A patient came in because his dentist was concerned about pathology associated with teeth Nos. 23 and 25 (Figure 1). He was a 67-year-old African-American male with a history of trauma. He was asymptomatic with no swelling, redness, or tenderness in the lower anterior area. Pulp testing to cold was nonresponsive on Nos. 23 and 25.
Do we jump in and do endodontic therapy? Not yet! Nonresponsive pulp testing to cold could be because aging can cause the pulp to recede and the dentin to thicken, creating little to no sensitivity to cold. It doesn’t necessarily mean it’s nonvital or necrotic.
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| Figure 1. Pre-operative radiograph showing radiolucent areas in blue on teeth Nos. 23 and 25. Tooth No. 24 had a previous root canal with no apparent radiolucent area. | Figure 2. Panoramic reconstruction from cone beam imaging of the maxilla and mandible. |
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| Figure 3. Focused field of view from cone beam imaging of teeth Nos. 23, 24, and 25, showing radiolucent area associated with teeth Nos. 23 and 25. | Figure 4. CBCT interpretation from the oral radiologist indicating the radiolucent areas associated with teeth Nos. 23 and 25 could be diagnosed as periapical cemental dysplasia due to vital pulp testing on both teeth. |
I performed an electric pulp test on both teeth, and they responded vital with no percussion sensitivity. Remember, a vital or “healthy” pulp rules out endodontic treatment. Now, I’m thinking about a non-odontogenic issue such as periapical cemental dysplasia (radiolucent stage), a true cyst (possibly traumatic) because a pocket cyst will usually heal with endodontic treatment and the pulp will be necrotic, or even a malignancy, which is very rare.
I decided to send him to an oral surgeon for an evaluation and second opinion. The surgeon performed a CBCT of the area (Figures 2-4). His diagnosis with the oral radiologist was more in line with periapical cemental dysplasia in the lucent stage. They recommended that I continue to watch the area. They didn’t think he needed a biopsy at this time. However, I would have liked them to do one just to be safe.
What are your thoughts? Please share them with me at dr.short@yahoo.com, or visit our related post on Facebook at facebook.com/DentistryToday/ or facebook.com/rootcanaldoc.
Rico D. Short, DMD, attended the Medical College of Georgia (MCG) School of Dentistry to attain a Doctor of Dental Medicine degree in 1999. In 2002, he earned his postdoctorate degree in endodontics from Nova Southeastern University and became a Diplomate of the American Board of Endodontics in 2009. Dr. Short is an expert consultant in endodontics to the Georgia Board of Dentistry and assistant clinical professor at the Dental College of Georgia in Augusta. Dr. Short also has published articles in several magazines and peer-reviewed journals including Dentistry Today, Inside Dentistry, Rolling Out Magazine, Upscale Magazine, and the Journal of Endodontics. He has lectured throughout the United States and the Carribean. Dr. Short is endorsed by the American Association of Endodontists speakers bureau, and his private practice, Apex Endodontics PC, is located in Smryna, Ga. Dr. Short also has authored a book, Getting to the Root of Your Problem: 365 Days of Inspirational Thinking.
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