Case #48 Discussion

Summary: The patient complains of progressive pain and swelling of three days duration.  Lying down increases the pain and interferes with sleep.  Clinical examination reveals a diffuse, tender, compressible, hemorrhagic enlargement of the upper lip and mucolabial fold with distortion of the nasal philtrum and partial obliteration of the mucolabial fold.  There is a palpable right nontender, anterior cervical lymph node at the level of the carotid bifurcation.  The maxillary left central incisor is mildly tender to percussion and does not respond to electrical or thermal stimulation.  The oral temperature is 37.7 degress C (99.8 degrees F). Lesions to Exclude from the Differential Diagnosis: The lesion is described as a soft tissue enlargement.  Within the category of soft tissue enlargements, the lesion is suggestive of a reactive lesion because it is of abrupt onset, painful and associated with a fever. From the category of reactive soft tissue enlargements, viral, mycotic, chemical, and allergic lesions can be excluded because these are not associated with pain upon tooth percussion or with a non-responsive pulp test.  Within the category of physical reactive soft tissue enlargements, traumatic granuloma, mucocele (salivary extravasation phenomenon), and necrotizing sialometaplasia can be excluded from the differential diagnosis.  Traumatic granuloma is excluded because these are associated with a history of trauma and are typically not painful.  Mucocele (mucous retention phenomenon) and necrotizing sialometaplasia can be excluded based on location and because these do not cause systemic or tooth symptoms. From the category of bacterial reactive soft tissue enlargements, acute sialadenitis can be excluded based on location.  Bacterial soft tissue enlargements secondary to periodontal abscess can be excluded because these are associated with increased periodontal probing depths. Definitive Diagnosis: The definitive diagnosis is a bacterial reactive soft tissue enlargement secondary to pulpal pathosis.  Within this diagnosis, the lesion could be a radicular cyst, granuloma, or abscess.  The lesion is most likely a radicular abscess because of the pain and fever.  The enlargement is due to acute inflammation and suppuration. Management: The source of the reactive lesion should be treated.  In this case, endodontic therapy with establishment of drainage and a course of systemic antibiotics are appropriate.  Close patient follow-up is necessary to ensure that the patient is responding to the therapy.