History of Present Illness
The patient presented with pain that started more than three weeks previously in the left side of the mandible. At that time her dentist prescribed antibiotics, which eased the pain. However, the pain returned four days before the current visit. She wears a maxillary removable complete denture and a mandibular removable partial denture. She denied prior problems in this area.
Past Medical History
The patient has a history of hypertension, which appears to be well controlled. She had a hip replaced four years ago and a diagnosis of breast cancer 17 years ago, for which she received chemotherapy and radiation therapy. She takes the following medications and supplements: potassium chloride, amlodipine besylate and benazepril hydrochloride, digoxin, spironolactone, metoprolol, aspirin, bumetanide, omega-3 fatty acids, vitamin B6, and acetaminophen. The patient stated that she is allergic to amoxicillin.
Clinically, there is an area of exposed hard tissue at the crest of the mandibular left alveolar ridge. The area is tender and the surrounding tissues are inflamed. The patient stated that her mandibular removable partial denture seemed a little tight. However, no obvious clinical expansion of the left side of the mandible was seen. The left and right sides of the mandible were symmetrical.
An initial periapical radiograph (Figure 1) showed a radiopaque mass in the shape of a retained root tip in the posterior left mandible, which was surrounded by a radiolucent border. In addition, there was an ill-defined radiopaque lesion apical to the root tip extending beyond the mesial and distal limits of the radiograph. A panoramic radiograph was made to further evaluate the extent of the lesion. (Figure 2)
The panoramic radiograph revealed multiple radiopaque masses in the mandible and maxilla. The masses were asymptomatic and of unknown duration; the patient was unaware of their presence. Neither the maxilla nor the mandible showed any clinical signs of expansion.
The masses were radiopaque, with a focal “cotton-wool” appearance. The mandible was diffusely involved, with lesions extending from the right posterior region across the midline to the left posterior mandible. A large, poorly delineated mass was seen in the left posterior edentulous maxilla. A smaller, well-defined radiopaque mass was also seen in the right posterior maxilla. Multiple mixed radiolucent/radiopaque lesions were seen in association with the apical aspects of the remaining mandibular teeth, with a radiolucent rim surrounding some of the radiopaque areas. The masses were superior to the inferior alveolar canals, but the canals appeared to be widened.
No biopsy was performed. The lesions were diagnosed based on the clinical and radiographic presentation.