Large periapical lesion in a patient with diabetic ketoacidosis
I like to share this very interesting case report which demonstrates the importance of considering systemic conditions when odontogenic infections behave unusually and beyond normal expectations. When something does not 'feel' right, we got to ask some questions!
The history: This 63 year old patient had a non-surgical root canal therapy done on tooth #3 in 2016. A year later she presented with complaints of pain. CBCT obtained by her endodontist demonstrated a significant enlargement of the original lesion. The adjacent teeth responded normally to vitality testing. Although she was recommended to have the tooth extracted by her endodontist, she insisted on having a retreatment and hope for improvement. Calcium hydroxide was placed in two visits and then she presented with ulcerated gingiva and swelling over tooth #3. The endodontist performed an incision and drainage and obtained a sample of the granulation tissue for histology. Following incision and drainage, she experienced excessive hemorrhage from the incision site that could not be controlled. She was then referred to me for emergency assessment of the bleeding and the enlarged lesion.
Exam: On presentation to me, the incision site was noted to be bleeding severely and not responding to topical pressure. Her blood pressure was taken with multiple readings showing systolic of 220 over diastolic 120. At this time, patient was convinced to go to hospital ER for immediate assessment of her hypertension which may have been a contributing factor to her excessive bleeding.
Hospital ER: Patient was seen in ER that evening and had complete medical assessment. Her hypertension was controlled with medications and the bleeding gradually diminished over the next few hours. Upon completion of CBC and other blood tests, she was diagnosed with diabetic ketoacidosis and was immediately admitted to ICU (intensive care unit). She was managed in hospital for 5 days before discharged home under care of an endocrinologist for management of her diabetes. Important to note: she had not had a physical exam in several years and was not aware of her severe diabetic condition at the time she presented to the endodontist and us.
Follow up Exam: Once stable, she was seen for follow up exam and a large window CBCT was obtained to assess the extent of the cystic lesion. It measured 1.5 to 2 cm in dimension with expansion to the sinus area and adjacent teeth. The result of the initial biopsy by the endodontist came back as a periapial cyst.
Plan: The treatment plan discussed included extraction of tooth #3 with complete enucleation of the cyst and graft with PRF. Tooth #2 was also recommended for extraction due to significant loss of bone from the expanding lesion.
Take away points:
- I am continually reminded of the importance of CBCT when teeth present with any type of lesion / pathology. PA X-rays are simply inadequate for diagnosis. CBCT provides critical information for the general dentist, endodontist, oral surgeon, and other specialists to make appropriate decisions. The significance and rapid enlargement of this lesion following endodontic therapy could not have been picked up without the CBCT.
- While patient was sent to hospital for severe hypertension, we did not expect diabetic ketoacidosis. With the severe state of her DKA, she could have gone into coma and her life was literally saved by this timely medical intervention. It also explained the unusual and rapidly expanding periapical cyst and its poor response to RCT.
- The biggest take away for me was the importance of considering possible systemic conditions that may be contributing to unusually aggressive oral lesions. Periapical cysts rarely expand so severely and rapidly as observed in this patient. This should have become a red flag and an indication to explore patient's general health and medical condition rather than assuming it is purely dental.