Case Challenge

By Lauren Belous, D.M.D.

A 65-year-old Caucasian male presented with chief complaint of, "My dentist found an infection on this tooth (points to upper right quadrant)." The patient reports being asymptomatic, with pain 0/10.

Med Hx & Rx:  

• Medical Conditions:
  • Hypertension
  • Hypercholesterolemia
• Medications:
  • Atenolol 25 mg 1x daily
  • Aspirin 81 mg 1x daily
  • Atorvastatin 80 mg 1x daily
• Allergies:
  • NKDA
• Vitals:
  • BP: 132/76
  • Pulse: 74
• ROS:
  • Pt denies further history or problems in HEENT, CNS, Resp, GI, GU, endocrine, musculoskeletal, or hematologic systems.

Surgical Hx:

• Pt denies any surgeries

Allergies:

• NKDA

HPI:  When cuspal fracture on #5 occurred, dentist incidentally discovered periodical radiolucency on the MB root #3 during radiographic examination. Root canal, post/core and crown #3 all completed (in close proximity) ~10 years prior to presentation.

EOE/IOE:

• EOE: Unremarkable - no lymphadenopathy, gross swelling, asymmetry, discoloration, trismus, dyspnea, dysphagia, or tenderness
• IOE:
  • Sinus tract buccal of #3
    • Located at gingival margin
  • Fractured palatal cusp #5

Radiographic Evaluation:

• #2:
  • MO/L amalgam restoration
• #3:
  • Previously treated, post and PFM crown
    • Well-sealed crown margins
    • MB root PARL, with PDL and LD obliterated
    • Potentially J-shaped lesion MB root
    • Sinus tract tracing to MB root apex

• #4:
  • Extracted for ortho
• #5:
  • Fractured palatal cusp
• Bony trabeculation WNL
• PDLs and LDs WNL #2 and #5

Clinical Evaluation:

Pre-op PA (2017):

PreOp BW (2017):

PreOp CBCT (2017):

Pretreatment Diagnosis:

• Pulpal #3: Previously Treated
• Periapical #3: Asymptomatic Apical Periodontitis

Treatment Plan:

• Endodontic:
  • Exploratory Surgery #3
    • VRF?? Root amputation??
    • Apicoectomy MB root??
  • NS-RCT #5 (pre-prosthetic)
• Restorative:
  • No further restorative recommended #3
  • Post and PFM crown #5
• Other Tx Options:
  • Extraction #3/#5
  • No Treatment

Treatment & Biopsy:

Final Diagnosis:
Soft Tissue, Right Posterior Maxilla, Excisional Biopsy:

Periapical Granuloma.