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Periodontal-endodontic (perio-endo) lesions involve pulpal and periodontal disease in the same tooth and are seen routinely by dental practitioners. An unusual presentation of a perio-endo lesion in the lower left mandible is demonstrated. It caused significant buccal expansion and perforation of the lingual plate, and was provisionally diagnosed as a malignancy. CPD/Clinical Relevance: This case has highlighted the need for clinicians to be aware of the unusual way that periodontal-endodontic lesions may present both clinically and radiographically.