• Users Online: 444
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 11  |  Issue : 4  |  Page : 225-228

A conservative approach to treat large periapical lesions: A report of two cases


1 Department of Conservative Dentistry, M.N.D.A.V. Dental College, Solan, Himachal Pradesh, India
2 Department of Periodontology, M.N.D.A.V. Dental College, Solan, Himachal Pradesh, India
3 Department of Public Health Dentistry, Swami Devi Dyal Dental College, Panchkula, Haryana, India
4 Depatment of Orthodontics, Himachal Pradesh Dental College, Mandi, Himachal Pradesh, India

Date of Submission24-Jul-2019
Date of Decision13-Sep-2019
Date of Acceptance13-Sep-2019
Date of Web Publication1-Oct-2019

Correspondence Address:
Saroj Kumar Thakur
Department of Conservative Dentistry, M.N.D.A.V. Dental College, Solan, Himachal Pradesh
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJDS.IJDS_82_19

Rights and Permissions
  Abstract 


Pulpal tissue necrosis transforms the pulpal chamber into an unprotected environment. This environment becomes susceptible to colonization by numerous microorganisms that inhabit the oral cavity. Periapical lesions are formed as a result of the immunologic host response to bacteria or its products. These periapical lesions cannot be differentially diagnosed as either radicular cysts or apical granulomas based on radiographic evidence alone. The exact mechanism by which periapical cysts heal is also not clearly understood. In these case reports, root canal treatment proved successful in promoting the healing of large periapical lesions. This confirms that periapical lesions can respond favorably to nonsurgical treatment.

Keywords: Endodontic therapy, healing, periapical lesions


How to cite this article:
Thakur SK, Thakur R, Sankhyan A, Patyal A. A conservative approach to treat large periapical lesions: A report of two cases. Indian J Dent Sci 2019;11:225-8

How to cite this URL:
Thakur SK, Thakur R, Sankhyan A, Patyal A. A conservative approach to treat large periapical lesions: A report of two cases. Indian J Dent Sci [serial online] 2019 [cited 2019 Nov 15];11:225-8. Available from: http://www.ijds.in/text.asp?2019/11/4/225/268424




  Introduction Top


Trauma to a tooth can damage its pulp even if the crown and root are not fractured. The pulp may survive or undergo necrosis, depending on the severity of the trauma and the type of inflammatory reaction that follows. This reaction may lead to extensive destruction of the periapical tissue and an ensuing periapical lesion. On the basis of histological findings, chronic periapical lesions of the pulpal origin are diagnosed as either periapical granulomas or cysts. In the past, large, chronic periapical lesions were generally managed by root canal treatment of the involved teeth and surgical excision of the periapical lesions. This was particularly true if the periapical lesion was suspected to be a cyst. Now, because of improvements in conventional endodontic therapy and a better understanding of the healing potential of periapical tissues, fewer patients need periapical surgery. Presented here are two cases of periapical lesions one of the maxilla and other of the mandible that were successfully treated by nonsurgical endodontic therapy. This article suggests that surgical removal of periapical lesions of pulpal origin is not mandatory and that irrespective of the size of the lesion, every effort should be made to treat such lesions by conservative means.


  Case Reports Top


Case 1

A 32-year-old male reported to the department of conservative dentistry and endodontics for pain and swelling in the lower anterior region of mouth. After clinical examination, there was a swelling in the lower anterior vestibule of mouth with slight discoloration of 41, 42, and 43 teeth. On radiographic examination, there is a large radiolucency found in the periapical region of 41, 42, and 43 [Figure 1]. It was provisionally diagnosed as chronic periapical lesion and nonsurgical endodontic therapy was planned for 41, 42, and 43. Access cavities were modified and cleaning and shaping of the root canals were done. 3% NaOCl was used as root canal irrigant. Since there was purulent discharge from the canal, calcium hydroxide (Ca[OH]2) was mixed with 2% chlorhexidine and it is used as intracanal medicament. Access cavities were restored with temporary filling material. The patient was recalled after 1 week. The patient was asymptomatic, and there was no discharge from the canals and swelling in the anterior has been resolved. Then Ca (OH)2 with iodoform was used as intracanal medicament and patient was recalled after 1 month. However, due to unavoidable circumstances, he did not report back after 1 month. He reported back after 3 months. The patient was asymptomatic, and on radiographic examination, there was decrease in periapical radiolucency [Figure 2]. Root canals were obturated with gutta percha and zinc-oxide sealer using lateral method of condensation. Two-year posttreatment radiograph revealed progressive healing of periapical lesion [Figure 3].
Figure 1: Preoperative radiograph showing periradicular radiolucency around tooth number 41,42 and 43

