A tricky patient case to diagnose

tricky patient caseJames Aquilina presents a case of a patient presenting with acute exacerbation of a chronic apical periodontitis or an acute infection of a periradicular cyst.

A 50-year-old female patient was seen at the local oral and maxillofacial surgery department. She complained of a swelling on the left side of her chin, which had been present for six months. Her general medical practitioner had treated the swelling with antibiotics but this had no effect on the swelling. The surgeon suspected there was a periradicular cyst associated with the LL3. She was referred to have appropriate endodontic treatment in preparation for surgical enucleation of the cyst.

On first presentation the patient reported that over the proceeding week the swelling had increased in size and she was experiencing constant throbbing pain which had been disturbing her sleep. Clinically, it was noted that there was an extra oral large firm tender swelling extending from the midline to the angle of the mandible on the left-hand side.

Opening was limited but a firm diffuse swelling was noted in the buccal sulcus. The patient had already been given a course of Amoxicillin and so arrangements were made to review.


At the review the swelling had subsided allowing a more thorough examination. Nearly the entire lower arch comprised of an extensive bridge replacing the LR2, LR1, LL1, LL2, UL2 and LL6. The restoration appeared to be intact with no sign of failure. The left-hand side bridge abutments (LL3, LL4 and LL7) all gave positive but varying responses to sensibility testing.

The LL4 and LL7 were found to be tender to percussion. Probing depths were within normal limits. Radiographic examination revealed a large circular radiolucent lesion with diffuse margins associated with the apex of the LL3. The apex of the LL3 was blunted and short (Figure 1).

A provisional diagnosis of an acute exacerbation of a chronic apical periodontitis or an acute infection of a periradicular cyst associated with the LL3 with apical resorption was made. The options were discussed with the patient who requested that conventional endodontic treatment be undertaken.

Figure 1: The apex of the LL3 was blunted and short


Endodontic treatment was commenced on the LL3 under local anaesthesia and rubber dam isolation. Access was made through the coronal restoration. The pulp was found to be necrotic. Copious amounts of pus and serous exudate were drained via the access cavity.

A Dentsply SX Protaper Gold rotary file was used to enlarge the coronal canal. A 3% hypochlorite solution was used for irrigation. The working length was established using an electronic apex locator (Dental Diagnostic Unit, KerrHawe UK). The apical preparation was performed with a Reciproc R25 instrument. A final irrigation regime of 17% EDTA followed by 3% hypochlorite was used. The canal was then dressed with a calcium hydroxide paste (Calcipaste) and the access was sealed with IRM (Dentsply Sirona).

Follow up

Figure 2: Radiograph confirms a good obturation

The patient attended the following week reporting that the tooth had been painful for a few hours. But had since been symptom free. The swelling had reduced and normal function reestablished. Under local anaesthesia and rubber dam isolation the canal was accessed and the intra canal dressing was removed with alternating irrigation with 17% EDTA and 3% hypochlorite solutions.

The canal was found to be clean and dry. The working length was confirmed with a cone fit radiograph. The canal was obturated with vertically compacted gutta percha and AH plus sealer (Dentsply Sirona). An IRM (Dentsply Sirona) base was used to seal the pulp chamber and the access cavity was restored with Chemfil Rock (Dentsply Sirona). A radiograph confirmed a good obturation (Figure 2).


At a six-month review appointment, the patient reported that the tooth had been symptom free with normal function. Clinically other than some supragingival calculus there was nothing to note. A radiograph showed a dramatic reduction of the periapical area (Figure 3). A diagnosis of early apical healing was made and the planned surgery at the local oral and maxillofacial surgery department was cancelled.

Figure 3: Radiograph shows a dramatic reduction of the periapical area

This article first appeared in Endodontic Practice magazine.

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