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J Conserv Dent. 2010 Oct-Dec; 13(4): 240245.doi: 10.4103/0972-0707.73384

PMCID: PMC3010029

Nonsurgical management of periapical lesions

Marina Fernandes and Ida de Ataide

Author information Article notes Copyright and License information

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Abstract

Periapical lesions develop as sequelae to pulp disease. They often occur w ithout any episode of acute pain andare discovered on routine radiographic examination. The incidence of cysts within periapical lesions variesbetween 6 and 55%. The occurrence of periapical granulomas ranges between 9.3 and 87.1%, and of abscessesbetween 28.7 and 70.07%. It is accepted that all inflammatory periapical lesions should be initially treatedwith conservative nonsurgical procedures. Studies have reported a success rate of up to 85% after endodontictreatment of teeth with periapical lesions. A review of literature was performed by using electronic and handsearching methods for the nonsurgical management of periapical lesions. Various methods can be used in thenonsurgical management of periapical lesions: the conservative root canal treatment, decompressiontechnique, active nonsurgical decompression technique, aspiration-irrigation technique, method usingcalcium hydroxide, Lesion Sterilization and Repair Therapy, and the Apexum procedure. Monitoring the

healing of periapical lesions is essential through periodic follow-up examinations.

Keywords: Calcium hydroxide, cyst, decompression, healing, granuloma, periapical

INTRODUCTION

Bacterial infection of the dental pulp may lead to periapical lesions.[1] They are generally diagnosed eitherduring routine dental radiographic examination or following acute pain in a tooth.[2] Most periapical lesions

(>90%) can be classified as dental granulomas, radicular cysts or abscesses.[3,4] The incidence of cysts withinperiapical lesions varies between 6 and 55%.[5] The occurrence of periapical granulomas ranges between 9.3and 87.1%, and of abscesses between 28.7 and 70.07%.[6] There is clinical evidence that as the periapicallesions increase in size, the proportion of the radicular cysts increases. However, some large lesions have beenshown to be granulomas.[7] The definitve diagnosis of a cyst can be made only by a histological examination.However, a preliminary clinical diagnosis of a periapical cyst can be made based on the following: (a) Theperiapical lesion is involved with one or more non-vital teeth, (b) the lesion is greater than 200 mm in size,(c) the lesion is seen radiographically as a circumscribed, well-defined radiolucent area bound by a thinradiopaque line, and (d) it produces a straw-colored fluid upon aspiration or as drainage through an accessedroot canal system.[8]

The ultimate goal of endodontic therapy should be to return the involved teeth to a state of health andfunction without surgical intervention.[9] All inflammatory periapical lesions should be initially treated with

conservative nonsurgical procedures.[10] Surgical intervention is recommended only after nonsurgicaltechniques have failed.[11] Besides, surgery has many drawbacks, which limit its use in the management ofperiapical lesions.[12,13] Various studies have reported a success rate of up to 85% after endodontic treatmentof teeth with periapical lesions.[1416] A high percentage of 94.4% of complete and partial healing ofperiapical lesions following nonsurgical endodontic therapy has also been reported.[17]

Search methodology

Performing your original search, differentiate between periapical abscess and cyst review pdf, in PMC willretrieve 0records.

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Diagnosis of the lesion

Proximity of the periapical lesion to adjacent vital teeth

Encroachment on anatomical structures

Patient cooperation

Age of the patient

Obstructions in the root canal system

Time involved for treatment

Cases refractory to nonsurgical management methods

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An electronic search was conducted in the PubMed database with appropriate MeSH headings and key wordsrelated to the nonsurgical management of periapical lesions. A hand search of journals was also conducted toenhance the electronic search results.

