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Aust Endod J 2013; 39: 176–179
C A S E R E P O RT
Florid cemento-osseous dysplasia mimicking apical periodontitis: A case report Ali Reza Rekabi, DMD, MS1; Rezvan Ashouri, DMD, MS2; Molok Torabi, DMD, MS3; Masoud Parirokh, DMD, MS3; and Paul V. Abbott, BDSc (WA), MDS (Adel), FRACDS (Endo), FPFA, FADI, FICD4 1 2 3 4
Private Practice, Tehran, Iran Endodontic Department, Shahed Dental School, Tehran, Iran Oral and Dental Diseases Research Center, Kerman University of Medical Sciences, Kerman, Iran School of Dentistry, University of Western Australia, Perth, Western Australia, Australia
Keywords cemento-osseous dysplasia, florid, periapical lesion, periapical surgery, radiopaque, root canal therapy. Correspondence Dr Masoud Parirokh, Oral and Dental Diseases Research Center, School of Dentistry, Shafa Street, 76185, Kerman, Iran. Email: [email protected] doi:10.1111/j.1747-4477.2011.00325.x
Abstract Cemento-osseous dysplasia may present as a focal, periapical or florid lesion in the mandible or maxilla. The lesion may sometimes appear similar to peri-radicular lesions on a periapical radiograph. This report presents a case with irreversible pulpitis and root resorption as well as a mixed radiolucent/ radiopaque lesion around a mandibular molar tooth root. Root canal treatment was performed and because of the radiographic signs of root resorption and the patient’s fear of having a malignant disease, periapical surgery was also performed. The histopathology report confirmed the presence of florid cementosseous dysplasia which was mimicking apical periodontitis. Follow-up radiography 12 months after the surgery illustrated complete healing of the radiolucent area.
Introduction
Case report
Cemento-osseous dysplasia (COD) is a group of disorders that occur in the tooth-bearing areas of the jaws (1). COD is an asymptomatic condition that is usually found during radiographic examination for other purposes (2). The lesion has been described as varying in appearance over time from a radiolucent lesion to a mixed radiolucent and radiopaque lesion. Two origins have been suggested for COD: (i) the periodontal ligament and (ii) a defect in extra-ligamentary bone remodelling. On the basis of the clinical and radiographic features, COD has been described as having three separate forms: (i) focal, (ii) periapical and (iii) florid (3). Focal COD involves a single site of involvement. Periapical COD appears as multiple radiolucent foci, mainly in the anterior portion of the mandible. Florid COD (FLCOD) is a multifocal involvement of the jaws that is predominantly observed in Black women. Usually FLCOD lesions are symmetrical with no symptoms (2,3). This report describes a case with a mixed radiolucent/ radiopaque periapical area in addition to irreversible pulpitis that was secondary to dental caries.
A 39-year-old White woman was referred to the postgraduate clinic of the Endodontic Department of Kerman Dental School, Iran. The patient’s medical history showed controlled hypertension and the use of a sedative medication. Her dental history indicated that she had recently visited a general dental practitioner for restoration of her right mandibular first molar tooth (tooth 46), which had extensive caries. The dentist commenced treatment, but after removing the caries, a pulp exposure with bleeding pulp tissue was noted despite the presence of a periapical radiolucency (Fig. 1). Hence, the dentist stopped treatment and referred the patient to the postgraduate clinic for further assessment and management. The patient was very anxious regarding her problem and she wished to have definite treatment. Despite the previous dental visit and the presence of a dressing in the tooth, she reported sensitivity to a cold pulp test (Roeko Endo-Frost, Roeko, Langenau, Germany), a heat test and an electric pulp tester (Element Diagnostic Unit: SybronEndo, Glendora, CA, USA). The patient had no expansion of the alveolar bone and there was no tenderness to palpation or
176
© 2011 The Authors Australian Endodontic Journal © 2011 Australian Society of Endodontology
FLCOD Similar to PA Lesion
A. R. Rekabi et al.
(a)
Figure 1 Preoperative periapical radiograph showing a radiolucent area with a thick radiopaque border (white arrow).
