1. Discussion & Conclusion
REVIEW OF GUIDELINES FOR USE OF CONE BEAM COMPUTED TOMOGRAPHY IN PERIAPICAL PATHOLOGY BASED ON A CASE REPORT OF PERIAPICAL AGGRESSIVE CENTRAL GIANT CELL GRANULOMA
AN Neuman, JE Bouquot , R Jurevic, D Forbes, B Weaver, and A Borgia. West Virginia University College of Dentistry, Morgantown WV
Figure 1: Initial asymptomatic presentation
Figure 2A: Seven months later, with pain
Figure 2B: Seven months later, with pain
Abstract
Discussion & Conclusion
Central giant cell granulomas of the jaws are typically known as being nonaggressive, nonneoplastic lesions initially termed “giant cell reparative granulomas.”1 These lesions most commonly present incidentally as unilocular radiolucency in the mandible.2 However, some present with pain and perforation of the cortical bony plate.3 We present a case of a central giant cell granuloma referred for endodontic evaluation when the patient presented with pain, swelling, and a necrotic pulp. Radiographically, the patient presented with a unilocular radiolucency associated with the root of a mandibular bicuspid causing spiking resorption. Further review of the patient’s radiographic history revealed the lesion was visible and much smaller at the initial visit 7 months prior to symptoms. Cone beam computed tomography (CBCT) evaluation revealed erosion of the buccal alveolar cortex. Biopsy proved the lesion to be a central giant cell granuloma (CGCG). As of January 2014, patient has healed properly with no recurrence of the lesion. In our case, CBCT provided additional information leading to immediate biopsy rather than root canal therapy. Though in up to 70% of cases additional clinically relevant data is obtained, CBCT use is not routine in endodontic therapy.4 We review the current guidelines for CBCT use for evaluation of periapical pathology.5
A joint position paper from the American Association of Endodontists and the American
Academy of Oral and Maxillofacial Radiology states that “CBCT must not be used routinely for endodontic diagnosis or for screening purposes in the absence of clinical signs and symptoms,” and “should only be used when the question for which imaging is required cannot be answered adequately by lower dose conventional dental radiography.”14 This paper goes on to say that use is appropriate for the “diagnosis of dental periapical pathosis in patients who present with contradictory or nonspecific clinical signs and symptoms, who have poorly localized symptoms associated with an untreated or previously endodontically treated tooth with no evidence of pathosis identified by conventional imaging.” These organizations conclude by stating that “radiographic examinations must be justified on an individual needs basis whereby the benefits to the patient of each exposure must outweigh the risks.”
In 2007, Hansen et al reported in 32 of 46 teeth (70%), all examiners agreed additional, clinically relevant information regarding periapical pathology was obtained when using a CBCT, compared to traditional periapical radiographs.13 However, a 2012 study involving 24 cases performed by Balasundaram et al showed no significant difference between treatment of periapical lesions whether diagnosed by 2D or 3D film.13
The present case appears to be an excellent example of the benefits of CBCT in providing enough additional diagnostic information to warrant a change in the treatment plan. The case was especially confusing because an aggressive CGCG was wrapped around the root of a tooth with unrelated pulpal disease. Without the additional imaging, endodontic therapy would have been performed and would have undoubtedly delay appropriate bone treatment for many months, probably with the additional stress of repeated endodontic procedures..
Case Report
Figure 3: CBCT shows large cortical destruction, much worse on buccal
Figure 4: Multinucleated giant cells and erythrocyte extravasation
A 26 year old Caucasian female presented to the West Virginia University School of Dentistry as a new patient seeking prophylactic and routine dental care. An asymptomatic, ill-defined radiolucency was present in the right posterior mandible at her initial visit (Figure 1), but no further diagnostic workup was elected. The patient returned seven months later complaining of a dull, throbbing pain in the region of the radiolucency and at that time periapical radiographs revealed a large, relatively well demarcated lesion without sclerotic rimming and with slightly scalloped borders surrounding the root of #29 (Figures 2A & 2B). Vitality testing was performed, including a cold test (Endo Ice®) along with percussion and palpation sensitivity evaluations. Teeth #28 and #30 responded to all testing within normal limits. Tooth #29 was positive for lingering pain to cold and tenderness to mild percussion. Upon endodontic access, the pulp was observed to be non-vital; CBCT evaluation at that time was, however more consistent with an aggressive neoplasm than an apical infection (Figure 3) and so two days later the premolar and bone lesion were surgically removed; biopsy proved the lesion to be a CGCG (Figure 5). At three months post-op, healing was normal with no recurrence (Figure 6).
References
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Figure 5: Immediately after surgery
Figure 6: Three months post-op, with healing
Introduction & Methods
CGCGs appearing at the apex of a tooth with a non-vital pulp have rarely been reported in the literature In a study encompassing 79 cases of CGCGs presenting as periapical radiolucency, only 20% were found to be associated with non-vital pulps.7 A review of the current English language literature revealed no computed tomography scans of such lesions as of this writing.12