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J Conserv Dent. 2010 Oct-Dec; 13(4): 240245.

PMCID: PMC3010029
doi: 10.4103/0972-0707.73384

Nonsurgical management of periapical lesions


Marina Fernandes and Ida de Ataide
Department of Conservative Dentistry and Endodontics, Goa Dental College and Hospital, Bambolim, Goa - 403 601, India
Address for correspondence: Dr. Marina Fernandes, Department of Conservative Dentistry and Endodontics, Goa Dental College and
Hospital, Bambolim, Goa - 403 601, India. E-mail: doc_marina@yahoo.co.in

Received 2010 Sep 11; Revised 2010 Sep 30; Accepted 2010 Oct 5.

Copyright Journal of Conservative Dentistry

This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract
Periapical lesions develop as sequelae to pulp disease. They often occur without any episode of acute pain
and are discovered on routine radiographic examination. The incidence of cysts within periapical lesions
varies between 6 and 55%. The occurrence of periapical granulomas ranges between 9.3 and 87.1%, and of
abscesses between 28.7 and 70.07%. It is accepted that all inflammatory periapical lesions should be
initially treated with conservative nonsurgical procedures. Studies have reported a success rate of up to
85% after endodontic treatment of teeth with periapical lesions. A review of literature was performed by
using electronic and hand searching methods for the nonsurgical management of periapical lesions.
Various methods can be used in the nonsurgical management of periapical lesions: the conservative root
canal treatment, decompression technique, active nonsurgical decompression technique, aspiration-
irrigation technique, method using calcium 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 either
during 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 within periapical lesions varies between 6 and 55%.[5] The occurrence of periapical granulomas
ranges between 9.3 and 87.1%, and of abscesses between 28.7 and 70.07%.[6] 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.[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) The periapical lesion is involved with one or more non-vital teeth, (b) the
lesion is greater than 200 mm2 in size, (c) the lesion is seen radiographically as a circumscribed, well-
defined radiolucent area bound by a thin radiopaque line, and (d) it produces a straw-colored fluid upon
aspiration or as drainage through an accessed root canal system.[8]
The ultimate goal of endodontic therapy should be to return the involved teeth to a state of health and
function without surgical intervention.[9] All inflammatory periapical lesions should be initially treated
with conservative nonsurgical procedures.[10] Surgical intervention is recommended only after
nonsurgical techniques have failed.[11] Besides, surgery has many drawbacks, which limit its use in the
management of periapical lesions.[12,13] Various studies have reported a success rate of up to 85% after
endodontic treatment of teeth with periapical lesions.[1416] A high percentage of 94.4% of complete and
partial healing of periapical lesions following nonsurgical endodontic therapy has also been reported.[17]

Search methodology
An electronic search was conducted in the PubMed database with appropriate MeSH headings and key
words related to the nonsurgical management of periapical lesions. A hand search of journals was also
conducted to enhance the electronic search results.

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

Diagnosis of the lesion Many bone destroying lesions closely resemble endodontically related periapical
lesions on radiographs. Some of these nonendodontic lesions include ameloblastoma, central fibroma,
giant cell lesions, fibrous dysplasia, central hemangioma, primary malignancies, metastatic neoplasms, and
inflammatory bone diseases. Teeth related to nonendodontic periapical lesions generally test vital to pulp
testing methods. It is essential that the clinician establishes the correct diagnosis to avoid unnecessary
treatment of vital healthy teeth.[19,20]

Proximity of the periapical lesion to adjacent vital teeth 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 the adjacent teeth, thereby compromising their vitality.[12,13]

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

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

Age of the patient Very old patients may not tolerate surgical procedures well and hence may require
nonsurgical treatment modalities.[19]

Obstructions in the root canal system 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]

Time involved for treatment 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 the patient will be lost to follow-up before complete healing.[11]

Cases refractory to nonsurgical management methods Inflammatory apical true cysts and the presence
of cholesterol 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 a
periapical lesion is evident on a radiograph. This may cause transitory inflammation and ulceration of the
epithelial lining resulting in resolution of the cyst.[24] Bender in his commentary on Bhaskars hypothesis
has added that penetration of the apical area to the center of the radiolucency establishes drainage and
relieves pressure. 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 the macrophages.[25] Although this proves to be an effective method Shah suggests the
possibility that quiescent epithelial 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 of large cysts like well-defined radiolucencies following conservative root
canal treatment has been reported. Although the cystic fluid contains cholesterol crystals, weekly
debridement and drying of the canals over a period of two to three weeks, followed by obturation has led
to a complete resolution of lesions by 12 to 15 months.[26]

Decompression technique
The decompression technique involves placement of a drain into the lesion, regular irrigation, periodic
length adjustment, and maintenance of the drain, for various periods of time.[27] The drain could either be
I shaped 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 the length 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 by the patient through the lumen of the drain using 0.12% chlorhexidine.[33,34] The
advantages of this technique are; it is a simple procedure, it minimizes the risk of damaging adjacent vital
structures, and is easily tolerated by the patient.[27] However, several disadvantages have also been noted;
patient compliance is very essential, inflammation of the alveolar mucosa, persistence of the surgical
defect at site, development of 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 buccal mucosa 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 connected to a micro 22-gauge needle, which is inserted in the root canal and activated for 20 minutes,
creating a negative pressure, which results in aspiration of the exudate. When the drainage partially stops,
the access cavity is closed with temporary cement, which helps in maintaining bacterial control. Unlike the
decompression 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 and aspirate the cystic fluid. A second syringe filled with saline is then used to rinse the bony
lesion. The new needle is inserted through the buccal wound and passed out through the palatal tissue
creating a pathway for the escape of the irrigant.[18] Accumulation of cystic fluid within a confined bony
cavity leads to increased hydrostatic pressure, which causes additional osteoclastic activity and growth of
the cyst.[37,38] Aspiration leads 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, which could 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]