Case selection

The current philosophy in the management of periapical lesions includes the initial use of nonsurgicalmethods. When this treatment approach is not successful a surgical approach may be adopted.[ 18] Thefollowing factors must be considered, while deciding on the management approach:

Many bone destroying lesions closely resemble endodontically related periapical lesionson radiographs. Some of these nonendodontic lesions include ameloblastoma, central fibroma, giant celllesions, fibrous dysplasia, central hemangioma, primary malignancies, metastatic neoplasms, andinflammatory bone diseases. Teeth related to nonendodontic periapical lesions generally test vital to pulptesting methods. It is essential that the clinician establishes the correct diagnosis to avoid unnecessarytreatment of vital healthy teeth.[19,20]

When the periapical lesion is in close proximity to the

apices of vital teeth, adopting a surgical approach may result in injury to the blood vessels and nerves of theadjacent teeth, thereby compromising their vitality.[12,13]

Surgery increases the risk of damage to the anatomic structures suchas mental foramen, inferior alveolar nerve and / or artery, nasal cavity and maxillary sinus.[19] Also, theaspirationirrigation technique, a nonsurgical method, is not recommended where adjacent tissue spaces orsinus cavities are involved.[18] In such cases, alternative nonsurgical methods can be used.

Considerable pain or discomfort can be experienced by the patient during or after asurgical procedure. A nonsurgical approach would be recommended for apprehensive and uncooperativepatients.[19] However, patient cooperation is also essential, while using the nonsurgical methods as severalfollow-up appointments may be required.

Very old patients may not tolerate surgical procedures well and hence may require

nonsurgical treatment modalities.[19]Ledges, calcified canals, separated instruments may prevent access to the

apical foramen and may warrant a surgical approach in managing periapical lesions related to such teeth.[21]

Enhanced healing kinetics are observed after performing apical surgery in teeth

with periapical lesions.[22] Although the surgery has many pitfalls, it may be advisable in cases when thepatient will be lost to follow-up before complete healing.[11]

Inflammatory apical true cysts and the presence ofcholesterol crystals have been suggested as possible causes that prevent healing of periapical lesions.[23]Surgery is recommended for such cases that do not respond favorably to nonsurgical methods of treatment.[11]

METHODS FOR NONSURGICAL MANAGMENT OF PERIAPICAL LESIONS

Conservative root canal treatment without adjunctive therapy

Bhaskar has suggested that instrumentation should be carried 1 mm beyond the apical foramen when aperiapical lesion is evident on a radiograph. This may cause transitory inflammation and ulceration of theepithelial lining resulting in resolution of the cyst.[24] Bender in his commentary on Bhaskars hypothesis hasadded that penetration of the apical area to the center of the radiolucency establishes drainage and relievespressure. Once the drainage stops, fibroblasts begin to proliferate and deposit collagen; this compresses the

capillary network, and the epithelial cells are thus starved, undergo degeneration, and are engulfed by themacrophages.[25] Although this proves to be an effective method Shah suggests the possibility that quiescentepithelial cells may be stimulated by instrumentation in the apical region, with resultant proliferation and

cyst formation, and thus stressed on the need for follow-up for a period of at least two years.[16] Healing oflarge cysts like well-defined radiolucencies following conservative root canal treatment has been reported.
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Aspiration through the root canal technique

Although the cystic fluid contains cholesterol crystals, weekly debridement and drying of the canals over aperiod of two to three weeks, followed by obturation has led to a complete resolution of lesions by 12 to 15months.[26]

Decompression technique

The decompression technique involves placement of a drain into the lesion, regular irrigation, periodic lengthadjustment, and maintenance of the drain, for various periods of time.[27] The drain could either be Ishaped pieces of rubber dam,[28] polyethylene tube along with a stent,[29] hollow tubes,[30,31] a polyvinyl

tubing,[27] suction catheter[32] or a radiopaque latex tubing.[33] There is no standard protocol as to thelength of time necessary to leave the drain. It may be different for different kinds, sizes or locations of lesions.[33] It can vary between two days[27] to five years.[32] Daily irrigation of the lesion can be carried out bythe patient through the lumen of the drain using 0.12% chlorhexidine.[33,34] The advantages of thistechnique are; it is a simple procedure, it minimizes the risk of damaging adjacent vital structures, and iseasily tolerated by the patient.[27] However, several disadvantages have also been noted; patient complianceis very essential, inflammation of the alveolar mucosa, persistence of the surgical defect at site, developmentof an acute or chronic infection, displacement or submergence of the drainage tube.[35,36] Rees suggests

placement of a small amount of red wax over the end of the drain to prevent ulceration of the labial or buccalmucosa adjacent to the drain.[32] The decompression technique is contraindicated in cases of large dental

granulomas or any solid cellular lesion, assince there is an absence of a fluid-filled cavity to decompress.[27]Active nonsurgical decompression technique

