25 February 2021

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Management of a patient with systemic diseases affected by large mandibular cyst

Authors:Christian Bacci, Elisa Bardhi, Annalisa Angelini, Marny Fedrigo, Chiara Castellani, Gastone Zanette

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Aim of the study: The aim of the study is to describe a significant case of the management of a patient with systemic pathologies, affected by a large mandibular cystic lesion, with long-term follow-up.

Materials & Methods:  A 70-year-old male patient with systemic pathologies and a history of coronary artery disease comes to the Dental Emergency Department of Padova complaining pain in the right inferior jaw. He also refers swelling on the same side that has appeared for about three weeks. The patient suffers from diabetes, hypertension, hypercholesterolaemia, moderate overweight, non-smoker, he had undergone coronary angioplasty 5 years earlier, currently on therapy with metformin, ramipril (ACE inhibitor) and metoprolol (beta blocker), acetylsalicylic acid and atorvastatin. His ASA physical status was recorded as class ASA III, since he is suffering from systemic diseases limiting the patient's working life and relationship. Upon physical examination, there is evidence of tense elastic swelling at the right lower jaw. The teeth of the lower arch are vital, except for the second lower right premolar, which is painful to percussion. Antibiotic therapy is prescribed and radiological investigation is required. After a few days the symptoms improve, but the swelling persists.  The orthopantomography of the dental arches and the computerized tomography show a radiolucent lesion with well-defined edges of large dimensions of about 12 cm, extending from the right retromolar trine to the lower left canine area. The differential diagnosis included apical inflammatory cyst, lateral periodontal cyst, follicular cyst, odontogenic keratocyst, unicistic ameloblastoma. The presumed diagnosis of apical inflammatory cyst is made and the intervention of extraction of element 45 and enucleation of the cyst by "bone lid" technique is planned. Days before the surgery, the patient suffered acute myocardial infarction. The patient is discharged after only 10 days of hospitalization and therapy, including the placement of two coronary stents, and the prescription of a second antiplatelet drug (clopidogrel). The early discharge, motivated by the benign characteristics of the infarct episode defined according to the guidelines of the American Heart Association, the risks of pathological fracture of the jaw, of recurrence of the infectious phlogistic fact, together with the contraindication to the presence of oral infectious foci in a heart patient , led to the decision to re-evaluating and to carry out the intervention, despite the patient being classified in the ASA IV class, since myocardial infarction still poses particular risks (re-infarction, serious rhythm disturbances, etc.) in the following 6 months. The patient is re-evaluated beyond 30 days after this episode and the intervention is rescheduled. Cystic enucleation and extraction of element 45 is performed under local anesthesia and conscious sedation, the bone hatch is fixed with plates and screws and antibiotic, pain reliever and antiseptic therapy is given. Therapeutic alternatives are exposed and discussed. 

Results: The short-term (6 months) and long-term (60 months) two-dimensional and three-dimensional radiographic images show an excellent healing and ossification of the cystic cavity treated according to the "bone lid" technique. The histological examination report confirms the presumed diagnosis of apical inflammatory cyst.

Conclusions: This case report presents a clinical diagnostic path that led to the resolution of a large cystic lesion in a patient with systemic pathology in a simple, effective and safe way, with long-term follow-up. It is a significant case that illustrates how coordination between various specialists can allow the safe management of a complex patient.

Clinical significance: The presented study, although presenting a clinical case, offers a didactic and analytical way of a diagnostic and therapeutic treatment scheme transferable to clinical practice.