Figure 2 Panoramic radiograph showing bilateral multiple radiopacities in the maxilla and the mandible (white arrows).
percussion. A periapical radiograph showed a radiolucent area with radiopaque borders (Fig. 1). A panoramic radiograph showed bilateral symmetric radiopaque lesions in the posterior regions of the mandible and the right posterior area of the maxilla (Fig. 2). On the basis of the clinical examination and pulp sensibility tests, the diagnosis for tooth 46 was irreversible pulpitis. Hence, root canal treatment was performed to relieve the patient’s symptoms. After injecting a cartridge of 3% prilocaine with felypressin (Prilonest, DFL Industria, Rio de Janeiro, Brazil) as a mandibular anaesthetic block, rubber dam was placed and an access cavity was prepared. The root canals were then prepared with Hero 642 series instruments (Micro-Mega, Besancon Cedex, France) and 2.5% sodium hypochlorite (NaOCl) as an irrigant. The canals were then medicated with calcium hydroxide for 1 week. At the next appointment, the calcium hydroxide and the smear layer were removed from the root canal system using 17% EDTA (Asia ChimiTeb, Tehran, Iran) and 2.5% NaOCl irrigating solutions. The root canals were then filled with gutta-percha (Asia Chimi-Teb) and AH26 (Dentsply De Tery, Konstanz,
© 2011 The Authors Australian Endodontic Journal © 2011 Australian Society of Endodontology
(b)
Figure 3 (a) Postoperative periapical radiograph after root canal filling of tooth 46. (b) Higher magnification of the mesial root illustrates external root resorption (white arrows).
Germany) cement using the lateral condensation technique. One week after completing the root canal filling, the patient had no symptoms. However, because the patient was aware of the unusual periapical radiographic appearance and she was taking medication for her anxiety which was largely related to her awareness of this lesion, she insisted on having periapical surgery for complete removal of the lesion. In addition, external resorption of the mesial aspect of the mesial root was observed on the postoperative radiograph after the root canal filling had been placed, and this provided further reason to perform periapical surgery (Fig. 3). Hence, a periapical curettage was performed under local anaesthesia using prilocaine 3% with felypressin. During surgery, a lesion consisting of soft tissue and solid calcified particles was encountered. The entire mass was removed as a block section without any difficulty (Fig. 4). The tissue was placed in 10% formalin and sent to the pathology laboratory for histological assessment. The apical end of the mesial root was resected and the apical root canal was prepared using an ultrasonic device (NSK-Various 750, Nakanishi Inc., Tochigi, Japan). White mineral trioxide aggregate (Angelus MTA, Londrina, Brazil) was mixed according to the manufacturer’s instructions with a 3:1 powder to liquid ratio and then placed into the prepared root canal (Fig. 5). The periosteal flap was sutured, routine postoperative instructions were provided and the patient was dismissed. One week later, the patient reported no symptoms and on examination, the periosteal flap was noted to be healing normally. The histopathology report indicated that the specimen was 10 ¥ 12 ¥ 5 mm in diameter and consisted of several amorphous brownish particles. Microscopic observation showed spindle-shaped fibroblasts, fine collagen fibres and calcified particles in the shape of woven bone, which led to a histological diagnosis of osseous dysplasia (Fig. 6). 177
FLCOD Similar to PA Lesion
A. R. Rekabi et al.
Figure 6 Histological image of the lesion illustrating spindle shape fibroblasts, fine collagen fibres and woven bone.
Figure 4 The tissue that was removed from the periapical area of the mesial root of tooth 46.
Figure 7 Periapical radiograph showing healing of the area 12 months after the periapical surgery.
Figure 5 Periapical radiograph taken after resecting the apical end of the root and placing MTA in the root canal.
The patient was reviewed 1 year after the periapical surgery and she reported no symptoms. A follow-up periapical radiograph taken at that time showed complete healing of the periapical area (Fig. 7).
