I would like to share with you the management of a large lesion with out surgical intervention.
 
Healthy 36 year old female  presents with a large periapical lesion associated with tooth 9,10, 11 and a palatal swelling that drains time to time. On pulpal examination, 9 and 11 tested WNL and 10 tested negative to thermal tests. Obviously, 10 is responsible for the lesion. Patient has two options as far as management is concerned:
 
1. To do endo in 10 and possibly (9 and 11) and do a surgical intervention. Since the lesion is so large it might end up involving the floor of the nasal cavity. As the surgery may possibly end up devitalising 9, 11 (the reason why I mentioned possible endo in 9,11).
 
2. The second type is to initiate RCT in 10, drain through  the tooth, place a drain for a week or two to decompress the lesion, and do the long term Calcium Hydroxide treatment and when the lesion starts to shrink and the canal can be dried, finish  rct.
 
There is no right or wrong. Every case needs a unique approach depending on your technique, type of patient you are dealing with, where you practice. As a clinician we have to pick what works for the case and run with it. However, in my mouth or my family member, I prefer the second appraoch. Much less invasive .
 
Here is the detail account of  my management sequence.
 
- Case was started 3/07
- Drainage obtained from tooth and as well as from the palatal swelling. I placed caoH in the canal and then placed a drain on the palatal and sutured it into place. patient is given a syringe and chlorhexidine so that she can irrigate the lesion through the needle tube drain.
- One week later I removed the drain.
- 5/07:  2 months later opened the tooth and obtained more drainage from the tooth. More caoh was placed.
- 9/07: 4 months later opened it and more drainage obtained.  More Caoh placed.
- 6/08:  9 months later, lesion is almost fully healed, canal is dry and I obturated it.
 
Last picture is the tissue at the last visit and the one before is 2 months after the drain is removed.
whole treatment lasted 15 months...
I am glad patient didnt need surgery...
I am actually very happy with the management of this case. Makes me feel like a healer.
 
Comments are welcome.

"I have enclosed the one year post treatment recall image taken  in may 2009 which shows excellent healing of the large lesion."