From: Sashi Nallapati
To: ROOTS
Sent: Saturday, July 03, 2010 3:41 AM
Subject: [roots] Large lesion, pack and whack?

Any ideas how would you handle a case like this?

36 yr old healthy male.
26 discolored and was accessed by the Referring Dentist.
all other teeth test WNL to thermal tests.
recommendations re: management? - Sashi Nallapati



I would leave it with Ca hydrox a la longue. - Cosmin Fetcu

The referral inform to you about vitality test results on 26?
The discloloration was previous to the access by the referal, isn´t it?
If 26 was non vital for sure, RCT of it with long term Ca(OH)2. - Nuria

26 was necrotic before GD accessed the case. i got a note that there was some drainage at the time of the access opening.
i am not sure what were the symptoms the patient before GP accessed the tooth apart from discoloration.  - Sashi

Sashi, Refer the patient to an oral surgeon because the lesion has probably destroyed the chin.  If the OS is going to get
a CBCT let him get it unless he wants you to take it for him.   You might want to clean out #26 and pack in a dry mix of
CH if you think the gp goofed it up before referring.    It’s odd that there would be apical resorption of #24, seems
like a very aggressive lesion that should be biopsied and cut for complete margins if necessary.  If the CT shows a
complete blow out of the chin the oral surgeon may want to do the procedure in the hospital and get immediate histo
analysis with a frozen section.  A pack n whack would be endodontically myopic and not looking at the bigger picture.

Other questions that need to be answered:  1. pain? (if there is pain it’s more likely to be something bad like metastatic
tumor)  2. race (if black probably a periapical cemental dysplasia but still could be something bad)  3. cortical expansion
(if yes might indicate a central giant cell lesion or a metastatic CA)? 4. Trauma history?

When these presentations have some features that are out of the endo norm (like distant root resorption, excessive size,
cortical expansion, unusual pain or numbness) I’m quick to send to an OS for a second opinion knowing they have the
facilities, hospital privileges, and experience to go further than garden-variety dental disease treatment.  It’s outside
our scope.  You don’t’ ever want to be caught presuming garden variety endo disease when it isn’t.  Conversely, it’s prudent
to have these things checked out by a different set of eyes with a different perspective.  Keratocysts, Giant Cell Lesions,
and cancers may be rare, but if you see hundreds or even a thousand patients a year you’re going to get caught with your
pants down at least once unless you maintain a broad perspective during diagnosis.  It’s the most important thing we do
and what we are the least appreciated for.   -  Terry

Good points terry.
when i saw the patient, 26 was discolored with a history of trauma.
i got a note from the GP that she obtained drainage from 26 when she accessed. I am not sure what exactly his chief
complaint was when he saw her. may swelling and pain, the garden variety endo symptoms.
the size of the lesion got me thinking, but every thing else seemed to point to lesion of endodontic origin.
the resorption on 24 was a strange presentation.
patient is afro jamaican. no cortical expansion could be seen clincally. - Sashi

It's probably a simple PCD that the referal misDx'd or a coincidental trauma/PCD combo that was mismanaged
but it's always good to protect your booty - Terry

Dear Sashi, I agree with Terry and Valery on this one.
I still believe that not taking a biopsy from such a lesion before any treatment or much more even before a diagnose
it is never the right call.The result after your treatment doesn't make your decision to treat it without knowing
exactly what it was correct. I am glad as the patient should be that you were lucky and it didn't turn to be something
worst (as Terry quoted above).

Aside all these, very nice recovery from such a big lesion, nice endo-work. -  Alexandros Toloumis

Dear Alexandros
There wasn't any doubt in my mind what the diagnosis was. It was LEO.
with out that diagnosis, i would not have progressed with the treatment.
I am posting this case to highlight  two points
1. Not all LEOs have to look a certain way.
2. LEOs that are large, treatment approach shall be slightly different from the routine. Surgery is not always necessary for these cases.
As far as me being lucky with this approach, i absolutely disagree.
It was the patient who got lucky. He got the correct treatment - Sashi

Ok. Here is my management for this  lesion.
since its established that it is a LEO (history of trauma, discoloration of the tooth,
RD reporting drainage from tooth)

my first reaction is to open, drain and apply CaOH , wait till canal is dry and wait and see.
if lesion is shrinking and canal is dry , obturate, and follow up. If lesion not shrinking,
canal not dry after multiple CaOH applications, do a surgery and send the specimen to the lab
or refer to OS depending on my comfort levels at that time. i prepared the patient for both endo
and surgery. the size of the lesion and the root resorption on 24 made me suspicious to the nature
of the disease. but, i stuck to my basics and took the conservative approach.