This technique uses the Endo-eze vacuum system (Ultradent, Salt Lake, Utah) to create a negative pressure,which results in the decompression of large periapical lesions. The high-volume suction aspirator is connectedto a micro 22-gauge needle, which is inserted in the root canal and activated for 20 minutes, creating anegative pressure, which results in aspiration of the exudate. When the drainage partially stops, the accesscavity is closed with temporary cement, which helps in maintaining bacterial control. Unlike thedecompression technique, this technique is minimally invasive as the entire procedure is done through the

root canal and causes less discomfort for the patient.[36]

Aspiration and irrigation technique

Hoen et al, suggested aspiration of the cystic fluid from the periapcial lesion using a buccal palatal approach.In this technique, an 18-gauge needle attached to a 20 ml syringe is used to penetrate the buccal mucosa andaspirate the cystic fluid. A second syringe filled with saline is then used to rinse the bony lesion. The newneedle is inserted through the buccal wound and passed out through the palatal tissue creating a pathway forthe escape of the irrigant.[18] Accumulation of cystic fluid within a confined bony cavity leads to increasedhydrostatic pressure, which causes additional osteoclastic activity and growth of the cyst.[ 37,38] Aspirationleads to decreased hydrostatic pressure, which slows the osteoclastic activity and enlargement of the defect.The gentle irrigation cleanses the bony defect and initiates bleeding and subsequent clot formation, whichcould be the start of the healing mechanism.[18] The disadvantage of this technique is the creation of buccal

and palatal wounds that may cause discomfort to the patient.[39]

To overcome the disadvantage of the traditional aspirationirrigation technique, a simple technique of aspiration through the root canal has been described. In thistechnique, aspiration of the cystic fluid is done through the root canal by passing the aspirating needlethrough the apical foramen. This technique eliminates the creation of buccal and palatal wounds, as in thetraditional aspirationirrigation technique. This minimizes the discomfort that the patient may experience.Severely curved canals may limit the use of this technique as the canal anatomy prevents the aspiratingneedle from reaching the apical foramen. This technique may also not be favorable in narrow-rooted teeth,for example, the mandibular incisors, as the root canal will have to be widened excessively to allow theaspirating needle to pass into the bony cavity, thus weakening the tooth structure.[39]

However, it is advisable not to use either aspirationirrigation or aspiration through the root canal techniqueswhere adjacent tissue spaces or sinus cavities are involved, when there is no fluid aspiration from the lesion,or in infected periapical lesions.[18,39]

Method using calcium hydroxide
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Calcium hydroxide is a widely used material in endodontic treatment because of its bactericidal effects.[4044] It is thought to create favorable conditions for periapical repair and stimulate hard tissue formation.[45,46] Souza et al,. suggested that the action of calcium hydroxide beyond the apex may be four-fold: (a)anti-inflammatory activity, (b) neutralization of acid products, (c) activation of the alkaline phosphatase, and

(d) antibacterial action.[47] A success rate of 80.8[15] and 73.8%[48] has been reported with calciumhydroxide, when used for endodontic treatment of teeth with periapical lesions. It has been suggested that thepresence of a cyst may impede or prevent root-end closure of an immature pulpless tooth even with the use ofcalcium hydroxide.[49] Contrary to this, alikan and Trkn have reported a case in which apical closure

and periapical healing have occurred in a large cyst-like periapical lesion following non-surgical endodontictreatment with calcium hydroxide paste and a calcium hydroxidecontaining, root-canal sealer.[ 35]Extrusion of calcium hydroxide beyond the apex was suggested as a factor for the lack of early healing ofperiapical lesions.[50] However, many investigators advocate that direct contact between calcium hydroxideand the periapical tissues is beneficial for the inductive action of the material.[46,51] A high degree of successhas been reported by using calcium hydroxide beyond the apex in cases with large periapical lesions.[15,35,47] It is barium sulphate that is added to the calcium hydroxide paste for radiopacity, which is notreadily resorbed when the paste extrudes beyond the apex. However, it has been reported that even thoughcomplete resorption of the paste does not occur in some cases, the periapical radiolucency around the pasteresolves.[15]

