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Periapical Lesion Involving a Mandibular Incisor Tooth

Case Challenge Number: 73

Diagnostic Information

History of Present Illness The patient is a 43-year-old African American female who recently moved to the area and presented for a new patient dental examination. The patient completed non-surgical periodontal therapy 4 years ago and has been on routine maintenance care. She has no specific dental complaints at this time. Medical History - Pertinent medical history: excellent health; hernia repair as child; childbirth: two healthy girls without complications

- Medications: none

- Adverse drug reactions: none

- Pertinent family history: maternal - breast cancer; paternal - hypertension, prostate cancer; siblings: older sister with breast cancer

- Social history: does not use tobacco products; social alcohol use; denies recreational drug use Clinical/Radiographic Findings Extraoral examination was unremarkable. No cervical lymphadenopathy or masses were noted. Intraoral examination revealed no mucosal lesions and an intact dentition without dental caries. Periodontal assessment revealed marginal inflammation with 4-5 mm maximum probing depths and bleeding on probing in the posterior sextants. Oral hygiene was good to fair with interproximal soft plaque accumulation. A full mouth radiographic series was obtained and revealed a circumscribed round radiolucency with central opacities at the apex of tooth #25 (Figure 1). The periodontal ligament appeared intact. The patient was unaware of this lesion and tooth #25 was asymptomatic. Teeth #23-27 tested vital to cold. There was normal tooth mobility and no tooth displacement. Probing depths around tooth #25 were 2-3 mm without bleeding. The overlying mucosa appeared normal with no facial or lingual cortical expansion. When informed of the lesion, the patient was very concerned about malignancy and requested a biopsy be performed.

Figure 1. Periapical radiograph showing circumscribed periapical radiolucency with central opacities involving tooth #25.

Histopathologic Findings The biopsy showed a moderately cellular intramedullary spindled fibrous stromal proliferation containing irregular trabeculae and globules of woven cemento-osseous extracellular matrix material (Figures 2 and 3). The lesion displayed poorly defined margins and seemed to blend into the adjacent normal bone. Focal osteoblastic lining cells, osteoid, and osteoclasts were noted. There was no associated inflammation.

Figure 2. Low-power histologic image showing cortical bone with intramedullary fibro-osseous lesion blending into adjacent normal bone.