We read with interest the case report involving an odontogenic keratocyst. We disagree with the use of the word “initial” in the title, since the lesion remained undiagnosed for more than a year, even after orthodontic treatment had commenced in its presence.

We wish to highlight several issues that may be helpful for AJO-DO readers. Figure 1 in the article illustrates a midradicular radiolucency between 2 teeth. Radiolucencies of endodontic origin normally appear apically. A periapical radiograph is mandatory for endodontic diagnosis; however this, together with intraoperative and postoperative views, is absent. Pulpal necrosis is unlikely to be associated with positive sensibility testing, vis-à-vis “pulp vitality testing” that is instead associated with blood flow. If vital tissue was present during endodontic treatment, one should be highly suspicious that the lesion is nonendodontic. It would be valuable to have this information. After “satisfactory endodontic treatment,” failure of treatment may still occur; it is a risk associated with any medical or surgical intervention. Thus, as part of the shared decision-making process, clinicians must inform patients of differential diagnoses, steps to reach a definitive diagnosis, and treatment options with their inherent benefits and risks, when obtaining informed consent.

Missed diagnosis and delayed management of pathologic lesions can lead to litigation due to the negative impact on a patient’s quality of life. Reporting of radiographic images should always be performed by the operator exposing the radiograph or the requesting clinician, so that the opportunity to fully use the diagnostic yield of a radiograph, for the benefit of the patient, is not missed. Occasionally, the information may be beyond the diagnostic interpretation of the requesting clinician, in case which the radiograph should be referred to a radiologist.

In this patient, orthodontic treatment commenced in the presence of an undiagnosed lesion. More than a year passed before the patient was referred, misdiagnosed for endodontic treatment, after which orthodontic treatment continued. Orthodontic treatment was abandoned only after histologic tests confirmed the nature of the lesion. Such lesions must be prioritized for management, since they are classified as having high-grade clinical importance requiring immediate attention. Recently, ultrasonography has been recommended for the differential diagnosis of bony jaw lesions, including odontogenic keratocysts.