Intraoral swelling and periapical radiolucency revealing lym
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The present case has been reported in the Journal of the American Dental Association.

A 34-year-old white man visited a general dentist's office with a chief complaint of an asymptomatic swelling of four months' duration in the maxillary right buccal vestibule apical to teeth nos. 3 to 6. Tooth no. 5 was nonvital and endodontic access on tooth no. 5 was done with the use of local anesthesia, but the dentist was unable to negotiate the canals adequately. Three weeks later, the dentist referred the patient to an endodontist for an evaluation and completion of nonsurgical endodontic treatment in tooth no. 5.

On clinical examination, the endodontist noted extraoral edema without erythema of the right cheek. Bilateral palpation of the lymph nodes revealed a firm, nontender and fixed right sub-mandibular lymph node approximately 7 to 9 millimeters in diameter. Intraorally, the clinician identified a nontender, firm, tissue-colored buccolabial edematous lesion measuring 30 × 15 mm and extending from tooth no. 3 to tooth no. 6. Tooth no. 5 exhibited evidence of previous endodontic access but otherwise was unrestored.

Percussion and periodontal findings were within the normal limits for the entire maxillary right quadrant. Transillumination revealed no evidence of tooth fracture. Teeth nos. 3, 4 and 6 responded normally to vitality tests, and the clinician did not note any tooth mobility. Periapical radiographic findings revealed a large periapical radiolucency with ill-defined borders associated with teeth nos. 3 through 5.

The endodontist refined the access into tooth no. 5 by using small working-length files without local anesthesia. The clinician achieved apical patency in tooth no. 5, but when he approached the apex, the patient noted sharp painful sensations in both canals. Because tooth no. 5 was vital, the clinician removed the restoration in tooth no. 4 and performed a cavity test on teeth nos. 4 and 6 to assess definitively the status of these teeth.

Both teeth responded positively to dentin stimulation and, thus, the endodontist assumed they had vital pulps. The clinician completed nonsurgical endodontic treatment of the previously accessed tooth no. 5 without incident and referred the patient to an oral surgeon for further evaluation. The oral surgeon did not aspirate any fluid from the lesion and performed a surgical biopsy. The biopsy results revealed a diffuse, large B-cell lymphoma (DLBCL) of the non-Hodgkin type.

Key takeaways:-
- If a clinician encounters vital tissues in the canals of a suspected non-vital tooth, he or she should reassess and reconsider the diagnosis.

- Intraoral malignancies are rare but should be considered in the differential diagnosis, especially when the patient's medical history or examination findings (including diagnostic test results) are equivocal.

- In such a circumstance, the clinician must consider appropriate and expedient referral to a specialist.

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