{"id":20403,"date":"2022-01-25T09:10:50","date_gmt":"2022-01-25T15:10:50","guid":{"rendered":"https:\/\/www.aae.org\/specialty\/?p=20403"},"modified":"2022-01-27T15:55:31","modified_gmt":"2022-01-27T21:55:31","slug":"case-challenge-4","status":"publish","type":"post","link":"https:\/\/www.aae.org\/specialty\/case-challenge-4\/","title":{"rendered":"Case Challenge"},"content":{"rendered":"\n\n\t<p><em>By Lauren Belous, D.M.D.<\/em><\/p>\n<p>A 65-year-old Caucasian male presented with chief complaint of, &#8220;My dentist found an infection on this tooth (points to upper right quadrant).&#8221; The patient reports being asymptomatic, with pain 0\/10.<\/p>\n<p><strong>Med Hx<\/strong><strong> &amp; Rx: \u00a0<\/strong><\/p>\n<ul>\n<li>Medical Conditions:\n<ul>\n<li>Hypertension<\/li>\n<li>Hypercholesterolemia<\/li>\n<\/ul>\n<\/li>\n<li>Medications:\n<ul>\n<li>Atenolol 25 mg 1x daily<\/li>\n<li>Aspirin 81 mg 1x daily<\/li>\n<li>Atorvastatin 80 mg 1x daily<\/li>\n<\/ul>\n<\/li>\n<li>Allergies:\n<ul>\n<li>NKDA<\/li>\n<\/ul>\n<\/li>\n<li>Vitals:\n<ul>\n<li>BP: 132\/76<\/li>\n<li>Pulse: 74<\/li>\n<\/ul>\n<\/li>\n<li>ROS:\n<ul>\n<li>Pt denies further history or problems in HEENT, CNS, Resp, GI, GU, endocrine, musculoskeletal, or hematologic systems.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p><strong>Surgical Hx: <\/strong><\/p>\n<ul>\n<li>Pt denies any surgeries<\/li>\n<\/ul>\n<p><strong>Allergies:<\/strong><\/p>\n<ul>\n<li>NKDA<\/li>\n<\/ul>\n<p><strong>HPI: <\/strong>\u00a0When 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.<\/p>\n<p><strong>EOE\/IOE: <\/strong><\/p>\n<ul>\n<li>EOE: Unremarkable &#8211; no lymphadenopathy, gross swelling, asymmetry, discoloration, trismus, dyspnea, dysphagia, or tenderness<\/li>\n<li>IOE:\n<ul>\n<li>Sinus tract buccal of #3\n<ul>\n<li>Located at gingival margin<\/li>\n<\/ul>\n<\/li>\n<li>Fractured palatal cusp #5<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/www.aae.org\/specialty\/wp-content\/uploads\/sites\/2\/2022\/01\/Picture1.jpg\" alt=\"\" width=\"169\" height=\"130\" \/><\/p>\n<p><strong>Radiographic Evaluation: <\/strong><\/p>\n<ul>\n<li>#2:\n<ul>\n<li>MO\/L amalgam restoration<\/li>\n<\/ul>\n<\/li>\n<li>#3:\n<ul>\n<li>Previously treated, post and PFM crown\n<ul>\n<li>Well-sealed crown margins<\/li>\n<li>MB root PARL, with PDL and LD obliterated<\/li>\n<li>Potentially J-shaped lesion MB root<\/li>\n<li>Sinus tract tracing to MB root apex<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<ul>\n<li>#4:\n<ul>\n<li>Extracted for ortho<\/li>\n<\/ul>\n<\/li>\n<li>#5:\n<ul>\n<li>Fractured palatal cusp<\/li>\n<\/ul>\n<\/li>\n<li>Bony trabeculation WNL<\/li>\n<li>PDLs and LDs WNL #2 and #5<\/li>\n<\/ul>\n<p><strong>Clinical Evaluation:<\/strong><\/p>\n<p><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/www.aae.org\/specialty\/wp-content\/uploads\/sites\/2\/2022\/01\/Clinical-Evaluation.jpg\" alt=\"\" width=\"600\" height=\"355\" \/><\/p>\n<p><strong>Pre-op PA <\/strong><strong>(2017):<\/strong><\/p>\n<p><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/www.aae.org\/specialty\/wp-content\/uploads\/sites\/2\/2022\/01\/Pre-Op-PA.png\" alt=\"\" width=\"559\" height=\"401\" \/><\/p>\n<p><strong>PreOp BW (2017):<\/strong><\/p>\n<p><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/www.aae.org\/specialty\/wp-content\/uploads\/sites\/2\/2022\/01\/Pre-OP-BW.png\" alt=\"\" width=\"966\" height=\"378\" \/><\/p>\n<p><strong>PreOp