Click here to view
Figure 2: Intraoperative radiograph showing periradicular healing around tooth number 41,42 and 43 after 3 months

Click here to view
Figure 3: Postobturation radiograph of tooth number 41,42 and 43 after 2 years

Click here to view


Case 2

A 25-year-old male patient was referred for root canal therapy of maxillary anterior teeth. Clinical examination showed discolored 11 and 12 teeth with sinus tract. Radiograph demonstrated well-defined radiolucency around the root apex of 11and 12 teeth [Figure 4]. After proper root canal access opening and cleaning and shaping of root canals, a Ca(OH)2 dressing was given as intracanal medicament. It was changed after 1 week up to 1 month followed by Ca(OH)2 with iodoform dressing for 3 months. After 3 months, periapical radiolucency was resolved and the patient was asymptomatic [Figure 5]. Root canals were obturated with gutta percha and zinc-oxide sealer using lateral method of condensation. Follow-up done after 2 years showed almost complete periapical bone healing [Figure 6].
Figure 4: Preoperative radiograph showing periradicular radiolucency around tooth number 11 and 12

Click here to view
Figure 5: Intraoperative radiograph showing decrease in periradicular radiolucency around tooth number 11 and 12 after 3 months

Click here to view
Figure 6: Postobturation radiograph of tooth number 11and 12 after 2 years

Click here to view



  Discussion Top


The precise mechanism involved in the formation of periapical lesions is not fully understood. Nevertheless, it is generally agreed that if the pulp becomes necrotic, its environment becomes suitable to allow microorganisms to multiply and release various toxins into the periapical tissues, initiating an inflammatory reaction and leading to the formation of a periapical lesion.[1],[2] Several studies have been carried out to examine the role of bacteria in the formation of periapical lesions.[3],[4] It has been observed that microorganisms are present in root canals of all teeth associated with periapical lesions.[4],[5] Periapical lesions of endodontic origin may develop asymptomatically and become large. Proper biomechanical preparation followed by Ca(OH)2 medication renewed periodically represents a nonsurgical approach to resolve extensive inflammatory periapical lesions.[6] Nonsurgical approach should be our first step. Other reports confirm that large periapical lesions can respond favorably to nonsurgical treatment.[7] The conservative treatment success in managing supposedly cystic periapical lesions could be explained based on the following aspects:

  • Biomechanical preparation and bacterial control
  • Lesion decompression achieved by apical patency
  • Complementary antiseptic action of Ca (OH)2 due to its alkalinity and its bony repair effect
  • Good immune response due to patients' age.[8]


In situation like this, one of the most dentists will advise a surgical approach for therapy of large periapical lesion with multiple teeth involving. This treatment did not exclude a need for additional periapical surgery in the future. At least it delayed surgical treatment until diminishing of pathological process in the apical periodontal region. In those circumstances, surgeon can take advantage of quite conservative approach, and maximally preserve local tissues, without weakening those fragile teeth. The current concept and rationale of endodontic treatment of periapical lesion are centered on stopping the bacterial stimulation of the host response at the apical foramen that would allow healing of the lesions. Ca(OH)2 was used as intracanal medicament in two of the above cases. The exact mechanism of action of Ca(OH)2 is speculative. It was suggested that the action of Ca(OH)2 beyond the apex maybe fourfold.[9]

  1. Anti-inflammatory activity
  2. Neutralization of acid products
  3. Activation of alkaline phosphatase
  4. Antibacterial action.


