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Table of Contents
CASE REPORT
Year : 2015  |  Volume : 5  |  Issue : 2  |  Page : 87-91

Deceptive periodontal pocket diagnosed later as odontogenic keratocyst


1 Department of Periodontology, Subharti Dental College, Meerut, Uttar Pradesh, India
2 Department of Oral and Maxillofacial Surgery, Subharti Dental College, Meerut, Uttar Pradesh, India
3 Department of Endodontics, PDM Dental College, Bahadurgarh, Haryana, India
4 Department of Oral Medicine and Radiology, Sardar Patel Dental College, Lucknow, Uttar Pradesh, India

Date of Web Publication5-Jan-2016

Correspondence Address:
Jaisika Rajpal
Department of Periodontology, Subharti Dental College, Meerut, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2229-5194.173227

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   Abstract 

A visual assessment of the periodontal tissues may be misleading. A periodontal pocket is the most important clinical feature of periodontal diseases. However, even the most reliable probing can be misleading at times and only X-rays of the area allow us to assess the exact clinical situation. This paper presents a report wherein the deceptive periodontal pocket later lead to the diagnosis of an odontogenic keratocyst.
CLINICAL RELEVANCE TO INTERDISCIPLINARY DENTISTRY
This case holds an important relevance to interdisciplinary dentistry as such cases are often reported by dental practitioners wherein, the patients chief complaint is very different from the clinical picture actually observed by the dentist. In this case a mere reporting of periodontal pocket would have led to mistreatment with curettage, whereas the actual treatment needed was enucleation.

Keywords: Odontogenic keratocyst, pathological migration, periodontal pocket


How to cite this article:
Rajpal J, Arora A, Arora P, Prasad R. Deceptive periodontal pocket diagnosed later as odontogenic keratocyst. J Interdiscip Dentistry 2015;5:87-91

How to cite this URL:
Rajpal J, Arora A, Arora P, Prasad R. Deceptive periodontal pocket diagnosed later as odontogenic keratocyst. J Interdiscip Dentistry [serial online] 2015 [cited 2019 Jun 18];5:87-91. Available from: http://www.jidonline.com/text.asp?2015/5/2/87/173227


   Introduction Top


A periodontal pocket is defined as pathologically deepened gingival sulcus. It is one of the most important clinical diagnostic features of periodontal diseases. However, the mere presence of periodontal pocket without any other clinical sign may lead to miss-diagnosis in certain cases. In such cases, X-rays of the area will only allow to assess the periodontal situation as you can accurately view the mesial and distal sides of the surrounding bone. One of the uncommon lesions that produce localized destruction of periodontal tissue along a lateral root surface, most often in the mandibular canine-premolar area is the periodontal cyst. Microscopically, the periodontal cyst may be a variant of the odontogenic keratocyst (OKC).

The OKC is a cystic lesion of odontogenic origin, which is classified as a developmental cyst derived from the dental lamina. This lesion was first described in 1956 by Phillipsen.[1] It is one of the most aggressive odontogenic cysts of the periodontal cyst. OKC is known for its rapid growth and its tendency to invade the adjacent tissues including bone. Symptoms such as pain, swelling, and drainage may be present, especially with larger lesions. However, at least half of all lesions are discovered as incidental radiographic findings.[2] Due to the propensity of OKCs to grow within the medullary bone, they have the potential to become extremely large without causing any clinical signs or symptoms.[3] This paper presents a case wherein the clinical presence of mere periodontal pocket later lead to the diagnosis of OKC.


   Case Report Top


A 43-year-old man reported to the Department of Periodontology with a chief complaint of pus discharge from gums of the lower right back tooth region. The patient had noticed this pus discharge over last 1 month but had no other complaint related to this area. On examination, the gingiva in the right mandibular premolar region (teeth 44 and 45) appeared absolutely normal without any signs of inflammation [Figure 1]. On palpation of the area with the bulb of the finger, the dip was felt in the bone and on pressure there was suppuration from
Figure 1: Area of chief complaint teeth number 44 and 45 appearing normal on visual examination

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the gingival sulcus in relation to tooth number 44 and 45. His medical history was noncontributory. Intraoral examination revealed periodontal probing depths of 11 mm [Figure 2]. A periapical radiograph of the area revealed a well-defined circumscribed radiolucent lesion between the roots of teeth 44 and 45 [Figure 3]. There were no signs of buccal cortical plate expansion. Vitality testing showed that both teeth 44 and 45 were vital but tender to percussion. Radiograph also revealed the pathological displacement of the root of tooth 44 mesially and 45 distally. There was no evidence of mobility of teeth. The differential diagnosis of lateral periodontal cyst and OKC was considered and treatment plan made. Aspiration of cyst revealed white cheesy material.
Figure 2: Periodontal pocket depth of 11 mm

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Figure 3: Preoperative diagnostic intraoral periapical

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Treatment

Root canal of both the teeth 44 and 45 was done in single visit [Figure 4]. Under aseptic conditions, local anesthesia (2% xylocaine) was delivered. Conventional access opening was done followed by biomechanical preparation; using CM flex files rotary system. Irrigation was done with 3% of sodium hypochlorite and
Figure 4: Radiograph after endodontic treatment

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2% chlorhexidine. Obturation was done using lateral condensation method. Finally, all the root canal treated teeth were restored using nanohybrid composite resin. The patient was recalled after 24 h for surgical management.

