A New Rationale for the Management of Periapical Granulomas and Cysts: An Evaluation of Histopathological and Radiographic Findings
TL;DR: Results show that periapical granulomas from cysts occur with almost equal frequency, that radiographic diagnosis has a 60% chance of reliability, and that size of the lesions is of diagnostic value only for lesions measuring more than 200 mm 2 .
Abstract: Conflicting data make it difficult for the practitioner to differentiate periapical granulomas from cysts. In this study, additional information was sought. Results show that both entities occur with almost equal frequency, that radiographic diagnosis has a 60% chance of reliability, and that size of the lesions is of diagnostic value only for lesions measuring more than 200 mm 2 .
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TL;DR: The microbial flora in canals after failed endodontic therapy differed markedly from the flora in untreated teeth, and infection at the time of root filling and size of the periapical lesion had a negative influence on the prognosis.
Abstract: Objective. The purposes of this study were to determine what microbial flora were present in teeth after failed root canal therapy and to establish the outcome of conservative re-treatment.
Study design. Fifty-four root-filled teeth with persisting periapical lesions were selected for re-treatment. After removal of the root filling, canals were sampled by means of advanced microbiologic techniques. The teeth were then re-treated and followed for up to 5 years.
Results. The microbial flora was mainly single species of predominantly gram-positive organisms. The isolates most commonly recovered were bacteria of the species Enterococcus faecalis. The overall success rate of re-treatment was 74%.
Conclusions. The microbial flora in canals after failed endodontic therapy differed markedly from the flora in untreated teeth. Infection at the time of root filling and size of the periapical lesion were factors that had a negative influence on the prognosis. Three of four endodontic failures were successfully managed by re-treatment.
1,449 citations
TL;DR: This communication is meant to provide a comprehensive overview of the etio-pathogenesis of apical periodontitis and the causes of failed endodontic treatments that can be visualized in radiographs as asymptomatic post-treatment periapical radiolucencies.
Abstract: Apical periodontitis is a sequel to endodontic infection and manifests itself as the host defense response to microbial challenge emanating from the root canal system. It is viewed as a dynamic encounter between microbial factors and host defenses at the interface between infected radicular pulp and periodontal ligament that results in local inflammation, resorption of hard tissues, destruction of other periapical tissues, and eventual formation of various histopathological categories of apical periodontitis, commonly referred to as periapical lesions. The treatment of apical periodontitis, as a disease of root canal infection, consists of eradicating microbes or substantially reducing the microbial load from the root canal and preventing re-infection by orthograde root filling. The treatment has a remarkably high degree of success. Nevertheless, endodontic treatment can fail. Most failures occur when treatment procedures, mostly of a technical nature, have not reached a satisfactory standard for the control and elimination of infection. Even when the highest standards and the most careful procedures are followed, failures still occur. This is because there are root canal regions that cannot be cleaned and obturated with existing equipments, materials, and techniques, and thus, infection can persist. In very rare cases, there are also factors located within the inflamed periapical tissue that can interfere with post-treatment healing of the lesion. The data on the biological causes of endodontic failures are recent and scattered in various journals. This communication is meant to provide a comprehensive overview of the etio-pathogenesis of apical periodontitis and the causes of failed endodontic treatments that can be visualized in radiographs as asymptomatic post-treatment periapical radiolucencies.
839 citations
TL;DR: This article provides a comprehensive overview of the causative factors of non-resolving periapical lesions that are seen as asymptomatic radiolucencies post-treatment.
