Diagnostic Challenge In Pediatric Toothache: Mandibular Osteomyelitis In Mixed Dentition

Chronic mandibular osteomyelitis in children often mimics acute pulpitis during mixed dentition, posing diagnostic challenges due to anatomical complexity and limited symptom articulation. This case highlights critical clinical insights through an 8-year-old patient’s diagnostic journey. An 8-year-old child presented with six months of recurrent right mandibular pain, initially diagnosed as "acute pulpitis"(#45, #46). Despite apexification and repeated root canal therapy, symptoms progressed to facial swelling and fever. Maxillofacial spiral CT revealed diffuse osteosclerosis with irregular bone destruction. Biopsy confirmed sclerosing osteomyelitis, while negative ANCA excluded vasculitis. Premature premolar eruption (#45, #46) and periodontitis suggested prior "acute pulpitis" in primary dentition, implicating untreated infection as a potential trigger for mandibular pathology. Early Diagnostic Pitfalls: Nonspecific pain localization and subtle periapical radiolucency on radiographs delayed osteomyelitis recognition. Advanced imaging (CBCT/MRI) was pivotal in detecting osteosclerosis. Mixed Dentition Complexities: High caries prevalence in transitional dentition (e.g., decayed #75, #84) and premature permanent tooth eruption obscured bone pathology, disrupting local bone homeostasis. Periodontal-Bone Interaction: Chronic gingival inflammation and periodontal pockets indicated alveolar bone involvement, suggesting bidirectional infectious routes. Multidisciplinary Resolution: Collaboration among oral surgery, radiology, and rheumatology enabled biopsy-confirmed diagnosis, emphasizing cross-specialty integration. Prioritize CBCT/bone scintigraphy for refractory post-treatment symptoms to rule out osteomyelitis. Link developmental anomalies (e.g., premature eruption) to bone metabolic disorders via dynamic imaging. Address acute pulpitis promptly in primary teeth to prevent secondary bone involvement. Train caregivers to identify nocturnal and spontaneous pain to expedite diagnosis.