7/2009  : started the treatment, obtained a lot of drainage, placed CaOH
9/2009 : more drainage and more CaoH
12/2009: definitely the lesion is shrinking.
1/2010 : canal was found dry. i obturated the tooth. bleached it internally.
7/2010: 90% osseous healing seen.

despite my recommendations, RD crowned the tooth Arrghhh - Sashi Nallapati




Excellent management Sashi, Endo rocks! - Carlos Murgel CD

Sashi.......I never expected anything less from you.....awesome case.  WEll done. - Glenn

Nice and exactly what I expected,  what on earth possessed anyone to crown that tooth? -  bill

Bill, In Israel the reply is easy,

1. Greed (unlike in Usa making a living in a country where the ratio of dentists:patients is 1:1200 is very hard)

2. Ignorance (20+ years ago they showed there is NO need for anterior crowns to strengthen them but they still use
   this to make them)

I guess the same for the rest of the world (especially where making money from dentistry is hard). At least the
crown looks with decent margins, not the Mexican sombreros I am used to see L, - Thomas

Thomas...I am fully aware from your posts that dentistry is tough in Israel.  1:1200 patients is not small though.
In Victoria on Vancouver Island the ratio can be as low as 1:300
I am a firm believer that if it is to be it is up to me.
I want people here on ROOTS to know that there is ALWAYS room at the top of the mountain.  You must be open minded,
committed and firm in your convictions and your worth effort and ethic to get there. but there is always room at
the pinnacle. - Glenn

Thomas, they still believe a tooth with a crown, even in this scenario, is more fracture resistant
than one with out - Sashi

Great management of such a big lesion. How long was the lesion present? Would it change your protocol if you knew
that the laesion was there for let's say 5 years? - Rafaël

dont know how long it was present. if i were to presume, atleast 5+ years. it wont change my protocol. - Sashi

EXCELLENT WORK DR.SASHI  AND I AM SURPRISED TO SEE EVEN SUCH LARGE LESIONS DOES'T REQUIRE SURGICAL INTERVENTION.
DO YOU PREFER PLAIN CAOH OR VITAPEX IN SUCH CASES? - kishore nallapati.

i use Caoh from Ultracal. i havent used vitapex. - Sashi

Sashi, Excellent result at this stage. Is other incisor with signs of resorbtion still vital ?
However, you should know that lesions with such signs of root resorbtion quite rarely are of endo origin
and one must be very carefull when diagnosing such case. Delay to refer the patient to an OS may play the
endo guy a very bad joke sometimes.

Besides, I am not in favour of approach when one makes a post asking for opinion of others while she/he
already has some results with that case. Ability to make correct diagnosis is the main part of any medical
doctor or dentist professionalism. Making correct diagnosis is at least 50 % of the treatment of a case.
If one really needs an advice or opinion, then he/she should ask for it at the time she/he really treats
the patient, not when she/he have already done it.

Just RX posted on-line can not be a single source on which a colleague can base her/his diagnosis.
It's very difficult to give advices without being able to see the patient by your own. Having just an RX and
some scarce pre-treatment anamnesis does not help much imho. My 2 cents. - Valeri

Valeri, Yes, 24 is vital.
I agree, when in doubt, always biopsy the lesion. In this case there was not much doubt in my mind. it was a
typical garden variety LEO  the slight apical root resorption in 24 not withstanding. However, as i outlined
in my treatment approach, i keep evaluating the healing response or nonresponse on a very regular basis.
I know i set you all up with this case. But if i posted this as a case  showcasing the management, the message
is not as effective. Not knowing what the treatment rendered was forces people to think through the protocols
they observe in their own practices. The idea is to discuss the diagnostic protocols and treatment protocols.
Not just for this case, but every similar case that comes into our practices. Now, having thought of their
protocol and then the successful treatment rendered in this case one has an instant gratification to see if
his/her protocols would have been appropriate in THIS case or not.

i didnt see many people posting much of their protocols on the diagnostic part or asking for more information ,
except terry. But i hope this case made them think. Thanks for your views. - Sashi

Sashi, The classic and correct approach to such case is to make a biopsy - first. I can tell that from experience
being an oral surgeon myself for over 20 years. I would not be that brave to make a diagnosis and perform treatment
of such cases without taking biopsy. Your endo is excellent and no one questions it ! What I say is - make diagnosis
first, so that you know what you are dealing with. If one fails to make a correct diagnosis, concequences for the
patiient may be severe.

