A Short Case Study: A Large PAP Close to the IANB

Rico D. Short, DMD


I hope you’re safe and well during this COVID-19 pandemic. Most offices are back up and running now, which is awesome. I wanted to discuss a very interesting case with you.

A patient came in with pain and slight numbness on the lower right side. I took a 2-D panoramic X-ray of tooth No. 31 (Figure 1). It was obvious that there was a lesion present, but it was difficult to see its proximity to the inferior alveolar nerve bundle (IANB).

Pulp testing revealed a necrotic pulp with acute apical periodontitis. I then took a large field-of-view CBCT to observe the size and location of the pathology to the IANB and the root canal anatomy (Figures 2 and 3). The periapical pathology (PAP) was very extensive, sitting very close to the IANB on the CBCT (Figures 3 and 4).

Figure 2. The CBCT rendered an image of the area involving tooth No. 31 as well.  Figure 3. The sagittal CBCT view showed periapical pathology on the tooth. 
Figure 4. The coronal CBCT view showed the inferior alveolar nerve and the proximity of the apex on tooth No. 31 with the periapical pathology.  Figure 5. Endodontic therapy was completed on the tooth. 

Figure 6. The image shows the inversion of the completion of therapy.

I performed endodontic treatment in one visit (Figures 5 and 6). Notice the severe curvature of the canals. I used heat-treated NiTi files on this case with bioceramic sealer. The heat-treated NiTi files are very strong and flexible, which minimizes file separation. The bioceramic sealer acts like calcium hydroxide and liquid MTA to promote healing. It’s a great seal, too.

The patient was asymptomatic and the numbness was relieved after one week.

Dr. Short attended the Medical College of Georgia School of Dentistry to attain a DMD degree in 1999. In 2002, he earned his post-doctorate degree in endodontics from Nova Southeastern University and then became a Diplomate of the American Board of Endodontics in 2009. Dr. Short is an expert consultant in endodontics to the Georgia Board of Dentistry, author, speaker, and assistant clinical professor at the Dental College of Georgia in Augusta. His private practice, Apex Endodontics PC, is located in Smryna, Ga. He can be reached at dr.short@yahoo.com.

Related Articles

A Short Case Study: A Large Overextended Silver Point With Periapical Pathology

A Short Case Study: Tooth No. 30—Cyst or Granuloma?

A Short Case Study: Is It Odontogenic Pain in the Upper Right Quadrant?