Discussion The final diagnosis for the present case was FLCOD because of the presence of a bilateral radiopaque lesion at the left and right posterior site of the mandible (Fig. 2). 178
The results of a meta-analysis on 158 FLCOD reported cases have shown that 97% of reported cases were present in women. Most of the FLCOD lesions were found in Black (59%) people followed by people of oriental origin (37%), whilst only 3% of cases were found in White people (4). The patient presented in this case report was a White woman in her fourth decade of her life. The differential diagnoses of COD includes broad types of lesions such as a periapical abscess, granuloma, cyst, ossifying fibroma, Paget’s disease, odontogenic keratocyst, ameloblastoma and a central giant cell granuloma (3,5). In the present case, the presence of irreversible pulpitis with sensitivity of the dental pulp can be used to dismiss the possibility of a periapical cyst and a periapical abscess. Ossifying fibroma can also be dismissed as this lesion normally causes expansion of the alveolar bone, which was not present. Paget’s disease of the bone usually affects the entire mandible in addition to having loss of the lamina dura, neither of which are seen with COD. In addition,
© 2011 The Authors Australian Endodontic Journal © 2011 Australian Society of Endodontology
FLCOD Similar to PA Lesion
A. R. Rekabi et al.
Paget’s disease often involves other bones such as the spine or femur. In the present case, except for the controlled hypertension and anxiety because of the awareness of the presence of a lesion around her tooth, no systemic disorders were observed or reported by the patient (5). If radiographic features such as multi-locular radiolucencies, root resorption or root displacement are present, or when the lesion envelops an unerupted tooth, then other lesions such as odontogenic keratocyst, ameloblastoma and central giant cell granuloma should be considered as part of the differential diagnosis for COD (5). In the present case, none of above conditions was observed except for external resorption of the mesial aspect of the mesial root of tooth 46. Treatment of COD is a matter of confusion and contention. As the lesion has no tendency to be neoplastic, they generally do not require surgical removal (3). However, when the lesion becomes sclerotic, it tends to be hypovascular and prone to necrosis with minimal provocation. Several case reports have been presented in the literature where endodontic treatment has been performed for teeth associated that have COD in the periapical region with the COD at different stages of maturity (radiolucent, mixed or sclerotic) and with varying pulp diseases (6–8). In all cases, the COD was not responsible for the pulp diseases that necessitated the endodontic treatment. In the present case, the observation of bilateral focal calcifications in the right and left posterior parts of the mandible was in favour of the diagnosis of FLCOD. The bilateral sclerotic areas in the right and left sides of the mandible were at the final stage of COD and completely calcified, whereas the lesion around tooth 46 was in the mixed radiolucent and radiopaque stage. An important point that produced doubt in this case was the presence of external root resorption of the mesial aspect of the mesial root which was noted on the postoperative radiograph following the root canal filling (Fig. 3). Previous reports of COD have not mentioned external root resorption as a diagnostic finding (2,3,6–12). It has been emphasised that an important way to differentiate between COD and ossifying fibroma during surgery is the texture and tendency of the lesion to adhere to the adjacent bone during curettage (3). COD has been described as a ‘gritty lesion’ that is easily fragmented and simply curetted, whereas ossifying fibroma can be removed as one or several large masses. In this case, the lesion was easily detached and curetted from the adjacent bone without any difficulty. One of the reasons for performing surgery in the present case was the cancer phobia exhibited by the patient. She had been taking an antidepressant to help her overcome her anxiety after she became aware of the presence of an unknown lesion around tooth 46 during
© 2011 The Authors Australian Endodontic Journal © 2011 Australian Society of Endodontology
her first visit with her general dental practitioner. Therefore, she insisted on having periapical surgery in order to obtain a definite diagnosis and treatment.
Conclusion When a dentist encounters a mixed radiolucent/ radiopaque lesion around the apex of a tooth that has a normal or inflamed pulp, then osseous dysplasia should be considered as one of the pathological disorders that may cause the condition. A panoramic radiograph should be taken in order to assist with the diagnosis.
