Misdiagnosis of florid cemento-osseous dysplasia leading to unnecessary root canal treatment: a case report
In 2009, a 30-year-old woman was referred to our institution for the evaluation and further treatment of the persistent lesions after root canal treatment of the mandibular anterior teeth (#32, 33, and 42) at a private dental clinic. The patient's medical history was unremarkable. The patient had visited the private dental clinic because of aesthetic concerns caused by congenitally missing mandibular anterior teeth (#31, and 41). The patient decided to receive an orthodontic treatment for teeth alignment and an implant surgery in the missing space. During orthodontic procedure, apical radiolucencies were detected and root canal therapies on those three teeth (#32, 33, and 42) were performed by her previous dentist. Based on the patient's report, she had received endodontic treatments because the dentist had suspected periapical pathosis due to the increased orthodontic force on the treated teeth. However, according to the previous dentist's referring notes, all of the teeth were vital at the time of treatment. On comparing a 4-year series of panoramic radiographs taken from 2005 to 2008, the previous dentist had observed that the apical radiolucencies on these teeth appeared to enlarge (). The dentist was concerned about the persistent periapical pathosis and referred to our institution for apicoectomies of the affected teeth. Panoramic radiographs obtained in 2007 and 2008 showed additional radiolucencies in the apical area of the mandibular right second premolar and the first molar as well as the left first premolar ().\nPanoramic and periapical radiographs obtained at the initial visit (after the patient referral) showed mixed radiolucent and radiopaque areas in the mandibular anterior region (#32, 33, 42 and the implant between 32 and 42) and multiple radiolucent areas on the right lower posterior teeth ().\nA clinical examination revealed no swelling or bony expansion in the mandibular anterior region. None of the teeth were sensitive to percussion. The rest of the teeth except for #42, 43, and 32 responded normally to the thermal and electronic pulp tests. The patient experienced slight discomfort during palpation of the buccal mucosa of the mandibular incisors.\nIn the periapical areas of #32, 33, 36, 42, 43, 45, 46 and the implant, lobular-shaped radiolucencies that contained small radiopaque masses were revealed by computed tomography (CT, Somatom Sensation 64, Siemens, Munich, Germany, 120 Kvp, 90 mA). All of the lesions were related to the cortical plates, and perforation of labial and lingual cortical bones was observed on the mandibular lateral incisors. No cortical bony expansion was detected (). Periapicies of maxillary teeth were examined as normal condition.\nBased on the clinical and radiographic findings, the possibility of endodontic pathosis was excluded. An excisional biopsy was performed in the area of the mandibular incisors because the patient had experienced occasional discomfort in that area during palpation.\nWhen the periodontal flap was elevated, the soft tissue was exposed through the perforated cortical bone around the apices of #42 and 32. After removal of the soft tissue, a sand-like structure with a firm consistency was detected. Histological analysis of the specimen revealed multiple small fragments without any fibrous capsules (). Multiple trabeculae of cementum-like material were observed in a dense fibrous tissue, with no signs of inflammation (). The calcified material was associated with collagen fibres in the trabeculae and fibroblasts. No signs of free haemorrhage or osteoclastic activity were observed. A definite diagnosis of COD was established at the following histopathological examination. Combined with the radiographic findings that showed multiple radiolucent and radiopaque lesions in both right and left mandibular teeth and incisors, our definite diagnosis for this case was FCOD.\nThe patient did not report any moderate or severe postoperative pain or discomfort. At the one-year follow-up appointment, the patient did not report any experience of pain or discomfort. She was scheduled for annual routine check-ups.\nThe patient visited the hospital without an appointment 21 months after the biopsy because of discomfort in the mandibular anterior vestibule. Her chief complaint was pain on palpation, which had started 2 days prior to her visit. No signs of infection were detected. Cone-beam CT (CBCT, Pax-Zenith3D, Vatech, Hwaseong, Korea, 104 Kvp, 5.5 mA) radiograph was taken to assess any changes in lesion size and development (). Based on CBCT views, the apical lesions of madibular anterior teeth and the implant appeared to become more radiopaque. The patient was requested to return if she exhibited any signs of fever, swelling or pain. She did not experience any discomfort after the emergency visit. The patient was instructed to maintain annual routine check-ups.