklar G, Socransky SS. Jawbone cavities and trigeminal facial neuralgias, Oral Surg 1979;48:3-20. 3. Roberts AM, Person P, Chandran NB, Hod JM. Further observations on dental parameters of trigeminal and atypical facial neuralgias. Oral Surg 1984;58:121-9. 4. Roberts AM, Person P. Etiology and treatment of idiopathic trigeminal and atypical facial neuralgias. Oral Surg 1979;48:298-308. 5. LeQuire AK, Cunningham CJ, Pelleu GB. Radiographic interpretation of experimentally produced osseous lesions of the human mandible. J Endodon 1977;3:274-6. 6. Bender IB, Seltzer S. Roentgenographic and direct observation of experimental lesions in bone. I. J Am Dent Assoc 1961 ;62:152-60. 7. Bender IB, Seltzer S. Roentgenographic and direct observation of experimental lesions in bone. II. J Am Dent Assoc 1961;62:708-16. 8. Shoha RR, Dowson J, Richards AG. Radiographic interpretation of experimentally produced bony lesions. Oral Surg 1974;38:294-302. 9. Ramadan AE, Mitchell DF. A roentgenographic study of experimental bone destruction. Oral Surg 1962;15:934-43.
You Might Be Interested to Know Most endodontists have a collection of x-rays of cases referred for retreatment which show a post placed through a perforation of the side of the root and secured in the surrounding alveolar bone. Now comes a report in the British Medical Journal accompanied by an x-ray of a femur which shows the canal filled with cement and a metal post floating free in soft tissue (BMJ 6730:301). It seems a 93-year-old woman had a hip replacement at age 80. She functioned with a walker for 13 years even though the surgeons apparently placed cement in the canal and the metal prosthesis elsewhere. We dentists are apparently not the only ones who can occasionally be a bit distracted and lose orientation during treatment.
Zachariah Yeomans
