Condensing osteitis is a diffuse radiopaque lesion believed to represent a localized bony reaction to a low-grade inflammatory stimulus, usually seen at the apex of a tooth in which there has been a long-standing pulpal pathosis.

Causes

Condensing osteitis is a mild irritation from pulpal disease that stimulates osteoblastic activity in the alveolar bone.

Symptoms

This disorder is usually asymptomatic. It is discovered during routine radiographic examination.

Diagnosis

The diagnosis is made from radiographs. Condensing osteitis appears in radiographs as a localized area of radio opacity surrounding the affected root. It is an area of dense bone with reduced trabecular pattern. The mandibular posterior teeth are most frequently affected.

Histopathology

Microscopically, condensing osteitis appears as an area of dense bone with reduced trabecular borders lined with osteoblasts. Chronic inflammatory cells, plasma cells, and lymphocytes are seen in the scant bone marrow.

Treatment

Removal of the irritant stimulus is recommended. Endodontic treatment should be initiated if signs and symptoms of irreversible pulpitis are diagnosed.

Prognosis

The prognosis for long-term retention of the tooth is excellent if root canal therapy is performed and if the tooth is restored satisfactory. Lesions of condensing osteitis may persist after endodontic treatment.

Bacterial portals to pulp: caries (most common source), exposed dentinal tubules (tubule permeability ↓ by dentinal fluid, live odontoblastic processes, tertiary and peritubular dentin)

1.        Vital pulp is very resistant to microbial invasion but necrotic pulps are rapidly colonized

2.        Rarely does periodontal disease → pulp necrosis

3.        Anachoresis: microbes carried in blood to area of inflammation where they establish infection

Caries → pulp disease: infecting bacteria are immobile, carried to pulp by binary fission, dentinal fluid movement

1.        Smooth surface and pit and fissure caries: S. mutans (important in early caries) and S. sobrinus

2.        Root caries: Actinomyces spp.

3.        Mostly anaerobes in deep caries. 

4.        Once pulp exposed by caries, many opportunists enter (e.g., yeast, viruses) → polymicrobial infection

Pulp reaction to bacteria: non-specific inflammation and specific immunologic reactions

1.        Initially inflammation is a chronic cellular response (lymphocytes, plasma cells, macrophages) → formation of peritubular dentin (↓ permeability of tubules) and often tertiary dentin (irregular, less tubular, barrier)

2.        Carious pulp exposure → acute inflammation (PMN infiltration → abscess formation).  Pulp may remain inflamed for a long time or become necrotic (depends on virulence, host response, circulation, drainage, etc.)

Endodontic infections: most commonly Prevotella nigrescens; also many Prevotella & Porphyromonas sp.

1.        Actinomyces and Propionibacterium species can persist in periradicular tissues in presence of chronic inflammation; they respond to RCT but need surgery or abx to resolve infection

2.        Streptococcus faecalis is commonly found in root canals requiring retreatment due to persistent inflammation

Root canal ecosystem: lack of circulation in pulp → compromised host defense

1.        Favors growth of anaerobes that metabolize peptides and amino acids rather than carbohydrates

2.        Bacteriocins: antibiotic-like proteins made by one species of bacteria that inhibit growth of another species

Virulence factors: fimbriae, capsules, enzymes (neutralize Ig and complement), polyamines (↑ # in infected canals)

1.        LPS: G(-), → periradicular pathosis; when released from cell wall = endotoxin (can diffuse across dentin)

2.        Extracellular vesicles: may → hemagglutination, hemolysis, bacterial adhesion, proteolysis

3.        Short-chain fatty acids: affect PMN chemotaxis, degranulation, etc.; butyric acid → IL-1 production (→ bone resorption and periradicular pathosis)

Pathosis and treatment:

1.        Acute apical periodontitis (AAP): pulpal inflammation extends to periradicular tissues; initial response

2.        Chronic apical periodontitis (CAP): can be asymptomatic (controversial whether bacteria can colonize)

3.        Acute apical abscess (AAA), phoenix abscesses (acute exacerbation of CAP), and suppurative apical periodontitis: all characterized by many PMNs, necrotic tissue, and bacteria

Treatment of endodontic infections: must remove reservoir of infection by thorough debridement

1.        Debridement: removal of substrates that support microorganisms; use sodium hypochlorite (NaOCl) to irrigate canals (dissolves some organic debris in areas that can’t be reached by instruments); creates smear layer