References 1. Mohammadi-Araghi H, Haery C. Fibro-osseous lesions of craniofacial bones. The role of imaging. Radiol Clin North Am 1993; 31: 121–34. 2. Su L, Weathers DR, Waldron CA. Distinguishing features of focal cemento-osseous dysplasia and cementoossifying fibromas. II. A clinical and radiologic spectrum of 316 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997; 84: 540–9. 3. Neville BW, Damm DD, Allen CM, Bouquot JE. Oral and maxillofacial pathology. 2nd ed. Philadelphia: W.B Saunders Co.; 2002. pp. 533–87. 4. MacDonald-Jankowski DS. Florid cemento-osseous dysplasia: a systematic review. Dentomaxillofac Radiol 2003; 32: 141–9. 5. Resnick CM, Novelline RA. Cemento-osseous dysplasia, a radiological mimic of periapical dental abscess. Emerg Radiol 2008; 15: 367–74. 6. Drazic´ R, Minic´ AJ. Focal cemento-osseous dysplasia in the maxilla mimicking periapical granuloma. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999; 88: 87–9. 7. Galgano C, Samson J, Kuffer R, Lumbardi T. Focal cement-osseous dysplasia involving a mandibular lateral incisor. Int Endod J 2003; 36: 907–11. 8. Tonioli MB, Schindler WG. Treatment of a maxillary molar in a patient presenting with florid cementoosseous dysplasia: a case report. J Endod 2004; 30: 665–7. 9. Toffanin A, Benetti R, Manconi R. Familial florid cemento-osseous dysplasia: a case report. J Oral Maxillofac Surg 2000; 58: 1440–6. 10. Harsha VB, Saraswathy K, Koteeswaran D. Florid cemento-osseous dysplasia. Indian J Dent Res 2005; 16: 119–21. 11. Jerjes W, Banu B, Swinson B, Hopper C. Florid cemento-osseous dysplasia in a young Indian woman. A case report. Br Dent J 2005; 198: 477–8. 12. Dag˘istan S, Tozog˘lu U, Göregen M, Cakur B. Florid cemento-osseous dysplasia: a case report. Med Oral Pathol Oral Cir Bucal 2007; 12: E348–50.
179
Aust Endod J 2013; 39: 176–179
C A S E R E P O RT
Florid cemento-osseous dysplasia mimicking apical periodontitis: A case report Ali Reza Rekabi, DMD, MS1; Rezvan Ashouri, DMD, MS2; Molok Torabi, DMD, MS3; Masoud Parirokh, DMD, MS3; and Paul V. Abbott, BDSc (WA), MDS (Adel), FRACDS (Endo), FPFA, FADI, FICD4 1 2 3 4
Private Practice, Tehran, Iran Endodontic Department, Shahed Dental School, Tehran, Iran Oral and Dental Diseases Research Center, Kerman University of Medical Sciences, Kerman, Iran School of Dentistry, University of Western Australia, Perth, Western Australia, Australia
Keywords cemento-osseous dysplasia, florid, periapical lesion, periapical surgery, radiopaque, root canal therapy. Correspondence Dr Masoud Parirokh, Oral and Dental Diseases Research Center, School of Dentistry, Shafa Street, 76185, Kerman, Iran. Email: [email protected] doi:10.1111/j.1747-4477.2011.00325.x
Abstract Cemento-osseous dysplasia may present as a focal, periapical or florid lesion in the mandible or maxilla. The lesion may sometimes appear similar to peri-radicular lesions on a periapical radiograph. This report presents a case with irreversible pulpitis and root resorption as well as a mixed radiolucent/ radiopaque lesion around a mandibular molar tooth root. Root canal treatment was performed and because of the radiographic signs of root resorption and the patient’s fear of having a malignant disease, periapical surgery was also performed. The histopathology report confirmed the presence of florid cementosseous dysplasia which was mimicking apical periodontitis. Follow-up radiography 12 months after the surgery illustrated complete healing of the radiolucent area.
