Diagnosis and treatment of teeth with primary endodontic lesions mimicking periodontal disease: three cases with long-term follow ups
A 67-year-old male patient visited our clinic for evaluation and further treatment of the left mandibular first molar (#36). His chief complaint was "my lower gum has been swollen." The patient's medical history was unremarkable. The patient had received a class II gold inlay restoration on that tooth several years ago. For the past month, he had felt a slight discomfort while chewing. A clinical examination revealed slight sensitivity to percussion and bite, 2 degrees of mobility, no response to cold, and a positive response to the electric pulp test. Gingival swelling, which was confined to the distal aspect of #36, was observed, and periodontal probing was within normal limits, except for the buccal and distal surfaces of the distal root. A periapical radiograph showed apical radiolucencies on both roots, and there was no alveolar bony support around the distal root (). The initial diagnosis of the tooth was partial or total necrosis of the pulp with an acute apical abscess. The possibility of root fracture was considered because of vertical bone loss, the large metallic restoration, and prior bite discomfort history. Endodontic treatment was considered as the first choice.\nAfter an inferior alveolar nerve block, anesthesia was achieved using 2% lidocaine containing 1 : 100,000 epinephrine, and the gold inlay was removed. The tooth was isolated with a rubber dam, 4 orifices were located, and the working lengths were determined with an electronic apex locator (RootZX, Morita, Tokyo, Japan). Upon access opening, two mesial canals were vital, however, two distal canals were necrotic. No crack lines were detected in the access cavity. The canals were instrumented using Gates Glidden Drills, stainless steel hand K-files, ProTaper, and ProFile rotary files (Dentsply Maillefer, Ballaigues, Switzerland). All canals were enlarged to the size of a #35 file and continuously irrigated using 2.5% sodium hypochlorite (NaOCl). The canals were dried, and calcium hydroxide was applied as a medicament. No antibiotics were prescribed as the swelling was localized and there were no signs of fever. A week later, at the second visit, the patient was asymptomatic, and the gingival swelling had subsided. The canals were irrigated using 2.5% NaOCl. At the third visit, 2 weeks after the procedure, the patient was asymptomatic. Master gutta percha cones were placed, and periapical radiographs were taken to confirm the working lengths. The canals were obturated with the continuous wave technique using System B and Obtura II (). The patient was sent to a prosthodontist for further tooth restoration. During an 8-year follow up, the patient remained asymptomatic, and the periapical radiolucency disappeared ().