Aspiration through the root canal technique To overcome the disadvantage of the traditional aspiration
irrigation technique, a simple technique of aspiration through the root canal has been described. In this
technique, aspiration of the cystic fluid is done through the root canal by passing the aspirating needle
through the apical foramen. This technique eliminates the creation of buccal and palatal wounds, as in the
traditional 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 aspirating
needle 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 the
aspirating 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
techniques where 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


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 calcium hydroxide, when used for endodontic treatment of teeth with periapical lesions. It has been
suggested that the presence of a cyst may impede or prevent root-end closure of an immature pulpless
tooth even with the use of calcium 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 endodontic treatment with calcium hydroxide paste and a calcium hydroxide
containing, root-canal sealer.[35] Extrusion of calcium hydroxide beyond the apex was suggested as a
factor for the lack of early healing of periapical lesions.[50] However, many investigators advocate that
direct contact between calcium hydroxide and the periapical tissues is beneficial for the inductive action of
the material.[46,51] A high degree of success has 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 not readily resorbed when the paste extrudes beyond the apex.
However, it has been reported that even though complete resorption of the paste does not occur in some
cases, the periapical radiolucency around the paste resolves.[15]

Some studies have reported that long-term exposure of root dentin to intracanal calcium hydroxide leads to
a decrease 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.,
for apexification of an immature tooth associated with a large periapical lesion. Calcium hydroxide is used
as an antibacterial 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 of
Lesion 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, and
periradicular 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
added to the mix.[60] The combination of drugs has been shown to penetrate efficiently through dentine
from the prepared root canals especially from the ultrasonically irrigated root canals.[55] The
commercially available drugs are powdered and mixed in a ratio of 1:3:3 (3 Mix) and mixed either with
macrogol-propylene glycol (3 Mix-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 discoloration induced by minocycline. Cefaclor and fosfomycin are
proposed as possible alternatives for minocycline, in terms of their antibiotic effectiveness, but further
clinical studies are needed to demonstrate their efficacy in the root canal.[63]

Apexum procedure
Surgically treated periapical lesions show enhanced healing kinetics compared with those treated
nonsurgically.[22] Surgical removal of the periapical, chronically inflamed tissue allows a fresh blood clot
to form, thereby converting a chronic inflammatory lesion into a new granulation tissue, where healing
might proceed much faster.[64,65] The Apexum procedure uses two sequential rotary devices, the Apexum
NiTi Ablator and Apexum PGA Ablator (Apexum Ltd, Or Yehuda, Israel), designed to extend beyond the
apex and mince 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 in the conventional root canal treatment group (39%) at six months, with significantly
less postoperative discomfort or pain. However, whether the procedure was able to remove all the
periapical inflammatory tissue was beyond the scope of the study conducted. Further studies regarding this
procedure are in progress.[22]

Materials under research


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

Epigallocatechin-3-gallate 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 by diminishing Cyr61 expression in osteoblasts and, subsequently, macrophage chemotaxis into
the lesions.[68]

Assessment of healing of periapical lesions Repair of periradicular tissues consists of a complex


regeneration involving bone, periodontal ligament, and cementum.[69] The area of mineral loss gradually
fills with bone and the radiographic density increases.[70] If the cortical plate is perforated, healing begins
with the regeneration 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 vascular network 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 anterior segments.[17]

Although clinical as well as radiographic data are used to monitor cases, the relative absence of clinical
symptoms in chronic apical periodontitis makes the assessment primarily a radiographic one. Various
methods 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 in radiographic appearance. The criteria for success are that: (a) the contours, width, and
structure of the periodontal 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
periradicular rarefaction; (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 system is strictly dichotomous, that is, there is no middle ground between success and
failure.[70] The area measurement assessment method can be used to monitor the healing of periapical
lesions. The rate of repair can be calculated by dividing the size differential between the initial and follow-
up visits by the number of elapsed months. On the basis of the average healing rate of approximately 3
mm2/mo, a 30 mm2 lesion will require 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, the measurement 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 ranging from healthy to severe periodontitis with exacerbating
features.[72] Of late, an ultrasound with color power Doppler 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. The radiograph usually shows a trabecular bone pattern radiating from the center that appears as
a reduced, but incompletely resolved radiolucency.[74]

Various authors have stressed on the importance of a long observation time for treated teeth with periapical
lesions.[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, and
two years, to assess the healing of periapical lesions. There is always the possibility that quiescent
epithelial cells may be stimulated by instrumentation in the apical region, with resultant proliferation and
cyst formation.[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 approach
should always be adopted before resorting to surgery. The decompression and aspirationirrigation
techniques can be used when there is drainage of cystic fluid from the canals. These techniques act by
decreasing the hydrostatic pressure within the periapical lesions. When there is no drainage of fluid from
the canals, calcium hydroxide or the triple antibiotic paste can prove beneficial. Periodic follow-up
examinations are essential and various assessment tools can be used to monitor the healing of periapical
lesions. The surgical approach can be adopted for cases refractory to nonsurgical treatment, in obstructed
or nonnegotiable 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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