Introduction
Case report
Cemento-osseous dysplasia (COD) is a group of disorders that occur in the tooth-bearing areas of the jaws (1). COD is an asymptomatic condition that is usually found during radiographic examination for other purposes (2). The lesion has been described as varying in appearance over time from a radiolucent lesion to a mixed radiolucent and radiopaque lesion. Two origins have been suggested for COD: (i) the periodontal ligament and (ii) a defect in extra-ligamentary bone remodelling. On the basis of the clinical and radiographic features, COD has been described as having three separate forms: (i) focal, (ii) periapical and (iii) florid (3). Focal COD involves a single site of involvement. Periapical COD appears as multiple radiolucent foci, mainly in the anterior portion of the mandible. Florid COD (FLCOD) is a multifocal involvement of the jaws that is predominantly observed in Black women. Usually FLCOD lesions are symmetrical with no symptoms (2,3). This report describes a case with a mixed radiolucent/ radiopaque periapical area in addition to irreversible pulpitis that was secondary to dental caries.
A 39-year-old White woman was referred to the postgraduate clinic of the Endodontic Department of Kerman Dental School, Iran. The patient’s medical history showed controlled hypertension and the use of a sedative medication. Her dental history indicated that she had recently visited a general dental practitioner for restoration of her right mandibular first molar tooth (tooth 46), which had extensive caries. The dentist commenced treatment, but after removing the caries, a pulp exposure with bleeding pulp tissue was noted despite the presence of a periapical radiolucency (Fig. 1). Hence, the dentist stopped treatment and referred the patient to the postgraduate clinic for further assessment and management. The patient was very anxious regarding her problem and she wished to have definite treatment. Despite the previous dental visit and the presence of a dressing in the tooth, she reported sensitivity to a cold pulp test (Roeko Endo-Frost, Roeko, Langenau, Germany), a heat test and an electric pulp tester (Element Diagnostic Unit: SybronEndo, Glendora, CA, USA). The patient had no expansion of the alveolar bone and there was no tenderness to palpation or
176
© 2011 The Authors Australian Endodontic Journal © 2011 Australian Society of Endodontology
FLCOD Similar to PA Lesion
A. R. Rekabi et al.
(a)
Figure 1 Preoperative periapical radiograph showing a radiolucent area with a thick radiopaque border (white arrow).
Figure 2 Panoramic radiograph showing bilateral multiple radiopacities in the maxilla and the mandible (white arrows).
percussion. A periapical radiograph showed a radiolucent area with radiopaque borders (Fig. 1). A panoramic radiograph showed bilateral symmetric radiopaque lesions in the posterior regions of the mandible and the right posterior area of the maxilla (Fig. 2). On the basis of the clinical examination and pulp sensibility tests, the diagnosis for tooth 46 was irreversible pulpitis. Hence, root canal treatment was performed to relieve the patient’s symptoms. After injecting a cartridge of 3% prilocaine with felypressin (Prilonest, DFL Industria, Rio de Janeiro, Brazil) as a mandibular anaesthetic block, rubber dam was placed and an access cavity was prepared. The root canals were then prepared with Hero 642 series instruments (Micro-Mega, Besancon Cedex, France) and 2.5% sodium hypochlorite (NaOCl) as an irrigant. The canals were then medicated with calcium hydroxide for 1 week. At the next appointment, the calcium hydroxide and the smear layer were removed from the root canal system using 17% EDTA (Asia ChimiTeb, Tehran, Iran) and 2.5% NaOCl irrigating solutions. The root canals were then filled with gutta-percha (Asia Chimi-Teb) and AH26 (Dentsply De Tery, Konstanz,
© 2011 The Authors Australian Endodontic Journal © 2011 Australian Society of Endodontology
(b)
Figure 3 (a) Postoperative periapical radiograph after root canal filling of tooth 46. (b) Higher magnification of the mesial root illustrates external root resorption (white arrows).