Thus your approach presented this way on-line would mean for some that they can go with endo first and if it fails
then they could reffer the case to an OS. This is a wrong approach to choose IMHO - Valeri

Valeri, thanks fior engaging me in this discussion.
I am attaching two cases here that i have seen in my practice.

Case 1:  garvey:  MH Non COntributory.
she was swollen, in pain, came to my office as an emergency, was on already AB for over a week. Pain not subsided,
Referring dentist started the RCT in 21,( LL1Premolar ) 3 days before she saw me, she was in more pain than before.
21 was very tender to percussion, tender to palpation, diffuse swelling in LL mandible.

Case 2: Brown. referred to me for  evaluation. he was not in any pain. LL Mandibular indurated, localised swelling
in 20. painful to palpation. No other symptoms. cortical expansion observed.

I am presenting the periapical views that i took in my office. (most dentists in this part of the world do not have
a Pan in their office). Shall i biopsy both these cases to confirm my diagnosis? what will you do? - Sashi




1. Treat Garvey - 2nd canal missed (think its the lingual canal that was missed)
2. Send Brown - for biopsy likely something going on there  -  Glenn

Glenn, what made you think you recommend biopsy in the second case ? - Sashi

Sashi, The two cases you have shown us are really garden variety LEO as you called it. Taking a look at the RXs it is more
than clear the lesions are of endo origin and do not show any signs to make us suspect malingnancy of any kind.

The clinical picture you have described for Case 1 is classical for an acute dental infection. Sometimes a dental infection
flares up before starting to subside depending on the approach of the dentist who first started treating it. Sometimes flare
up can not be explained with actions taken by the dentist and then it is up to the immune system of the patient.

Case 2 - picture of subacute dental infection. Pulp necrosis is the reason and reaction on bone's side is what could be
expected in case like that. Such leasion can stand like that for a long time before going into exacerbated state when pain
appears and case will need emergency treatment. Nothing special on RX, too.

In both cases there is no multiple root resorbtion and you can also pay attention on the RX views of  both lesions borthers.

I'd kindly mention that differencial diagnosis in "border" cases must be done by an OS who usually sees more malignancies
than an endo colleague. Best, Valeri

Dear Valeri Before an oral surgeon sees the patient, an endodontist shall rule out dental infection as the etiology.
In my experience, very few oral surgeons know how to test vitality of teeth.

i work with world class OMFS in Kingston. They are as good as it gets in their field. however, they do not know how to
pulp test if their life depended on it ;-)) - Sashi

Dear Sashi, Here before one enters into OS specialisation she/he surely learns how to do a vitality test while being
on GP practice.

I would not dare to classify myself as "extraordinary world class" surgeon ( although I have certain achievements in
the field of my specialty at international level ), but I surely know how to do vitality test and I even know how to
use an apex locator and I can do a decent endo as evident from the cases I post on the list. In socialism years here
I  worked as OS exclusively, but after 1996  I started doing more of other dentistry due to changes which happened to
profession and economy

( hyperinflation in 1997) in Bulgaria.

So, it seems that all depends on the curriculum at dental school. Unfortunately in last years dental education in
Bulgaria has deteriorated significantly as far as pre-clinical medical background is of question. When I was a student
we studied all pre-clinical disciplines at the same level as medical students and studied whole human body, while now
students for example study very little anatomy, pathoanatomy and pathophysiology. Much less pharmacology, too - Valeri

Dear Valeri, In case 2 , How did you make a determination that it was subacute dental infection? - Sashi

Sashi, Just curious if in Case1 the dentist who has seen the patient first time has done A,B,C of oral surgery before
prescribing AB for one week - incision and drainage of the swelling + opening the tooth and removing the necrotic tissues
from the root canals and placing CaOH or antibacterial/antiinflamatory paste inside the canal ?

There are some basic Oral Surgery things which need to be done at once when we treat such case. My experience shows that
most local endo guys just prescribe antibiotic and do not do incision and drainage, which usually results in patient seeing
an OS within a day or two later - Valeri

Dear Valeri, In case 1 Garvey: the dentist who saw the patient diagnosed it was a dental infection and started the RCT.
obtained drainage. Put patient on AB. she was still in a lot of pain. she opened the tooth again and cleaned it further.
Patient was still in pain. that's how i got involved.

In my 15 years of practice i have a lot fewer cases that needed incision and drainage compared to cases that were endo
treated with thorough debridement and disinfection of the canal space and RX broad spectrum AB. Of course i only treated
them after i made the diagnosis that it was dental infection.