2.        Intracanal medication: recommend calcium hydroxide (greatest antimicrobial effect between appointments) inserted into pulp chamber then driven into canals (lentulo spiral, plugger, or counterclockwise rotation of files) and covered with sterile cotton pellet and temporary restoration (at least 3mm thick)

3.        Drainage: for severe infections to ↓ pressure (improve circulation), release bacteria and products; consider abx

4.        Culturing: rarely needed but if so, sterilize tissue with chlorhexidine and obtain submucosal sample via aspiration with a 16- to 20-gauge needle

Weine Classification

The Weine classification divides root canal systems into three main categories:

The pulp canal system is complex, and it may branch, divide, and rejoin. Weine categorized the root canal systems in any root

into four basic types. Others, using cleared teeth in which the root canal systems had been stained with hematoxylin dye, found a

much more complex canal system. They identified eight pulp space configurations, that can be briefly described as following :

Type I : A single canal extends from the pulp chamber to the apex (1).

Type II: Two separate canals leave the pulp chamber and join short of the apex to form one canal (2-1).

Type III: One canal leaves the pulp chamber and divides into two in the root; the two then merge to exit as one canal (1-2-1).

Type IV: Two separate, distinct canals extend from the pulp chamber to the apex (2).

Type V: One canal leaves the pulp chamber and divides short of the apex into two separate, distinct canals with separate apical foramina (1-2).

Type VI: Two separate canals leave the pulp chamber, merge into the body of the root, and redivide short of the apex to exit as two distinct canals (2-1-2).

Type VII: One canal leaves the pulp chamber, divides and then rejoins in the body of the root, and finally redivides into two distinct canals short of the apex (1-2-1-2).

Type VIII: Three separate, distinct canals extend from the pulp chamber to the apex (3).

Techniques for Compaction of Gutta-Percha

1. Lateral Condensation

   • Description: This technique involves the use of a master cone of gutta-percha that is fitted to the prepared canal. Smaller accessory cones are then added and compacted laterally using a hand or rotary instrument.
   • Advantages:
     • Simplicity: Easy to learn and perform.
     • Adaptability: Can be used in various canal shapes and sizes.
     • Good Sealing Ability: Provides a dense fill and good adaptation to canal walls.
   • Disadvantages:
     • Time-Consuming: Can be slower than other techniques.
     • Risk of Overfilling: Potential for extrusion of material beyond the apex if not carefully managed.
     • Difficult in Complex Canals: May not adequately fill irregularly shaped canals.

2. Vertical Condensation

   • Description: In this technique, a master cone is placed in the canal, and heat is applied to the gutta-percha using a heated plugger. The softened gutta-percha is then compacted vertically.
   • Advantages:
     • Excellent Adaptation: Provides a better seal in irregularly shaped canals.
     • Reduced Voids: The heat softens the gutta-percha, allowing it to flow into canal irregularities.
     • Faster Technique: Generally quicker than lateral condensation.
   • Disadvantages:
     • Equipment Requirement: Requires specialized equipment (heated plugger).
     • Risk of Overheating: Potential for damaging the tooth structure if the temperature is too high.
     • Skill Level: Requires more skill and experience to perform effectively.

3. Thermoplasticized Gutta-Percha Techniques

   • Description: These techniques involve heating gutta-percha to a temperature that allows it to flow into the canal system. Methods include the use of a syringe (e.g., System B) or a warm vertical compaction technique.
   • Advantages:
     • Excellent Fill: Provides a three-dimensional fill of the canal system.
     • Adaptability: Can adapt to complex canal anatomies.
     • Reduced Voids: Minimizes the presence of voids and enhances sealing.
   • Disadvantages:
     • Equipment Cost: Requires specialized equipment, which can be expensive.
     • Learning Curve: May require additional training to master the technique.
     • Potential for Overfilling: Risk of extrusion if not carefully controlled.

4. Single Cone Technique

   • Description: This technique uses a single gutta-percha cone that is fitted to the canal and sealed with a sealer. It is often used with bioceramic or resin-based sealers.
   • Advantages:
     • Simplicity: Easy to perform and requires less time.
     • Less Technique-Sensitive: Reduces the risk of procedural errors.
     • Good for Certain Cases: Effective in cases with simpler canal systems.
   • Disadvantages:
     • Limited Adaptation: May not adequately fill complex canal systems.
     • Potential for Voids: Increased risk of voids compared to other techniques.
     • Less Retention: May not provide as strong a seal as other methods.