Some studies have reported that long-term exposure of root dentin to intracanal calcium hydroxide leads to adecrease in the fracture resistance of teeth.[52,53] A method using calcium hydroxide, demineralized freeze-dried bone allograft, and Mineral Trioxide Aggregate (MTA) has been described by Chhabra et al., forapexification of an immature tooth associated with a large periapical lesion. Calcium hydroxide is used as anantibacterial agent for only 15 days, following which it is irrigated out of the canal using sodium hypochlorite.The demineralized, freeze-dried bone allograft is then packed in the periapical area to form an apical matrix,with the help of finger pluggers. The demineralized bone matrix also acts as an osteoconductive and possibly

as an osteoinductive material. MTA is then compacted over the matrix, forming a 5 mm apical plug.[ 54]

Lesion sterilization and repair therapy

The Cariology Research Unit of the Niigata University School of Dentistry has developed the concept ofLesion Sterilization and Tissue Repair (LSTR) therapy that uses a triple antibiotic paste of ciprofloxacin,metronidazole, and minocycline, for disinfection of oral infectious lesions, including dentinal, pulpal, andperiradicular lesions.[5557] Repair of damaged tissues can be expected if lesions are disinfected.[58]

Metronidazole is the first choice because it has a wide antibacterial spectrum against anaerobes.[59]However, some bacteria are resistant to metronidazole, and hence, ciprofloxacin and minocycline are addedto the mix.[60] The combination of drugs has been shown to penetrate efficiently through dentine from theprepared root canals especially from the ultrasonically irrigated root canals.[55] The commercially availabledrugs are powdered and mixed in a ratio of 1:3:3 (3 Mix) and mixed either with macrogol-propylene glycol (3Mix-MP) or a canal sealer (3 Mix-sealer).[58] A 1:1:1 ratio of the drug combination has also been used.[61]Although the volume of the drugs applied in this therapy is small, care should be taken to check if the patients

are sensitive to chemicals or antibiotics.[62] A disadvantage of the triple antibiotic paste is tooth discolorationinduced by minocycline. Cefaclor and fosfomycin are proposed as possible alternatives for minocycline, interms of their antibiotic effectiveness, but further clinical studies are needed to demonstrate their efficacy inthe root canal.[63]

Apexum procedure

Surgically treated periapical lesions show enhanced healing kinetics compared with those treatednonsurgically.[22] Surgical removal of the periapical, chronically inflamed tissue allows a fresh blood clot toform, thereby converting a chronic inflammatory lesion into a new granulation tissue, where healing mightproceed much faster.[64,65] The Apexum procedure uses two sequential rotary devices, the Apexum NiTi

Ablator and Apexum PGA Ablator (Apexum Ltd, Or Y ehuda, Israel), designed to extend beyond the apex andmince the periapical tissues on rotation in a low-speed handpiece, followed by washing out the minced tissue.[66] A clinical trial reported significantly faster periapical healing in the Apexum-treated group (95%) than inthe conventional root canal treatment group (39%) at six months, with significantly less postoperativediscomfort or pain. However, whether the procedure was able to remove all the periapical inflammatory
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Simvastatin

Epigallocatechin-3-gallate

Assessment of healing of periapical lesions

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tissue was beyond the scope of the study conducted. Further studies regarding this procedure are in progress.[22]

Materials under research

Simvastatin, a hydroxymethylglutaryl-coenzyme A reductase inhibitor, is used as a cholesterolreducing agent that also possess anti-inflammatory activities. Simvastatin has significantly suppressed theprogression of induced rat periapical lesions, possibly by diminishing the cysteine-rich 61 (Cyr61) expressionin osteoblasts, a potential osteolytic mediator, which in turn suppressed the infiltration of macrophages.[67]

