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Endo tips    Better Endo    Endo abstracts    Endo discussions

Cyst: A big one... or??

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From: "Dan Path"
To: "ROOTS"
Sent: Thursday, November 06, 2008 3:22 PM
Subject: [roots] Cyst: A big one... or??

I'd like a second opinion on this case I've seen this morning.

The patient, female, is 30 years old, have recently born a child (5 months
ago) and soon after she began to feel pain and a tumefaction
developed in the right side of her mandible. I would like a second
opinion about the diagnosis and the next steps. I was going to
perform an antibiogram on the pus, if I can collect any, but not sure
anymore.

History:

* no reported history regarding this part of the mouth / these teeth
* the patient reported that the symptoms came from 0 to 100% in about 1.5
  months (symptoms: swelling and pain).
* she visited a dentist 2 months ago and he opened tooth #4.5. I don't know
  the original diagnostic or what that dentist found in the canal or what
  he did. Though, the patient reported that she didn't feel any kind of relief
  during the treatment or after. The treatment was 15-20 minutes long...

Clinical exam:

* oral hygiene: good, but not excellent
* inspection: extra-oral: the tumefaction is barely visible with

mouth closed
           : intra-oral: normal mucosa, tooth #4.5 presents discromia
* palpation: tumefaction in the vestibule, from, #4.4 >>> #4.7,
             mostly under the external ridge
           : barely felt a tumefaction on the lingual side of the
             mandible
           : hard feeling on palpation, it feels like she still has
             cortical bone. painful upon palpation.
* percution: #4.5, #4.6 positive, rest of them negative
* mobility: #4.5, #4.6 - mobility 2
* perio probing: upon normal limits
* vitality tests:
           #4.4: positive
           #4.5: negative
           #4.6: slightly positive
           #4.7: positive
           #4.8: positive
* carious lesions, treated or not: NO

I would appreciate any input on this, thank you!

OOOOH sign me up honey - Clay Stuart Dan, I would refer this one to an oral surgeon, I think the differential diagnosis would include more than a lesion of endodontic origin. The lesion is so large I would worry about a pathologic fracture. It seems to have displaced the teeth and resorbed some of the root tips. What kind of vitality tests did you do? Electric or thermal? Also note the other pathology on the other side. I am not sure what Clay is offering... Dan Shalkey this is indeed something for the oral surgeon. you definitely need a pathology report. also a conebeam CT could help... Bart Here is a response from my Oral Path Professor buddy at Temple University who runs one of the busiest oral path services:..... this is the Power of Roots! Ken has created an unbelievable opportunity to docs and ultimately their patients. Hi Fred Very interesting radiographs. The lesion appears unilocular on the pan and also looks like it is a thru and thru lesion, altho the clinician stated cortical bone is still present. Not sure what happened with 45 and why it is half done endodontically. The roots of the adjacent teeth have certainly been resorbed. On the pan the lesion does not appear to be centered on 45 apically (the dead tooth). The PA radiograph suggests it is more centered on 46, but I think the clinician stated it was vital and the PA radiograph does not provide me a reason to think it wouldn't be vital. The pan suggests the lesion center is between 45 and 46. And there is tumefaction. I didn't find any information as to the patient's age, gender, medical history, but..... From what has been provided, a periapical inflammatory process seems less likely. Radiolucencies that can occur with vital teeth include ameloblastoma, OKC, central giant cell granuloma, etc. With those types of lesions at the top of your list then a biopsy of the lesion is in order to establish the diagnosis because the treatment for each of the lesions listed above is considerably different. Thanks for the opportunity to review the case with you. Let me know what happens. - Gord +1 on biopsy. - Mark I'm going to answer this before I read what the Fred says. This is not an endodontic case. This is a case for an oral surgeon. The regularity suggests a cyst but they are not always actually what they appear to be. I've seen one hemangioma that appeared with a smooth regular border...dangerous stuff. Could be anything but it belongs in the hands of a capable OMFS and a reconstructive ENT. There are specialist in everything now. I had my entire lower left eyelid removed by a Mohs specialist and the next day a reconstructive opthomologists grafted skin from my baggy top lids to the lower. Other than a small droop when I'm tired...can't tell it. This is specialist territory. - Guy Where are you Dan? Fred has pointed at a major medical center. That would be my advice. I've found with my many basal and squamous cell carcinomas, it costs no more to go to the best...same with my heart stents. I'd find the best around because this is going to need some reconstruction. I've sent this film to my brother-in-law in Charlotte, NC for his opinion but have gotten no response so far. He is a reconstructive ENT and works closely with a OMFS who specializes in these type lesions, trauma and cancer surgery. If you are near the Raleigh/Durham area, you have access to multiple centers. Find the best before going forward. Travel is cheap when it comes to your health. - Guy

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