Unless patient has massive cellulitis or Ludwigs angina, i will not get the OS involved. It has worked well for me.
- Sashi

Dear Sashi, What do you do in cases of perimandibular abcess or submandibular abcess ( not at stage of Ludwig's Angina)
- you do not do surgical drainage and you leave the patient on AB and tooth root canals debridement only ???

How you define the diagnosis - massive cellulitis ? Broad spectrum antibiotics are to be forbiden for dental infections
which are not life threatining ! There are certain  antibiotics which are indicated for use to treat dental infection !
Just my 2 cents. - Valeri

Dear Valeri, patients with most sub mandibular space infections associated with an infected tooth, my management involves,
immediate access of the offending tooth and obtain drainage.
Put patient on cocktail of Penicillin/Amoxicillin and metronidazole if no allergies to these AB.
This combination is very effective for  Gm + and - bacterial spectrum.

what i meant by  cellulitis, is when patient is swollen and in my clinical judgement there is a possibility of more facial
spaces involving including the possibility of ludwigs, there are sure signs patient being febrile, running temperature,
trismus with limited mouth opening, then i prefer the patient to be handled by the OMFS in a hospital setting with IV AB.
- Sashi

Dear Sashi, If I got it correct you manage a patient, for example, with submandibular abcess by opening a tooth and
obtaining a "drainage" through the tooth canals only, while prescribing the patient a combination of  Amoxicillin +
Metronidazole ? The basic principle is to let the body's immune system to take care of the infection. It is the immune
system that fights the infection and not the antibiotics.By a  good surgical drainage of affected anatomic space  pus can
be easily evactuated and this way the immune sytsem  is helped to take care of infection.

It is not advisable to use Amoxicillin + Metronidazole for infection of single anatomical space which is known to be of
dental origin. Such combination should be reserved for more severe dental infections where Penicillin alone is not
effective against anaerobic bacteria involved in such infection. The extended spectrum of Amoxicillin may be indicated
when you have also involvement of the maxillary sinus, but not for cases with "regular" dental infection.

In these days over-prescription of AB is a global problem and resistance of bacterias to AB is becomming a serious problem
in dentistry, too.

I would say your approach is not the best to be chosen, but everyone has the right of her/his own opinion - Valeri

Dear Sashi, Infection process which is evident on RX ,involves a tooth (which seems to be a cause for it) and
periradicular jaw bone, too while not showing typical signs of an acute infection is defined as subacute dental infection.
( fact that periosteum has reacted to it and at the same time palpation is painfull to the patient are both signs it is
in subacute stage and may exacerbate at any moment if left untreated)

I guess we have gone too deep into oral surgery and that may be boring for some of  ROOTS subscribers. But if you wish
we may elaborate on the subject further - Valeri

Dear Valeri, Ok. Here it is.

In case 2 (Brown): i was expecting you to ask me for more information , like what are pulp testing results for
the LL quadrant. i have not provided that info to you in the mail. You have presumed that 20 was infected and it was
responsible for the lesion. when i pulp tested the LL quadrant, all teeth tested WNL to all tests.





so i sent the patient for further investigations to the  OMFS i refer to. i have attached the pictures. Borwn was
ultimately diagnosed with an aggressive non odontogenic tumor. DD was ameloblastoma, OKC etc.. The OMFS was to get
back to me with the final diagnosis.





As far as Case 1 (Garvey) is concerned, as glenn guessed it , even though the RD started the RCT and entered the tooth
again after she didnt respond, there were two canals in the premolars and the RD only found one canal.She didnt realise
the second canal. a dx was made as dental infection and i opened the tooth, drained the tooth further, located the
second canal, multiple CaOH applications and the one year recall shows full healing.

Reason why i posted these two cases is to highlight the importance of taking accurate history,  testing for vitality,
record the signs and symptoms, and use your clinical judgment to determine which one is a garden variety LEO and which
one is Zebra.

Hope this exercise helped you. - Sashi

Dear Sashi, I must admitt that you have original way of presenting cases ;- ).  If I go your way I would show you
two of the roots of a molar which have no PA lesion and ask you to tell me if there is a PA lesion on the third root
which is not visisble at all on the picture I have sent you ?

As I have already written to you when communicating over Internet things should have to be said straight and clear.
But it seems it's a hobby for you to try to set up people ;-). Well, as Terry correctly mentioned I am not the type
of a guy who get's mad about such neglectable things in life.