Germany) cement using the lateral condensation technique. One week after completing the root canal filling, the patient had no symptoms. However, because the patient was aware of the unusual periapical radiographic appearance and she was taking medication for her anxiety which was largely related to her awareness of this lesion, she insisted on having periapical surgery for complete removal of the lesion. In addition, external resorption of the mesial aspect of the mesial root was observed on the postoperative radiograph after the root canal filling had been placed, and this provided further reason to perform periapical surgery (Fig. 3). Hence, a periapical curettage was performed under local anaesthesia using prilocaine 3% with felypressin. During surgery, a lesion consisting of soft tissue and solid calcified particles was encountered. The entire mass was removed as a block section without any difficulty (Fig. 4). The tissue was placed in 10% formalin and sent to the pathology laboratory for histological assessment. The apical end of the mesial root was resected and the apical root canal was prepared using an ultrasonic device (NSK-Various 750, Nakanishi Inc., Tochigi, Japan). White mineral trioxide aggregate (Angelus MTA, Londrina, Brazil) was mixed according to the manufacturer’s instructions with a 3:1 powder to liquid ratio and then placed into the prepared root canal (Fig. 5). The periosteal flap was sutured, routine postoperative instructions were provided and the patient was dismissed. One week later, the patient reported no symptoms and on examination, the periosteal flap was noted to be healing normally. The histopathology report indicated that the specimen was 10 ¥ 12 ¥ 5 mm in diameter and consisted of several amorphous brownish particles. Microscopic observation showed spindle-shaped fibroblasts, fine collagen fibres and calcified particles in the shape of woven bone, which led to a histological diagnosis of osseous dysplasia (Fig. 6). 177
FLCOD Similar to PA Lesion
A. R. Rekabi et al.
Figure 6 Histological image of the lesion illustrating spindle shape fibroblasts, fine collagen fibres and woven bone.
Figure 4 The tissue that was removed from the periapical area of the mesial root of tooth 46.
Figure 7 Periapical radiograph showing healing of the area 12 months after the periapical surgery.
Figure 5 Periapical radiograph taken after resecting the apical end of the root and placing MTA in the root canal.
The patient was reviewed 1 year after the periapical surgery and she reported no symptoms. A follow-up periapical radiograph taken at that time showed complete healing of the periapical area (Fig. 7).
Discussion The final diagnosis for the present case was FLCOD because of the presence of a bilateral radiopaque lesion at the left and right posterior site of the mandible (Fig. 2). 178
The results of a meta-analysis on 158 FLCOD reported cases have shown that 97% of reported cases were present in women. Most of the FLCOD lesions were found in Black (59%) people followed by people of oriental origin (37%), whilst only 3% of cases were found in White people (4). The patient presented in this case report was a White woman in her fourth decade of her life. The differential diagnoses of COD includes broad types of lesions such as a periapical abscess, granuloma, cyst, ossifying fibroma, Paget’s disease, odontogenic keratocyst, ameloblastoma and a central giant cell granuloma (3,5). In the present case, the presence of irreversible pulpitis with sensitivity of the dental pulp can be used to dismiss the possibility of a periapical cyst and a periapical abscess. Ossifying fibroma can also be dismissed as this lesion normally causes expansion of the alveolar bone, which was not present. Paget’s disease of the bone usually affects the entire mandible in addition to having loss of the lamina dura, neither of which are seen with COD. In addition,
© 2011 The Authors Australian Endodontic Journal © 2011 Australian Society of Endodontology