CBCT (2017):<\/strong><\/p>\n<p><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/www.aae.org\/specialty\/wp-content\/uploads\/sites\/2\/2022\/01\/Pre-op-CBCT.png\" alt=\"\" width=\"558\" height=\"395\" \/><\/p>\n<p><strong>Pretreatment Diagnosis: <\/strong><\/p>\n<ul>\n<li>Pulpal #3: Previously Treated<\/li>\n<li>Periapical #3: Asymptomatic Apical Periodontitis<\/li>\n<\/ul>\n<p><strong>Treatment Plan:<\/strong><\/p>\n<ul>\n<li>Endodontic:\n<ul>\n<li>Exploratory Surgery #3\n<ul>\n<li>VRF?? Root amputation??<\/li>\n<li>Apicoectomy MB root??<\/li>\n<\/ul>\n<\/li>\n<li>NS-RCT #5 (pre-prosthetic)<\/li>\n<\/ul>\n<\/li>\n<li>Restorative:\n<ul>\n<li>No further restorative recommended #3<\/li>\n<li>Post and PFM crown #5<\/li>\n<\/ul>\n<\/li>\n<li>Other Tx Options:\n<ul>\n<li>Extraction #3\/#5<\/li>\n<li>No Treatment<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p><strong>Treatment &amp; Biopsy:<\/strong><\/p>\n<p><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/www.aae.org\/specialty\/wp-content\/uploads\/sites\/2\/2022\/01\/TreatmentandBiopsy1.png\" alt=\"\" width=\"700\" height=\"328\" \/><\/p>\n<p><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/www.aae.org\/specialty\/wp-content\/uploads\/sites\/2\/2022\/01\/TreatmentandBiopsy2.png\" alt=\"\" width=\"700\" height=\"297\" \/><\/p>\n<p><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/www.aae.org\/specialty\/wp-content\/uploads\/sites\/2\/2022\/01\/TreatmentandBiopsy3.png\" alt=\"\" width=\"700\" height=\"310\" \/><\/p>\n<p><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/www.aae.org\/specialty\/wp-content\/uploads\/sites\/2\/2022\/01\/TreatmentandBiopsy4.jpg\" alt=\"\" width=\"700\" height=\"276\" \/><\/p>\n<strong>Final Diagnosis:<\/strong><br \/>\nSoft Tissue, Right Posterior Maxilla, Excisional Biopsy:\n<p>Periapical Granuloma.<\/p>\n<p><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/www.aae.org\/specialty\/wp-content\/uploads\/sites\/2\/2022\/01\/TreatmentandBiopsy5-300x136.png\" alt=\"\" width=\"700\" height=\"318\" \/><\/p>\n\t<p><em>Dr. Lauren Belous is a member of the AAE&#8217;s Public and Professional Relations Committee.<\/em><\/p>\n\n","protected":false},"excerpt":{"rendered":"<p>By Lauren Belous, D.M.D. A 65-year-old Caucasian male presented with chief complaint of, &#8220;My dentist found an infection on this tooth (points to upper right quadrant).&#8221; The patient reports being&hellip;<\/p>\n","protected":false},"author":12,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"content-type":"","_relevanssi_hide_post":"","_relevanssi_hide_content":"","_relevanssi_pin_for_all":"","_relevanssi_pin_keywords":"","_relevanssi_unpin_keywords":"","_relevanssi_related_keywords":"","_relevanssi_related_include_ids":"","_relevanssi_related_exclude_ids":"","_relevanssi_related_no_append":"","_relevanssi_related_not_related":"","_relevanssi_related_posts":"","_relevanssi_noindex_reason":"","footnotes":""},"categories":[266],"tags":[],"feature":[236],"class_list":["post-20403","post","type-post","status-publish","format-standard","hentry","category-uncategorized","feature-paperpoint"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.1.1 - 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