Epigallocatechin-3-gallate (EGCG) is a major polyphenol of green tea that has anti-inflammatory properties. EGCG suppressed the progression of apical periodontitis in a rat model, possibly bydiminishing Cyr61 expression in osteoblasts and, subsequently, macrophage chemotaxis into the lesions.[68]

Repair of periradicular tissues consists of a complex regenerationinvolving bone, periodontal ligament, and cementum.[69] The area of mineral loss gradually fills with boneand the radiographic density increases.[70] If the cortical plate is perforated, healing begins with theregeneration of the external cortical plate and proceeds from the outside of the lesion toward the inside.[71]

Maxillary lesions resolve faster than mandibular lesions due to the presence of a more extensive vascularnetwork in the maxilla, which facilitates resolution. Anterior lesions of both the maxilla and mandible heal at

a faster rate than posterior lesions due to the close proximity of the buccal and lingual plates in the anteriorsegments.[17]

Although clinical as well as radiographic data are used to monitor cases, the relative absence of clinicalsymptoms in chronic apical periodontitis makes the assessment primarily a radiographic one. Variousmethods can be used to assess the healing of periapical lesions by interpretation of periodic recall radiographs.[70] The successfailure criteria laid down by Strindberg is primarily a system designed to detect changes inradiographic appearance. The criteria for success are that: (a) the contours, width, and structure of theperiodontal margin are normal; (b) the periodontal contours are widened mainly around the excess filling;and the criteria for failure are: (a) a decrease in the periradicular rarefaction; (b) unchanged periradicularrarefaction; (c) an appearance of new rarefaction or an increase in the initial rarefaction.[ 71] Even though

the periapical conditions are viewed as a continuous process of healing or developing periodontitis, the systemis strictly dichotomous, that is, there is no middle ground between success and failure.[70] The areameasurement assessment method can be used to monitor the healing of periapical lesions. The rate of repaircan be calculated by dividing the size differential between the initial and follow-up visits by the number ofelapsed months. On the basis of the average healing rate of approximately 3 mm /mo, a 30 mm lesion willrequire 10 months for complete resolution. If the lesion becomes larger, remains the same size or

demonstrates a below average rate of healing, then surgical intervention must be considered. However, themeasurement involves only two dimensions, because it is not possible to evaluate the buccolingual extent.[ 17]Another assessment tool is the periapical index (PAI), which provides an ordinal scale of five scores rangingfrom healthy to severe periodontitis with exacerbating features.[72] Of late, an ultrasound with color powerDoppler has been demonstrated to be an efficacious monitoring tool in the healing of periapical lesions.[73]

At times, scar tissue can develop after conventional endodontic treatment as well as after periapical surgery.[3] If there are no untoward clinical findings, it indicates fibrous healing or healing by scar formation. Theradiograph usually shows a trabecular bone pattern radiating from the center that appears as a reduced, butincompletely resolved radiolucency.[74]

Various authors have stressed on the importance of a long observation time for treated teeth with periapicallesions.[14,48,68] In a clinical review by alikan, a follow-up examination ranged from two to ten years.[48] Shah suggested that patients should be recalled at intervals of three months, six months, one year, andtwo years, to assess the healing of periapical lesions. There is always the possibility that quiescent epithelialcells may be stimulated by instrumentation in the apical region, with resultant proliferation and cystformation.[16] Hence, follow-up is extremely essential for a period of at least two years.[75]

CONCLUSION

Nonsurgical management of periapical lesions have shown a high success rate. A nonsurgical approachshould always be adopted before resorting to surgery. The decompression and aspirationirrigation

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techniques can be used when there is drainage of cystic fluid from the canals. These techniques act bydecreasing the hydrostatic pressure within the periapical lesions. When there is no drainage of fluid from thecanals, calcium hydroxide or the triple antibiotic paste can prove beneficial. Periodic follow-up examinationsare essential and various assessment tools can be used to monitor the healing of periapical lesions. Thesurgical approach can be adopted for cases refractory to nonsurgical treatment, in obstructed ornonnegotiable canals and for cases where long-term monitoring of periapical lesions is not possible.

Footnotes

Source of Support: Nil

Conflict of Interest: None declared

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