Elsevier

Journal of Endodontics

Volume 46, Issue 9, September 2020, Pages 1330-1336
Journal of Endodontics

Case Report/Clinical Techniques
Non-Hodgkin's Lymphoma of the Anterior Maxilla Mimicking a Chronic Apical Abscess

https://doi.org/10.1016/j.joen.2020.06.010Get rights and content

Abstract

Non-Hodgkin lymphomas (NHLs) are malignant neoplasms of the lymphatic system, typically occurring in the fifth through seventh decades of life. Tumors develop from abnormal lymphocyte proliferation and accumulation. Although a majority of NHLs occur in nodal regions, 40% of cases appear in extranodal sites involving the stomach, spleen, Waldeyer's ring, central nervous system, lung, skin, and bone. Extranodal NHL presents a diagnostic challenge because it may mimic endodontic disease when occurring in intraosseous and soft tissue sites. This case report presents misdiagnosis of a diffuse large B-cell lymphoma (DLBCL) of the anterior maxilla in a 72-year-old man with a history of Waldenstrom's macroglobulinemia, where the lesion was thought to be associated with a necrotic pulp and a chronic apical abscess on tooth #7. Clinical findings of a facial sinus tract, a nonresponsive pulp, large periapical radiolucency, and history of trauma were in support of this diagnosis for tooth #7. On encountering vital pulpal tissues during cavity access of tooth #7, a cone-beam computed tomography scan and lesion biopsy were obtained. Through immunohistochemistry and histologic analysis, a diagnosis of DLBCL was made. During evaluation of lesions with suspected endodontic etiology, the clinician should consider all factors of the patient's health history, hereditary risk, and comprehensive clinical testing to attain a differential diagnosis. A nonodontogenic etiology of disease should always be considered unless ruled out otherwise. Atypical presentation or testing may prompt the need for biopsy and interspecialty assessment.

Section snippets

Case Report

A 72-year-old man with American Society of Anesthesiologists grade 3 and a smoker (42 pack-years) with history of Waldenstrom's macroglobulinemia presented to his general dentist with a chief complaint of a “pimple in his gums, mobility, and pain to chewing” (on tooth #7). On examination, a facial fistula was noted in the interproximal of teeth #6 and 7 with yellowing of the clinical crowns (Fig. 1A). Class 2 mobility, pain to percussion, and a negative thermal response were observed on tooth

Discussion

NHL of the maxilla often mimics endodontic disease, frequently sharing characteristics of pain, swelling, tooth mobility, and radiographic destruction of supporting structures6,9,10,13,14,24,25. Current methodology for vitality testing can yield unreliable results5,11,15. However, if teeth associated with periapical pathology respond positively to vitality testing, the clinician should consider lesions of nonodontogenic origin in the differential diagnosis5,9,26 (Table 3). Pontes et al9

Conclusion

When evaluating and treating lesions of suspected endodontic disease, oral health care professionals must comprehensively evaluate all factors related to health history, hereditary risk, and thorough clinical examination to achieve an accurate differential diagnosis. Regardless of clinical presentation, one should always consider a nonodontogenic etiology until proven otherwise. Atypical testing and unresolved lesions recalcitrant to conventional treatments should prompt the need for additional

CRediT authorship contribution statement

Joseph A. Shilkofski: Conceptualization, Visualization, Methodology, Data curation, Writing - original draft, Writing - review & editing. Osman A. Khan: Conceptualization, Visualization, Writing - original draft, Writing - review & editing, Validation. Nader K. Salib: Supervision, Writing - review & editing, Data curation.

Acknowledgments

The authors deny any conflicts of interest related to this study.

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