Restor Dent Endod.  2022 Aug;47(3):e26. 10.5395/rde.2022.47.e26.

Persistent pain after successful endodontic treatment in a patient with Wegener’s granulomatosis: a case report

• Machado R
• Pereira JA
• Vitali FC
• Bolan M
• Rivero ERC

• KMID: 2548130
• DOI: http://doi.org/10.5395/rde.2022.47.e26

Abstract

Wegener’s granulomatosis (WG) is a condition with immune-mediated pathogenesis that can present oral manifestations. This report describes the case of a patient diagnosed with WG 14 years previously, who was affected by persistent pain of non-odontogenic origin after successful endodontic treatment. A 39-year-old woman with WG was diagnosed with pulp necrosis and apical periodontitis of teeth #31, #32, and #41, after evaluation through a clinical examination and cone-beam computed tomography (CBCT). At the first appointment, these teeth were subjected to conventional endodontic treatment. At 6- and 12-month follow-up visits, the patient complained of persistent pain associated with the endodontically treated teeth (mainly in tooth #31), despite complete remission of the periapical lesions shown by radiographic and CBCT exams proving the effectiveness of the endodontic treatments, thus indicating a probable diagnostic of persistent pain of non-odontogenic nature. After the surgical procedure was performed to curette the lesion and section 3 mm of the apical third of tooth #31, the histopathological analysis suggested that the painful condition was likely associated with the patient's systemic condition. Based on clinical, radiographic, and histopathological findings, this unusual case report suggests that WG may be related to nonodontogenic persistent pain after successful endodontic treatments.

Keyword

Case reports; Granulomatosis with polyangiitis; Root canal therapy; Toothache

Figure

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  Figure 1 Images referring to the first phase of the treatment (diagnosis and completion of the endodontic interventions). (A) Initial periapical radiography. Red arrow: tooth #31 with previous root canal access and periapical lesion. Yellow arrows: teeth #32 and #41 with apical periodontal ligament space thickening. (B and C) Initial cone-beam computed tomography images (axial view). Large periradicular lesion affecting the anterior region of the mandible and the root apices of teeth #31 (blue arrow), #32 (yellow arrow), and #41 (red arrow). (D) Final periapical radiography, with teeth #32 and #41 filled with gutta-percha and endodontic sealer, and tooth #31 filled with mineral trioxide aggregate.

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  Figure 2 Images referring to the first follow-up. (A) 6-month follow-up radiography. (B and D) Cone-beam computed tomography (CBCT) images (sagittal views) of teeth (B) #32, (C) #31 and (D) #41 with evidence of the apical repair process. (E-G) CBCT images (axial views), (E) cervical, (F) middle, and (G) apical sections with evidence of the apical repair process and decreased lesion size.

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  Figure 3 Images referring to the second follow-up (A-D), and 1 month after the surgical procedure (E). (A) 12-month follow-up radiograph indicating complete apical repair. (B-D) Cone-beam computed tomography images (axial views), (B) cervical, (C) middle, and (D) apical sections with evidence of complete apical repair and total remission of the lesion. (E) Periapical radiograph 1 month following apical surgery.

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  Figure 4 Histopathological analysis (hematoxylin and eosin, ×400). (A) Well-organized fibrous connective tissue with mild perivascular inflammatory infiltrate. (B) Congested blood vessels. (C) Blood vessels with wall thickening. Arrowheads: inflammatory cells.

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