FLCOD Similar to PA Lesion
A. R. Rekabi et al.
Paget’s disease often involves other bones such as the spine or femur. In the present case, except for the controlled hypertension and anxiety because of the awareness of the presence of a lesion around her tooth, no systemic disorders were observed or reported by the patient (5). If radiographic features such as multi-locular radiolucencies, root resorption or root displacement are present, or when the lesion envelops an unerupted tooth, then other lesions such as odontogenic keratocyst, ameloblastoma and central giant cell granuloma should be considered as part of the differential diagnosis for COD (5). In the present case, none of above conditions was observed except for external resorption of the mesial aspect of the mesial root of tooth 46. Treatment of COD is a matter of confusion and contention. As the lesion has no tendency to be neoplastic, they generally do not require surgical removal (3). However, when the lesion becomes sclerotic, it tends to be hypovascular and prone to necrosis with minimal provocation. Several case reports have been presented in the literature where endodontic treatment has been performed for teeth associated that have COD in the periapical region with the COD at different stages of maturity (radiolucent, mixed or sclerotic) and with varying pulp diseases (6–8). In all cases, the COD was not responsible for the pulp diseases that necessitated the endodontic treatment. In the present case, the observation of bilateral focal calcifications in the right and left posterior parts of the mandible was in favour of the diagnosis of FLCOD. The bilateral sclerotic areas in the right and left sides of the mandible were at the final stage of COD and completely calcified, whereas the lesion around tooth 46 was in the mixed radiolucent and radiopaque stage. An important point that produced doubt in this case was the presence of external root resorption of the mesial aspect of the mesial root which was noted on the postoperative radiograph following the root canal filling (Fig. 3). Previous reports of COD have not mentioned external root resorption as a diagnostic finding (2,3,6–12). It has been emphasised that an important way to differentiate between COD and ossifying fibroma during surgery is the texture and tendency of the lesion to adhere to the adjacent bone during curettage (3). COD has been described as a ‘gritty lesion’ that is easily fragmented and simply curetted, whereas ossifying fibroma can be removed as one or several large masses. In this case, the lesion was easily detached and curetted from the adjacent bone without any difficulty. One of the reasons for performing surgery in the present case was the cancer phobia exhibited by the patient. She had been taking an antidepressant to help her overcome her anxiety after she became aware of the presence of an unknown lesion around tooth 46 during
© 2011 The Authors Australian Endodontic Journal © 2011 Australian Society of Endodontology
her first visit with her general dental practitioner. Therefore, she insisted on having periapical surgery in order to obtain a definite diagnosis and treatment.
Conclusion When a dentist encounters a mixed radiolucent/ radiopaque lesion around the apex of a tooth that has a normal or inflamed pulp, then osseous dysplasia should be considered as one of the pathological disorders that may cause the condition. A panoramic radiograph should be taken in order to assist with the diagnosis.
References 1. Mohammadi-Araghi H, Haery C. Fibro-osseous lesions of craniofacial bones. The role of imaging. Radiol Clin North Am 1993; 31: 121–34. 2. Su L, Weathers DR, Waldron CA. Distinguishing features of focal cemento-osseous dysplasia and cementoossifying fibromas. II. A clinical and radiologic spectrum of 316 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997; 84: 540–9. 3. Neville BW, Damm DD, Allen CM, Bouquot JE. Oral and maxillofacial pathology. 2nd ed. Philadelphia: W.B Saunders Co.; 2002. pp. 533–87. 4. MacDonald-Jankowski DS. Florid cemento-osseous dysplasia: a systematic review. Dentomaxillofac Radiol 2003; 32: 141–9. 5. Resnick CM, Novelline RA. Cemento-osseous dysplasia, a radiological mimic of periapical dental abscess. Emerg Radiol 2008; 15: 367–74. 6. Drazic´ R, Minic´ AJ. Focal cemento-osseous dysplasia in the maxilla mimicking periapical granuloma. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999; 88: 87–9. 7. Galgano C, Samson J, Kuffer R, Lumbardi T. Focal cement-osseous dysplasia involving a mandibular lateral incisor. Int Endod J 2003; 36: 907–11. 8. Tonioli MB, Schindler WG. Treatment of a maxillary molar in a patient presenting with florid cementoosseous dysplasia: a case report. J Endod 2004; 30: 665–7. 9. Toffanin A, Benetti R, Manconi R. Familial florid cemento-osseous dysplasia: a case report. J Oral Maxillofac Surg 2000; 58: 1440–6. 10. Harsha VB, Saraswathy K, Koteeswaran D. Florid cemento-osseous dysplasia. Indian J Dent Res 2005; 16: 119–21. 11. Jerjes W, Banu B, Swinson B, Hopper C. Florid cemento-osseous dysplasia in a young Indian woman. A case report. Br Dent J 2005; 198: 477–8. 12. Dag˘istan S, Tozog˘lu U, Göregen M, Cakur B. Florid cemento-osseous dysplasia: a case report. Med Oral Pathol Oral Cir Bucal 2007; 12: E348–50.
179
