History of Present Illness
Larry is 49 year-old male who presented for his 6 month dental recall examination. He was doing well and had no dental complaints. Periodontal evaluation revealed a 10 mm probing depth on the distal of tooth #2. The probing depths in this area 6 months earlier were 3 to 4 mm. A radiograph revealed a distal periradicular and apical radiolucency involving tooth #2. Tooth #2 did not respond to vitality testing and a diagnosis of a combined endodontic/periodontic lesion was established. Nonsurgical endodontic therapy and scaling and root planing were completed. A follow-up radiograph in 3 months showed no evidence of healing of the defect and the presence of a new periapical lesion around tooth #3 (Figure 1). Nonsurgical endodontic therapy was then completed on tooth #3. The patient remained asymptomatic but radiographic expansion of the lesion was noted at a three month follow-up exam (Figure 2). No cortical expansion, fistula tract, or drainage was noted. Moderate tooth mobility was present. Teeth #2 and #3 were then extracted a a fleshy tan-white tissue was curetted from the extraction sites and submitted for histologic examination.
The periapical radiographs of the right posterior maxilla show an enlarging destructive radiolucent lesion involving the roots of teeth #2 and #3 (Figures 1 and 2).
The histologic sections of the biopsy showed an infiltrate composed predominantly of histiocytes with interspersed eosinophils, lymphocytes and rare plasma cells (Figure 3). The histiocytes display bean shaped indented/grooved nuclei and abundant pink cytoplasm. Occasional multinucleated giant cell were present (Figure 4). Immunohistochemical stains showed the histiocytes to be positive for CD1a (Figure 5) and CD207 (Figure 6).