Abstract
A 7-year-old boy presented with a periodontal problem related to an erupting lower molar. The tooth showed a 15 mm deep periodontal pocket on the buccal aspect. A microbiological DNA test excluded a periodontal origin. The treatment consisted of local antimicrobial therapy and cleaning and filling of the pocket with Atridox R . 2 years after therapy the pocket completely disappeared. Finding periodontal pockets on freshly erupted teeth with acute symptoms should suggest the diagnosis of a cyst. This could prevent surgical endodontal or periodontal therapy. This problem can be managed effectively with minimal therapy and local antibiotics.
The paradental cyst is a soft tissue lesion of unknown cause, analogous to the dentigerous cyst found in bone. Paradental cysts were first reported in 1970 . The cysts were associated with few symptoms, mainly lower cheek swelling and, in children, delayed eruption of the teeth involved. Photoradiographs showed a characteristic inclination of the teeth involved towards the buccal area and the prominence of the lingual cusps. The paradental cyst has to be distinguished from an eruption cyst, which is always associated with tooth eruption . The eruption cyst develops when the dental follicle separates from an erupting tooth and fluid or blood accumulates in the follicular space. The clinical appearance is a raised, bluish gingival mass on the alveolar ridge .
Case report
The following case describes an unusual paradental cyst in a 7-year-old boy who had distinct, palpable, painful buccal cheek swelling in combination with a 15 mm deep periodontal pocket at the first lower right molar shortly after eruption of the tooth. A minimal invasive treatment regimen without surgical enucleation of the cyst is reported.
The boy was referred with a distinct palpable buccal cheek swelling and spontaneous tooth ache with the radiological diagnosis ‘periodontal pocket and apical radiolucency tooth 30’ ( Fig. 1 ). The mother reported that the ache in the right mandibular had increased in the last 4 weeks to a point where her son could not sleep without analgesics. The ache had been continuously increasing and caused discomfort and difficulties in eating.
Clinical examination showed that the patient had a caries-free mixed dentition. Pulp sensibility testing with carbon dioxide snow resulted in a positive sensibility for all teeth. Periodontal probing was painful and a 15 mm deep bleeding pocket was found ( Fig. 2 B ). Owing to the suspicion of a localized aggressive periodontitis, a micro-IDent® periodontal DNA hybridization test (Hain-Lifescience GmbH, Nehren, Germany) sample was taken from the affected pocket for identification of possible periodontal pathogenic microorganisms.
Endodontic treatment was not carried out and conservative treatment of the acute periodontal pocket was used to reduce the clinical signs of inflammation. The treatment was equivalent to the treatment of a periodontal abscess with the exception that the root surface was not scaled. Subsequent to rinsing with chlorhexidine 1% a local delivering metronidazol (Elyzol, Colgate-Palmolive GmbH, Hamburg, Germany) was inserted in the pocket. The co-author suggested that this inflammation could be a harmless cyst associated with tooth eruption and advised no surgical intervention, because controlling the inflammation by opening and draining the pocket could be sufficient to make the cyst disappear.
The DNA test results showed no typical pathogenic microorganisms that would confirm the diagnosis of ‘local aggressive periodontitis’ ( Fig. 2 A). Neither Actinobacillus actinomycetem-comitans nor microorganisms of the red complex were detected, but high amounts of Fusobacterium nucleatum , a bacterium typically found in a periodontal abscess, were present .
2 weeks later, the patient reported that the problems improved for a few days after treatment but the clinical symptoms then worsened. Owing to the boy’s reduced compliance, the pocket epithelium was cleaned and scaled under local anaesthesia to extend the space for the local antibiotics. The aim of the treatment was to open, drain and disinfect the pocket simultaneously with a minimal invasive surgical procedure. Atridox R (Collagenex Pharmaceuticals Inc., Newton, Pennsylvania, USA) was applied. It is a 10% doxycyline hyclate gel, which hardens on contact with water, sulcus fluid or blood and remains stable for a long time in the pocket, slowly releasing antibiotics over 10 days . This procedure disinfects the pocket and keeps it open to avoid further inflammation.
This treatment improved the clinical signs of inflammation within the following week. The inflammation did not reoccur and at the next appointment, 6 months later, a clearly reduced probing depth of 6 mm was found ( Fig. 2 C). The tooth was carefully cleaned and the local antibiotic therapy was not repeated.
2 years later the pocket had completely disappeared. At the same site, a maximum probing pocket depth of 3 mm was found with no signs of bleeding or pain ( Fig. 2 D). Control orthopantomography (OPT) showed no differences between the lower right and lower left first molar. The apical translucency also disappeared ( Fig. 3 ).
