CASE REPORT

Paediatric Dentistry
Periapical granuloma
mimicking a dental
cyst -Case Report
and Diagnostic
Implications

Abstract
Radiographic differentiation of periapical lesions is always
an inconclusive arena in endodontic diagnosis. This paper
describes a case of periapical granuloma in the anterior maxilla
of a 9 year old boy, which was provisionally misdiagnosed as a
cyst because of its large size and tooth migrating ability. The
Dr. V. Sandeep
lesion was treated by endodontic retreatment and periapical
Reader
curettage. This paper supports the conjecture that radiographs
Correspondence Address being the commonest investigation used in general practice
G Pulla Reddy Dental College and Hospital fails to differentiate between periapical lesions.
Kurnool 518 002, Andhra Pradesh, India
|| Key Words
Periapical cyst, Periapical granuloma, Radiographs.

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|| Introduction
Periapical cyst, periapical granuloma and periapical
abscess are the three histopathological variants
of chronic apical periodontitis constituting 90%
of the apical lesions, out of which the incidence of
cysts varies between 6 and 55% and of granuloma
between 45 and 94%[1].Recently Schulz reported
clinical abscess or sinus discharge in the gingiva [Fig.-
1]. The tooth was tender on percussion and all the
vitality tests were negative. Radiographic examination
revealed an incomplete obturation of 21 with a large
unilocular radiotransparent periapical lesion [Fig-2].
The lesion was approximately 1.5 cm in diameter with

 

 

  
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periapical granuloma ranging between 9.3 and
87.1%, and of abscess between 28.7 and 70.07%[2].
Persistent apical periodontitis is a sequel of chronic
pulpal infection or may be due to endodontic failures
[3]
. Usually periapical granuloma is associated with the
apex of a non vital tooth comprising of granulation
 

extending from the root of lateral incisor to mid
palatine suture. The root was pushed towards distal
aspect producing mesiolabial rotation of the crown.
Aspiration of the lesion was done using a wide bore
needle yielding 0.5cc of straw coloured exudates.
Based on the investigation a provisional diagnosis
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 of periapical cyst in 21 causing pathological tooth
lymphocytes, plasma cells, mast cells, macrophages migration was given.
and, less commonly, histiocytes and gaint cells.[4,5]
Periapical cyst predominantly consists of macrophages,
lymphocytes, plasma cells and less frequently mast
cells and eosinophils. The presence of epithelium
and characteristic Rushton bodies substantiates the
diagnosis of a cyst.[6]
Treatment modality varies for both the lesions. Oral
surgeons indicate extraction of the offending tooth
followed by curettage of cyst and granuloma, while
endodontists believe in non surgical and conservative
treatment.[7,8] Hence, there is a need to have a Fig.1: Pre operative photograph showing mesiolabial rotation of 21

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There is clinical evidence that as the periapical lesions
increase in size, the proportion of the radicular cysts
increases. However, some large lesions have been
shown to be granulomas. [9,10] The present report
describes a large periapical granuloma without cystic
transformation mimicking a dental cyst because of its
size and tooth migrating ability.

|| Case Report
A 9 year old male child was referred from a local
practitioner to the Department of Paediatric dentistry
with pain and swelling associated with the upper front
tooth since one month. Parental history revealed that
the child had a traumatic experience one year back
leading to fracture of the anterior tooth which was
endodontically managed by the practitioner. Clinical
examination revealed the following features: Early
permanent dentition Stage, Ellis class 3 fracture
associated with left upper central incisor with mild
mesolabial rotation of the crown and without any Fig.2: Pre operative radiograph showing unilocular radiotransparent
lesion in relation to 21

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 Fig.3: Surgical flap and curettage

Fig.6: 10X photomicrograph showing multiple lymphocytes with

blood capillaries

Under local anaesthesia endodontic retreatment was

performed with a prior disinfection carried out for 3
days. Surgical intervention was planned after 3 days.
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accessed and all the contents of the cavity were curetted
out and sent for histopathological investigation [Fig.3].
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used to close the defect and healing was uneventful
[Fig.4,5].Histopathological evaluation revealed
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along with few blood capillaries. There was no evidence
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case was diagnosed as periapical granuloma causing
pathological tooth migration in 21.
Fig.4: Post operative radiograph after 3 months

|| Discussion
Radiographically a cyst is characterized by round,
sharp delineated sclerotic border larger than 10mm
diameter, whereas granuloma is diffuse with fuzzy
appearance without distinct shape and usually less
than 10mm in diameter [10]. Similarly Eversole stated
that a cyst can be anticipated when the lesion is
associated with a non-vital teeth with size greater than
200 mm2  <
  
area bound by a thin radiopaque line[11].This criteria
was contradicted by many studies done earlier[12]. The
present case report shows a radiographic evidence of
1.5 cm diameter with irregular outline and sclerotic
Fig.5: Post operative clinical photograph
border and lead to tooth migration mimicking a
dental cyst but it was proved to be granulomatous by
histological evaluation.

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 Many authors have tried to differentiate periapical || Conclusion
lesions based upon radiometric methods[13,14], As many decompression techniques are available in the
radioopaque outline[15,16], size and symmetry of literature to manage a cyst conservatively preliminary
the lesion[17,18] but they were unsuccessful. Recent diagnosis of a periapical lesion is imperative before
advances like tomography and ultrasound were  
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also not promising[12] @
 
 
 
 enigma in endodontic literature. The present report
histopathological diagnosis of a cyst is possible only
through serial sectioning or step-serial sectioning of
the lesions which are removed in toto [1].
Co-authors
Dr. Rajesh N. Dr. P. Jyotsna
Reader Private Practitioner
|| References
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th
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