Endodontics · patient case question
What is the apical diagnosis for tooth #9?
Patient case: The Bridge That Never Settled
Patient: 58-year-old male
Chief Complaint: “That front tooth aches when I bite, and a little bump keeps coming and going on the gum.”
Background: Anterior maxillary fixed bridge placed five years ago. Root canal treatment on tooth #9 two years ago. No relevant medical history.
Medications: None
Vital Signs: BP 128/78 mmHg · HR 74 bpm · RR 16 · T 98.4°F
Findings: Tooth #9 is tender to percussion and gives no response to cold. A small red, raised lesion is present on the labial gingiva apical to #9, which the patient reports drains intermittently. A periapical film shows a radiolucency at the apex of #9 and a second, separate radiolucency between #8 and #9.
Show answer and explanation
Correct answer: B. Chronic apical abscess
- A. Symptomatic apical periodontitis gives pain to percussion and biting, but there is NO sinus tract and no drainage. The parulis is what moves the diagnosis past this label.
- B. CORRECT. A previously treated, non-responsive tooth with a periapical radiolucency and an INTERMITTENTLY DRAINING SINUS TRACT (the red bump on the gingiva, a parulis) is a chronic apical abscess. The defining feature is the tract — continuous low-grade drainage vents the pressure, which is why these lesions are usually only mildly symptomatic despite an obvious radiolucency.
- C. Condensing osteitis is a RADIOPAQUE (sclerotic) reaction to chronic low-grade pulpal inflammation, not a radiolucency with drainage.
- D. An acute apical abscess presents with rapid onset of severe pain, diffuse swelling, malaise and often fever, WITHOUT an established drainage pathway. Radiographic change may be minimal because the process is too fast for bone to resorb.
Note: Trace every sinus tract with a gutta-percha point before assuming which tooth is responsible. The tract does not always lead where you expect.