On the day of surgery, anesthesia was achieved by buccal and lingual infiltration using articaine 1:100,000 with epinephrine (1.5 mL). A crevicular incision was made on the buccal marginal gingiva extending from the mesial aspect of tooth 43 to the distal aspect of tooth 46. A vertical releasing incision was given extending beyond the mucogingival junction on the mesial aspect of tooth 43. A full thickness mucoperiosteal flap was elevated to gain access to the defect. A well-defined lesion, measuring approximately 1.5 cm × 1.0 cm was found [Figure 5]. The lesion was enucleated without rupture and sent for histopathologic examination. The bony defect was thoroughly debrided until it bled [Figure 6]. The walls were decorticated using a half round bur. The defect was irrigated with povidone-iodine and normal saline. The defect was filled with G-Graft (Surgiwear ®) which contained hydroxyapatite granules with collagen [Figure 7]. The flap was replaced and sutured using simple interrupted sutures of Mersilk 3-0, and primary closure was achieved [Figure 5]. The patient was prescribed amoxicillin with potassium clavulanate 625 mg TID and ibuprofen 400 mg BD for 5 days, along with written and oral instructions. The patient was advised 0.2% chlorhexidine rinse twice a day for 7 days for maintaining oral hygiene. Sutures were removed after 1 week. Healing was uneventful at 1 and 3 months recall appointment, and results were deemed satisfactory.
Figure 5: Approximately 1.5 cm × 1.0 cm lesion seen after raising full thickness flap

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Figure 6: Defect after complete debridement

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Figure 7: Defect after placement of bone graft

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The histopathologic report revealed that the cystic lining of all three lesions was para keratinized stratified squamous epithelium of uniform 6–8-cell thickness [Figure 8]. Specimen showed a uniform epithelial layer with an absence of rete ridges, a corrugated orthokeratinized luminal layer, and a prominent basal cell layer. The height of the epithelial cells and the number of nuclei they contained were reduced. A few inflammatory cells were also seen in the lumen. All the histopathological, radiographic, and clinical features guided to the final diagnosis of OKC.
Figure 8: Histopathological slide

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   Discussion Top


The OKC is a well-known pathologic lesion of the jaws derived from rests of the dental lamina.[3] It represents approximately 10%[4] of all jaw cysts and may occur in a wide age range of patients. OKC commonly occurs in the mandible. The body of the mandible is the most common location.[5] Clinical diagnosis of OKC is rather difficult due to the paucity of classic

radiologic/clinical findings. Majority of these lesions are incidental findings on routinely performed radiographs. Due to the propensity of OKCs to grow within the medullary bone, they have the potential to become extremely large without causing any clinical signs or symptoms.[3] OKC is known for its rapid growth [6] and its tendency to invade the adjacent tissues including bone.[7] It has a high recurrence rate.[8] The origin of jaw cysts is either developmental or inflammatory. Their frequency is due to epithelial remnants within the jaws.[9] They are reported to be occurring most often in the third decade of life.[10] A similar male predominance also reported by Neville et al.[11] Some cases are diagnosed clinically, but others histologically from biopsied specimens. They may include bone involvement and may give rise to gingival swelling. In the adult, the most frequent site is between the mandibular canine and premolar, which is also a site for a lateral periodontal cyst. This can lead to confusion in the diagnosis, as in this case, as an OKC can present as a lateral periodontal cyst or gingival cyst like lesion.

Clinically, OKC occurs most often as painless alveolar swelling,[12] sometimes associated with pain.[13] The clinical significance of the OKC is potential for morbidity association with extensive expansion and recurrence rate after surgery.[13] Radiographically, OKCs appear as a round or ovoid radiolucency, which may be multilocular.[2] The OKC presents as a well-defined radiolucency with thin corticated margins. Root resorption is relatively uncommon. Histopathologically, solitary keratocysts have greater epithelial height and more nuclei and basal nuclei. It is lined with a thin layer of connective tissue covered by an ortho or parakeratinized stratified squamous epithelium with columnar or cuboidal basal cells. If the cyst is infected, inflammatory cells are present. They may also contain cholesterol clefts, as in the case described above. OKCs tend to recur, especially the parakeratinized type. Because of this, continued regular examination of the patient is recommended.