It has also been reported that treatment with Ca(OH)2 resulted in a high frequency of periapical healing, especially in young patients.[10] Healing of lesions may take many months. In all our cases, though we recalled the patients at intervals of 1, 3, 6, and 12 months, none of them returned as per appointments. This can be attributed to the lack of interest on patient part in rural areas. A study compared the healing of periapical lesions following surgical and nonsurgical retreatment. At 12 months, a significant difference was found in favor of surgical treatment that faded by 48 months to almost no difference between the groups.[11] Surgical management of periapical lesions can be associated with damage to vital structures, scar formation, and unpleasant experience to the patient. However, for the cases which are not responding to nonsurgical endodontic therapy, surgical intervention may be the last option. It is now believed that the activated macrophages in the periapical lesion are the reason for delayed healing of the lesions in the absence of bacterial antigens. The futuristic view of treating the periapical lesions include placement of biodegradable local sustained drug delivery points into the lesion before obturating the tooth to deactivate the macrophages and enhancing the faster healing of the lesions.[12]


  Conclusion Top


In this case series, nonsurgical endodontic therapy proved successful in promoting the healing of periapical lesions. Irrespective of the size of the lesion, every attempt should be made to treat the periapical lesions with nonsurgical endodontic therapy.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Shear M. Histogenesis of the dental cyst. Dent Pract 1963;13:238-243.  Back to cited text no. 1
    
2.
Yanagisawa S. Pathologic study of periapical lesions 1. Periapical granulomas: Clinical, histopathologic and immunohistopathologic studies. J Oral Pathol 1980;9:288-300.  Back to cited text no. 2
    
3.
Andreasen JO, Rud J. A histobacteriologic study of dental and periapical structures after endodontic surgery. Int J Oral Surg 1972;1:272-81.  Back to cited text no. 3
    
4.
Walton RE, Ardjmand K. Histological evaluation of the presence of bacteria in induced periapical lesions in monkeys. J Endod 1992;18:216-27.  Back to cited text no. 4
    
5.
Ramachandran Nair PN. Light and electron microscopic studies of root canal flora and periapical lesions. J Endod 1987;13:29-39.  Back to cited text no. 5
    
6.
Soares J, Santos S, Silveira F, Nunes E. Nonsurgical treatment of extensive cyst-like periapical lesion of endodontic origin. Int Endod J 2006;39:566-75.  Back to cited text no. 6
    
7.
Oztan MD. Endodontic treatment of teeth associated with a large periapical lesion. Int Endod J 2002;35:73-8.  Back to cited text no. 7
    
8.
Soares JA, Brito-Júnior M, Silveira FF, Nunes E, Santos SM. Favorable response of an extensive periapical lesion to root canal treatment. J Oral Sci 2008;50:107-11.  Back to cited text no. 8
    
9.
Farhad A, Mohammadi Z. Calcium hydroxide: A review. Int Dent J 2005;55:293-301.  Back to cited text no. 9
    
10.
Saatchi M. Healing of large periapical lesion: A non-surgical endodontic treatment approach. Aust Endod J 2007;33:136-40.  Back to cited text no. 10
    
11.
Kvist T, Reit C. Results of endodontic retreatment: A randomized clinical study comparing surgical and nonsurgical procedures. J Endod 1999;25:814-7.  Back to cited text no. 11
    
12.
Zvi M, Itzhak A. Periapical lesion of endodontic origin. In: Ingle JI, Bakland LK, Craig Baumgartner J. Ingles Endodontics. 6th ed. Solan, Himachal Pradesh: Hamilton, BC Decker Inc.; 2008. p. 511.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Case Reports
Discussion
Conclusion
References
Article Figures

 Article Access Statistics
    Viewed51    
    Printed0    
    Emailed0    
    PDF Downloaded14    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]