Case Presentation – F.W.

F.W. – June 8, 2017 Age/Sex: 30 year-old female Referral: school patient Reason: bone pattern periapical to tooth 4.7 Back story : a student walked in and asked for our opinion as he was unsure what the periapical bone pattern surrounding tooth 47 We initially called the patient in for educational purposes, but found that the patient was in fact symptomatic.

History of chief complaint Chief Complaint: “I have occasional pain here.” (points to the area of the right antegonial notch). 2007 (approximately): endodontic procedure carried out in Libya (teeth 4.7 and 4.8) following symptoms of dental pain. 2017: occasional pain on chewing pain on palpation in the right antegonial notch area patient decided to obtain care at the University of Toronto dental clinic. She had some images taken at a dentist at Bathurst but unable to recall which one, and we are unable to trace them.

Medical History no known drug allergies (NKDA) no known medical conditions medications none

Clinical examination patient: pain on chewing extra-oral: right submandibular lymph node tender to palpation intra-oral: teeth 4.7 and 4.8 elicited pain on percussion and tested non-vital no evidence of osseous expansion soft tissue in the floor of the mouth was within the range of normal

Dentition: periodontal status : gingivitis Tooth 4.8 4.7 4.4 4.3 palpation - percussion + mobility periodontal probing within the range of normal cold pulpal status previously treated normal periapical status symptomatic apical periodontitis periodontal status : gingivitis

Radiographic Survey 1 panoramic image 1 periapical image 1 bitewing image 1 limited field-of-view cone beam CT study 2 lateral mandibular occlusal images and 18 periapical images (dated February 17, 2017) were also reviewed

Sixteen periapical images (February 17, 2017) Incidentally, the roots of teeth 1.8, 1.7, and 3.4 are retained and have associated rarefying and sclerosing osteitis. Tooth 2.8 is a microdont. There are carious lesions involving multiple teeth in the maxillary and mandibular dentition.  

Tooth 4.7 There is a well-defined, spherical, mixed high- and low-attenuation (radiopaque/radiolucent) region of altered bone located lingual and periapical to the apices of tooth 4.7. The area of altered bone extends from the alveolar crest to the superior cortex of the right inferior alveolar canal, from the periapical area of tooth 4.8 to the edentulous 4.6 area, and between the buccal and lingual cortical plates. The epicentre of the alteration in bone is lingual to the distal root apex of tooth 4.7. There is a thin peripheral radiolucent band, and a narrow zone of transition as it abuts the normal surrounding trabecular bone. Internally, there are concentric, alternating radiolucent/radiopaque bands.

mandibular lateral occlusal image

panoramic image

Tooth 4.7 periapical image bitewing image