Presenting just part of the information does not help receiving useful answers. What you do is what kids do at
kindergarden. I have a colleague here in Bulgaria who's doing same thing on Bulgarian forum. He must have learned
this from you since he is on this list, too :-).

The information from a small RX was not revealing the fact that this is a large cystic lesion which interconnects
with a smaller cystic lesion on the left. So, the RX you intentionally posted this way first was definetly misleading.
That means that based on the information you provided in your first message my assumptions still stand strong as far
as any conclusions can be made without seeing the patient myself. ( because you have intentionally missed to write
about important clinical signs present I guess based on information of CT images I now saw ).

And what you do is not an diagnostic exercise whatever you think that means. To have a true diagnostic quiz you
MUST provide ALL the information available on the case. See how Terry's posting his qiz cases. The way you do it is
just like a game between the kids. - Valeri

Dear Valeri, Ok. Here it is. In case 2 (Brown): i was expecting you to ask me for more information , like what are pulp
testing results for  the LL quadrant. i have not provided that info to you in the mail. You have presumed that 20 was
infected and it was responsible for the lesion. when i pulp tested the LL quadrant, all teeth tested WNL to all tests.

so i sent the patient for further investigations to the  OMFS i refer to. i have attached the pictures. Borwn was
ultimately diagnosed with an aggressive non odontogenic tumor. DD was ameloblastoma, OKC etc.. The OMFS was to get
back to me with the final diagnosis.

As far as Case 1 (Garvey) is concerned, as glenn guessed it , even though the RD started the RCT and entered the tooth
again after she didnt respond, there were two canals in the premolars and the RD only found one canal.She didnt realise
the second canal. a dx was made as dental infection and i opened the tooth, drained the tooth further, located the second
canal, multiple CaOH applications and the one year recall shows full healing.

Reason why i posted these two cases is to highlight the importance of taking accurate history,  testing for vitality,
record the signs and symptoms, and use your clinical judgment to determine which one is a garden variety LEO and which
one is Zebra.

Hope this exercise helped you. best regards - Sashi

WOW I was right.......what do I win.
Sashi, please tell me what happened to this patient with the tumor as looks to be the whole lower jaw....frightening.
Now I told you this from just the two images.....pretty impressive huh.
All the best .....but I am disappointed.   Your lower premolar had only 2 canals NOT 3.....
must have been a tourist huh. - Glenn

Hi Sashi, Excellent outcome and very conservative treatment indeed!
To take a biopsy or not is always a dilemma in cases like these.
In hindsight, your treatment was spot-on and saved the patient a lot of trouble but I'm just wondering
what if it didn't work out?

If the lesion showed no signs of healing at 6 months and the biopsy showed malignancy, what would be your
defence in allowing the malignacy to progress for 6 months without treatment? Would the oncologist support you?

Just for discussion's sake :-)) - Siju

Siju, Diagnosis is critical.
Diagnosis comprises of an accurate history taking, recording all  the clinical signs, symptoms, radiographic
analysis and finally laboratory tests including biopsy. if the etiology is not certain

biopsy becomes even more critical. One has use to their clinical experience to assimilate all this info,
which shall bring up the antenna up for any zebras and then make the decision on

Biopsy or no biopsy?  on an individual case by case basis.

As far as the your question on malignancy is concerned, of course it is not acceptable to waste 6 months of
critical time in case of an malignancy. My approach to prevent this possibility is as outlined above. get an
accurate diagnosis.

there is a fine line between treatment and over treatment. depending on who you ask you will get different
perspectives. In a surgically oriented practice, the treatment approach to this tooth would be  curettage,
possible devitalizing other teeth in the vicinity, root canal treatment and apicoectomy and bone graft and
possible membrane. and there will be absolute justification from their stand point it is the safest and the
most appropriate treatment.

if it is my mouth, i want the treatment that was provided by me to this patient - Sashi

You can’t argue with success and it was a nicely handled case..  I just felt your case presented with enough
odd signs that it should be checked out with a biopsy by an oral surgeon.  I’ve had several large lesion cases
like that.  I’ve seen one or two Giant Cell lesions, and OKC’s before.  Odds were great it was a garden variety
endo lesion which it was.  If a previous dentist opens one of these teeth up then you don’t’ know if you have
something weird plus an iatrogenic endo problem caused by an initial misdiagnosis.

These things are like playing guess which M&M has the cyanide in it when you have one poison M &M in a Jar of 2000.
Are you going to snack on an M&M out of that jar knowing there is 1 out of 2000 that would kill you?  - Terry