Abstract: Apical periodontitis is a chronic inflammatory disorder of periradicular tissues caused by aetiological agents of endodontic origin. Persistent apical periodontitis occurs when root canal treatment of apical periodontitis has not adequately eliminated intraradicular infection. Problems that lead to persistent apical periodontitis include: inadequate aseptic control, poor access cavity design, missed canals, inadequate instrumentation, debridement and leaking temporary or permanent restorations. Even when the most stringent procedures are followed, apical periodontitis may still persist as asymptomatic radiolucencies, because of the complexity of the root canal system formed by the main and accessory canals, their ramifications and anastomoses where residual infection can persist. Further, there are extraradicular factors -- located within the inflamed periapical tissue -- that can interfere with post-treatment healing of apical periodontitis. The causes of apical periodontitis persisting after root canal treatment have not been well characterized. During the 1990s, a series of investigations have shown that there are six biological factors that lead to asymptomatic radiolucencies persisting after root canal treatment. These are: (i) intraradicular infection persisting in the complex apical root canal system; (ii) extraradicular infection, generally in the form of periapical actinomycosis; (iii) extruded root canal filling or other exogenous materials that cause a foreign body reaction; (iv) accumulation of endogenous cholesterol crystals that irritate periapical tissues; (v) true cystic lesions, and (vi) scar tissue healing of the lesion. This article provides a comprehensive overview of the causative factors of non-resolving periapical lesions that are seen as asymptomatic radiolucencies post-treatment.
787 citations
Cites background from "A New Rationale for the Management ..."
...…diagnosed into cystic and non-cystic lesions based on radiographs alone (Priebe et al. 1954, Baumann & Rossman 1956, ª 2006 International Endodontic Journal International Endodontic Journal, 39, 249–281, 2006 259 Wais 1958, Linenberg et al. 1964, Bhaskar 1966, Lalonde 1970, Mortensen et al. 1970)....
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TL;DR: The results show the low incidence of radicular cysts among periapical lesions as against the widely held view that almost half of all periAPical lesions are cysts; and the occurrence of two classes of radicle cysts.
Abstract: Objectives To determine (1) the frequency of the incidence of abscess, granuloma, and radicular cyst among human periapical lesions obtained with extracted teeth; and (2) whether periapical cysts occur in two categories when histologically analyzed in relation to the root canals. Study design A total of 256 lesions were analyzed. The specimens were decalcified and embedded in plastic. Serialsections or step-serial sections were prepared, and the sections were evaluated on the basis of predefined histopathologic criteria. Results The 256 specimens consisted of 35% periapical abscess, 50% granuloma, and 15% cysts. The latter occurred intwo categories, the apical true cysts and the apical pocket cysts. Conclusions These results show (1) the low incidence of radicular cysts among periapical lesions as against the widely held view that almost half of all periapical lesions are cysts; and (2) the occurrence of two classes of radicular cysts. We are of opinion that the pocket cysts may heal after root canal therapy but the true cysts are less likely to be resolved by conventional root canal treatment.
326 citations
TL;DR: From a clinical point of view a periapical pocket cyst may heal after conventional root canal therapy whereas an apical true cyst is less likely to be resolved without surgical intervention.
Abstract: During the past few decades several authors have perpetuated the notion that nearly half of all periapical lesions are radicular cysts. A few studies, based on meticulous serial sectioning of periapical lesions retrieved in toto, have shown that the actual incidence of radicular cyst is only about 15% of all periapical lesions. Equally significant was the discovery in 1980 and recent confirmation that radicular cysts exist in two structurally distinct classes namely, those containing cavities completely enclosed in epithelial lining (periapical true cysts) and those containing epithelium-lined cavities that are open to the root canals (periapical pocket cysts). From a clinical point of view a periapical pocket cyst may heal after conventional root canal therapy whereas an apical true cyst is less likely to be resolved without surgical intervention.
252 citations
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TL;DR: It was shown that an apical radiolucency may represent any one of nine distinct clinicopathologic lesions and the radicular cyst was found to comprise 42 per cent of all apical diseases.
234 citations
TL;DR: Radicular cysts were found to be almost as common as granulomas in both posterior and anterior areas of the mouth, and posterior lesions resolve without surgical endodontic therapy as frequently as anterior lesions.
121 citations
79 citations
TL;DR: A study was undertaken to evaluate, roentgenographically and clinically, areas of periapical rarefaction in persons who have never sought definitive dental treatment and evaluate histopathologically the specimens obtained from these areas.
52 citations