Case #4

Summary: Pain, and fluctuant swelling present around #9. Pus is evident upon probing. Tooth is nonvital. Radiographically there is a well-circumscribed lesion at the apex. Lesions to Include/Exclude: Several characteristics of this lesion allow us to make a definitive diagnosis. Of the lesions causing pain, we can exclude malignant lesions because they aren't well-defined. Exclude primary diseases of bone because they involve multiple bones or are diffuse. Exclude cysts, benign odontogenic lesions, benign nonodontogenic lesions and other localized lesions because they don't present with pain and pus. We can exclude osteomyelitis because the patient will have fever, lymphadenopathy, and evidence of bone necrosis radiographically. Langerhans cell disease is excluded because it does not present with pus. Sclerosing osteitis can be excluded because it is radiopaque and does not present with pus. This lesion is obviously associated with a cause. Tooth #9 is nonvital and broken down. It is an inflammatory process producing a host response of pain and purulent discharge due to neutrophil aggregation and reaction. The lesion is well-circumscribed, and radiolucent. Given these clues, we include only periapical abcess in our differential diagnosis. Management: Management of this lesion is accomplished in either endodontic therapy or extraction. Antibiotics are not needed as there is no systemic involvement. Future evaluation is warranted to observe healing. Prognosis: Good to Excellent depending on the endodontic therapy.