Case Challenge

Posted in Uncategorized | January 25, 2022

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