Endodontic Specialists of Colorado, PC

Palatal Swelling of Unknown Etiology

•58 yo caucasian male presents with CC:  “ I have had facial swelling, muscle contractions, and clenching issues for 3 weeks, but this morning at 5am my palate swelled up behind my front teeth and it feels like my throat and face swelled too.  10/10 pain.”  pt. self-medicated with benadryl
 
•Med HX: patient has history of 2 pulmonary embolisms (PEs) approximately 1 year ago and is taking warfarin.  His INR is 3.8 which is really pretty high.  He also has hypertension and is taking Losartan.
 
•Clinical Findings:  Pt has a 2cmx2cm palatal swelling on the palatal aspect of #8-10 area.  Patient is in so much pain he didn’t want us to turn the lights on and had difficulty speaking.  #8-10 are all quite sensitive to percussion and palpation.  #6-11 all respond to cold with no lingering.   PA number 8-9 reveals a heart-shaped lesion which is splaying the roots of both teeth distally.  All teeth have intact lamina duras. 
palatal1Palatal 
Because of the odd presentation I also ordered a CBCT.  CBCT revealed a football shaped lesion that extended from the nasal cavity down to just behind the central incisors.  The palatal swelling appeared to be continuous with the lesion and was exquisitely sensitive to palpation. 
 
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•DX:   Nasopalatine duct cyst with concomitant , non-odontogenic infection.
 
•TX:  Due to the warfarin use I decided to use my anesthetic for a needle aspiration of the palatal lesion to rule out hemangioma.  This resulted in a purulent exudate.  At this point I made a 2mm incision at the anterior portion of the swelling and proceded to message out the purulent exudate. I was able to drain the lesion to the point that it had a deflated look and the patient expressed notable decrease in the pressure/pain.  Hemostasis was achieved readily and I prescribed: 
–Dexamethazone 4mg, Disp 6tabs, Sig:  take one in the morning and one at noon for three days
–PenVK 500, Disp 30 tabs, Sig:  Take 1q6hrs until gone.
–Ibuprofen 600, Disp 20 tabs, Sig:  Take 1q6hrs prn pain.
 
•Referral:   Referral to Oral surgery for the next morning to determine source of infection and definitive treatment.  The next day the patient was feeling 90% better so the OS referral scheduled him for a week from now.  His explanation was that the Nasopalatine duct became seeded with bacteria from some unknown reason, but it was clear that it wasn’t from an odontogenic infection based on my testing and the CBCTs revealing the intact lamina dura of all the teeth in the area.
 
 

REGENDO – ES Case Files

Endodontic Specialists of Colorado, PC  has  realized some success in the new field of regenerative endodontics, also known as “regendo” whereby pulp and dentin tissues damaged by trauma, disease or infection are being regenerated through revascularization of necrotic root canal systems.   What follows is a case from our own files.

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9 y.o. male arrived with father to our office complaining of mild cold sensitivity on tooth #8.  Father reported trauma 3 weeks previous.  Pt slipped and fell and chipping tooth #8 and bumping #9.  Both #8 and #9 were incompletely developed with open apices.  Tooth #8 was repaired with composite and tooth #9 did not respond to initial cold testing at his general dentist’s office.  The child had also started palatal expansion with later orthodontic treatment planned.   The child was referred for endodontic evaluation of tooth #9. 

At the initial evaluation in our office, tooth #8 responded normally to cold, percussion and palpation.  Tooth #9 did not respond to cold or EPT.  Because recent trauma can sometimes alter responses to sensitivity testing for a period of time we asked the pt to return in 3 weeks to retest.  

At the second visit, tooth #9 was still non-responsive to vitality testing.  Because #9 was immature with an open apex, the decision was made to access #9 and attempt a revascularization or regenerative procedure.   We advised the parent and also consulted with the orthodontist that palatal expansion could continue but complete development of the root-end would ideally need to be evident prior to placing brackets for orthodontic treatment. 

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Local infiltration anesthesia was administered, rubber dam placed and #9 was accessed.  Copious but gentle irrigation of the canal was applied with NaOCl.  Next, the canal was irrigated with sterile saline followed by  0.12% CHX (Peridex).  The canal was dried and then a triple antibiotic paste (mixture of 1:1:1 Ciprofloxacin, Metronidazole, Minocycline) was delivered into the canal with a Centrix syringe (CaOH has also been used in some case reports).   The access was restored with Cavit.  The patient was scheduled to return in 3-4 weeks.

At the second appointment, local anesthetic was administered this time with 3% Carbocaine with NO EPI.  The canal was irrigated with 17% EDTA.  The canal was dried with paper points and then a file was placed beyond the apex to induce bleeding into the canal.  The bleeding was stopped 3mm short of canal orifice and allowed to clot.  A piece of Collaplug was placed over the clot to form a barrier over the canal.  3-4mm of White MTA was placed over the Collaplug barrier and the access was restored with a bonded composite restoration. 

Pt returned for a 2 week post operative follow up.  Pt presented asymptomatic.  Tooth #9 responded normally to cold, percussion and palpation.  There was no evidence of intra/extra oral swelling or a sinus tract.  Pt was scheduled for a 6 month recall appointment.

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Pt returned for a 6 month recall.  Pt presented asymptomatic.  Tooth #9 responded normally to cold, percussion and palpation.   Again there was no evident intra/extra oral swelling nor was there a sinus tract.   Tooth #9 showed some root development since the last appointment.  The walls of the root also showed thickening with additional length.  However, complete development was not evident.   We recommended waiting to place orthodontic brackets and placed pt on another 6 month recall. 

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