Case Report

Hong Li

Subjective:
Chief Complaint: “My upper front tooth has an infection. It swelled up last month. I took antibiotics and the swelling went away. The tooth is still tender when I press on it.”Medical History: Patient is a 67-year-old Caucasian female. She has high blood pressure, hypothyroidism and asthma. She is taking Cozaar 50mg qd, Synthroid 112mg qd, Premarin 0.625 mg qd and Advair inhaler as needed. She is allergic to latex. ASA Class II.
Dental History: Patient had history of surgical removal of # 6, #11, and “extra teeth” many years ago. #7 had RCT 2 year ago. But the lesion associated with #7 has continued to expand. Patient was referred to Graduate Endodontology to OHSU for #7 RCT evaluation and treatment.

Objective:
BP: 146/73   Pulse: 70
Extra-oral exam: WNL. No swelling, lymphadenopathy, facial asymmetry or pathosis was noted.

Intra-oral exam: #7 RCT was acceptable, has large composite restoration without open margin or recurrent caries.  #8 has PFM crown, #6 and #11 were missing without spaces. #10 has RCT and crown, possible apicoectomy treatment. There was no significant finding with respect to the oral cancer screen.  Oral hygiene was fair, with mild plaque accumulation. Generalized adult periodontitis with moderate bone loss and gingival recession are noted. No swelling and sinus tract was found.

Radiographic Evaluation:
#7 RCT. PARL with 8x10 mm in diameter. There is a radiopaque mass located at the superior border of radiolucency lesion. There is a supernumerary tooth #8+ impacted at #8 apical palatal area as indicated by cone shift technique.

Preoperative radiograph:

Assessment:
#7:  Previously treated, Symptomatic Apical Periodontitis. Etiology: Persistent infection? Apical abscess? Apical granuloma? Apical cyst? Neoplasm?

Plan:
PARQ: Recommend apical surgery and biopsy #7, possible removal of the #8 plus the supernumerary tooth. Prognosis is favorable.  The alternative treatment options including extraction and no treatment were presented to patient. Oral Surgery consultation was carried out regarding the supernumerary tooth. The recommendation was do not remove it unless it is exposed to the lesion, to avoid devitalize #8. The patient was informed of the risks associated with surgery, including possibly devitalizes the adjacent teeth, gingival recession, and other possible complications, and if the surgery fails, extraction with oral surgeon could follow treatment. The importance of full crown coverage restorations upon completion of surgery was stressed to patient. Patient consented to #7 periradicular surgery.

Treatment:
Patient took 800 mg Ibuprofen and rinse with 0.12% Chlorhexidine prior to surgery. After administered 36 mg Lidocaine, 0.018 mg epinephrine and 172 mg cabocaine via buccal infiltration and palatal ASA block, sub-marginal horizontal incision from #5 to #10 was made and full thickness flap was raised. #7 had a large fenestration defect from buccal through palatal cortical plates, had purulent exudates and large amount of granuloma tissue, which was removed for biopsy. The #8 plus supernumerary tooth was not exposed to the lesion cavity. #7 apical root was resected about 3 mm, hemostasis was achieved with 2.25% racemic epi. The root was stained with methylene blue and no root fracture was noticed. The root end was retro- prepared with ultrasonic tips into canal about 3 mm, and white MTA was used to retro-filled the cavity. One periapical radiograph was taken to exam the retrofilling. After irrigation of the surface with 0.12% Chlorhexidine, the flap was re-approximated and continuous locking suture with 5-O Vicryl was used to secure the flap tissue and gain primary closure. Post-operative instructions were given and Ibuprofen 800mg x 20: 1 q8h prn pain was prescribed. Also, 0.12% Chlorhexidine was given to patient for mouth rinse. Patient was scheduled to return for suture removal in 3 days.  Phone call to patient home in the evening was made, and patient reported that she was doing fine, no pain, mild swelling, no fever and no bleeding. 3 days later, patient came back for suture removal, #7 apical area slightly swelling, incision is healing, no bleeding, no sign of infection. #7 percussion is +, mobility is I. The suture was removed. She is to return in 3 months for a re-evaluation.

Pre-op photos:

After resection and staining:	After retro-prep:	After retro-filling:

Suture:	Final films:

Pathology Report: Microscopic examination reveals sections of irregular fragments of fibrous connective tissue containing heavy mixed inflammatory cell infiltrate consisting of plasma cells and polymorphonuclear leukocytes. Diagnosis: #7 dental granuloma with acute inflammation.