Ideal treatment includes curettage with peripheral osteotomy. Curettage alone will suffice if the outer cortex of mandible is intact. If conroy solution is used after curettage, these daughter cysts can be destroyed.[14] In cases of large cysts, after marsupialization the cavity can be obliterated using autogenous graft. In cases with very large cysts, the entire procedure can be staged. The decompression procedure can be performed under two steps. In the first step, the cyst is opened, and a drain is placed. Enucleation can be performed at a later date after the cyst has shrunk to a more manageable size. OKCs are considered to be benign cystic neoplasms and require modified surgical procedures, such as curettage of bony walls, peripheral ostectomy with a bone bur or, occasionally, jaw resection.[15] At present, there is no consensus regarding the optimal management modality in treating these patients.


   Conclusion Top


All methods of treatment advocated by various authors in OKC are satisfactory which primarily close the bone cavity and which at the same time attempt to reduce the empty space and prevent infection of the blood clot. In this case, it was expected that minimal regeneration would take place without the use of regenerative techniques. A bone allograft improved the outcome of the treatment after total surgical removal with debridement and decortication. Finally, regardless of the surgical method used during the treatment of OKCs, we believe that recurrences will occur in all cases during which part of the cystic capsule remains in the cavity, or beside the basic cystic capsule are so called microcystic satellite changes that develop in the immediate vicinity. Therefore, follow-up for OKC's is once in a year for at least 5 years is recommended.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Phillipsen H: On keratocysts in the jaws. Tandleagebladet 1956;60:963.  Back to cited text no. 1
    
2.
Boffano P, Ruga E, Gallesio C. Keratocystic odontogenic tumor (odontogenic keratocyst): Preliminary retrospective review of epidemiologic, clinical, and radiologic features of 261 lesions from University of Turin. J Oral Maxillofac Surg 2010;68:2994-9.  Back to cited text no. 2
    
3.
Neville BW. Oral and Maxillofacial Pathology. 3rd ed. St. Louis, MO: Elsevier/Saunders; 2009.  Back to cited text no. 3
    
4.
Zecha JA, Mendes RA, Lindeboom VB, van der Waal I. Recurrence rate of keratocystic odontogenic tumor after conservative surgical treatment without adjunctive therapies – A 35-year single institution experience. Oral Oncol 2010;46:740-2.  Back to cited text no. 4
    
5.
Oda D, Rivera V, Ghanee N, Kenny EA, Dawson KH. Odontogenic keratocyst: The northwestern USA experience. J Contemp Dent Pract 2000;1:60-74.  Back to cited text no. 5
    
6.
Stoelinga PJ, Bronkhorst FB. The incidence, multiple presentation and recurrence of aggressive cysts of the jaws. J Craniomaxillofac Surg 1988;16:184-95.  Back to cited text no. 6
    
7.
Lund VJ. Odontogenic keratocyst of the maxilla: A case report. Br J Oral Maxillofac Surg 1985;23:210-5.  Back to cited text no. 7
    
8.
Forssell K, Forssell H, Kahnberg KE. Recurrence of keratocysts. A long-term follow-up study. Int J Oral Maxillofac Surg 1988;17:25-8.  Back to cited text no. 8
    
9.
Nxumalo TN, Shear M. Gingival cyst in adults. J Oral Pathol Med 1992;21:309-13.  Back to cited text no. 9
    
10.
Chow HT. Odontogenic keratocyst: A clinical experience in Singapore. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;86:573-7.  Back to cited text no. 10
    
11.
Neville BW, Damm DD, Brock T. Odontogenic keratocysts of the midline maxillary region. J Oral Maxillofac Surg 1997;55:340-4.  Back to cited text no. 11
    
12.
Ahlfors E, Larsson A, Sjögren S. The odontogenic keratocyst: A benign cystic tumor? J Oral Maxillofac Surg 1984;42:10-9.  Back to cited text no. 12
    
13.
Rud J, Pindborg JJ. Odontogenic keratocysts: A follow-up study of 21 cases. J Oral Surg 1969;27:323-30.  Back to cited text no. 13
    
14.
Chirapathomsakul D, Sastravaha P, Jansisyanont P. A review of odontogenic keratocysts and the behavior of recurrences. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:5-9.  Back to cited text no. 14
    
15.
Myoung H, Hong SP, Hong SD, Lee JI, Lim CY, Choung PH, et al. Odontogenic keratocyst: Review of 256 cases for recurrence and clinicopathologic parameters. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;91:328-33.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]


This article has been cited by
1 Long-term observation of a large keratocystic odontogenic tumour of the mandible treated by a single enucleation procedure: A case report and literature review
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International Journal of Surgery Case Reports. 2017; 34: 119
[Pubmed] | [DOI]



 

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