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Endodontic Topics 2014, 30, 2328 2014 John Wiley & Sons A/S.
All rights reserved Published by John Wiley & Sons Ltd

ENDODONTIC TOPICS
1601-1538

The incidental discovery of apical


periodontitis
PAUL R. WESSELINK

The incidental detection of asymptomatic apical periodontitis raises the question of whether or not this lesion
should be treated. Arguments favoring treatment are that the inflammation may cause pain in the future, may
enlarge, or may negatively affect the hosts resistance. Reasons for not treating may be that treatment weakens the
tooth, may cause iatrogenic damage, and that treatment is expensive and burdensome for the patient and does not
lead to complete recovery in all cases. Scientific evidence supporting either choice, whether treating the lesion or
not, is lacking. Therefore, in making such decisions, the personal judgements of the patient and the dentist
concerning the impact on the quality of life of the patient play an important role.

Received 17 March 2014; accepted 23 March 2014.

Introduction influence might a possible treatment have on the


quality of life of the patient?
Once the incidental discovery of apical periodontitis
has been made and ascertained to be of endodontic
origin, it raises the question of whether the dentist
Case
should treat it immediately or if a wait-and-watch
attitude can be adopted whereby the lesion is only While taking a bitewing radiograph for a new patient,
treated if the condition worsens or if the patient suffers a 52-year-old male, the dentist unintentionally
pain or other symptoms. As more precise diagnostic captured the apex of tooth 25. This tooth showed a
methods come into common use, such as cone beam periapical radiolucency (Fig. 1). The tooth did not
computed tomography, more incidental discoveries react to sensitivity tests, had negative percussion and
are expected (1). palpation tests, and there were no deep periodontal
The European Guidelines recommend that dentists pockets. According to the patient, a coronal
should perform a root canal treatment if the pulp restoration was placed more than 15 years ago and
status of the tooth is necrotic and without any since then he had never experienced any pain in the
evidence of periapical radiolucency on the radiographs tooth itself or in the surrounding area.
(2). This is based on the aim of eliminating any Apparently the cause of the periapical radiolucency
infection or potential source of infection, such as a was apical periodontitis as a result of a necrotic,
necrotic pulp. The idea is that the patient will then infected pulp. The radiolucency indicated an infection
not be confronted with unexpected exacerbations of the pulp space (4). According to the patient, this
associated with apical periodontitis such as pain and situation had possibly existed for a long time without
occasional swelling or adverse systemic effects of local causing any problems. It is possible that this was a
infection and inflammation (3). The question is how balance between the bacterial load and the local
often do these exacerbations appear and how much immune response that had been in existence for years.
negative influence these relatively small inflammations It was therefore not clear if any change would soon
really cause to the patients general health. What occur.

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a b c

Fig. 1. (a) Bitewing radiograph, made for caries diagnosis, also shows the apical area of tooth 25, with a periapical
radiolucency present. (b) Periapical radiograph of tooth 25 showing the borders of the radiolucency. (c) Clinical
picture of tooth 25.

Considerations neighboring structures in the jaw and as well as the


neighboring teeth are affected. During surgical
A case of this nature raises the question of whether an intervention for the treatment of this lesion, other
incidental discovery of a pathological condition teeth or structures from the area could be damaged.
requires treatment or if it is better for the patient to The timely treatment of the lesion may prevent this.
monitor the development until there are clear How often a chronic periapical condition requires
symptoms of a disturbed balance or if it is clear that surgical intervention is unknown, but clinical
this pathological condition negatively affects the experience suggests that it is not frequent (Fig. 2).
general health of the patient. There are several reasons However, sometimes the inflammation can take on
to advise the patient to get the treatment done, but at dramatic forms (Fig. 3).
the same time there are also other reasons to advise the
patient not to undergo the treatment.
(iii) Any infection with accompanying
Reasons for treatment inflammation is a risk
(i) The inflammation can exacerbate In the case of long-existing, non-painful apical
(flare-up) periodontitis, there appears to be an equilibrium
between the bacterial attack and the local immune
Dentists are confronted with patients who develop
system of the patient. To what extent such
sudden pain caused by a periapical inflammation on a
inflammation threatens the health of the patient
regular basis. This can be inconvenient both for the
has never been established. Some studies suggest
patient and the dentist. That is why dentists often
that there is no relationship between periapical
prefer to treat immediately upon discovery of an
radiolucencies and the markers of the presence of
inflammation by coincidence. The question is how
systemic diseases, such as a large amount of C-reactive
great is the chance of this type of exacerbation (flare-
proteins and interleukins (5,6). There also appears to
up) occurring and if it indeed requires direct
be no clear causative correlation between periapical
treatment. There is no clear evidence about how often
inflammation and systemic disorders such as
a chronic inflammation will flare up and cause
atherosclerosis, chronic heart disease, and diabetes
symptoms. Therefore, the opinion of the dentist is
mellitus (2). However, in a recent review it was
purely based on experience and assumptions.
concluded that the available evidence is limited but
consistent, suggesting apical periodontitis is associated
(ii) The inflammation could grow
with increased levels of systemic inflammation in
If a dentist decides to leave a lesion untreated with the humans. Unfortunately the presented data of this
patients agreement, it could grow so large that the meta-analysis did not allow for conclusions regarding

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The incidental discovery of apical periodontitis

Fig. 2. Periapical radiolucency at tooth 35 seen in 2011 and 2014 showing a stable situation.

a b c

Fig. 3. (a) Periapical radiograph of tooth 21 showing a large radiolucency. (b) CBCT scan showing the borders of the
lesion. (c) 3D reconstruction of the lesion, after a CBCT scan.

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the effectiveness of endodontic treatment in reducing indeed a substantial reduction in the number of
serum levels of the different biomarkers of microorganisms. As a result, the bacterial burden on
inflammation (7). the body is very much reduced. What this actually
Nevertheless, such a connection cannot be means for the health and well-being of a patient and
completely ruled out because in all investigations the what the gain of the treatment for the patient is
diagnosis of apical periodontitis was made on the basis remains unknown.
of conventional periapical radiographs. These are
known to leave a substantial number of lesions
(ii) The treatment is burdensome, costs money,
undetected (1,8). Thus it cannot be ruled out that the
and can cause postoperative pain
patients who are listed in these studies as without
lesions actually have small periapical inflammations. Patients are very often opposed to root canal
The studies therefore fail to demonstrate such a treatment even though, in retrospect, it usually
correlation. appears not to have been a very bad experience (14).
Despite the lack of evidence, there is great concern Moreover, treatment costs time and money, which the
among biological medicine and dentistry about the patient might prefer to spend in other ways. Finally, it
impact that such an inflammation might have on the is a well-known clinical experience that occasionally
patients general health. There are cases that suggest a pain develops after starting treatment on an
relationship between this kind of inflammation and asymptomatic tooth.
general health but clear data are lacking (9).
There appears to be a link between severe untreated (iii) The treatment weakens the tooth
marginal periodontitis, systemic diseases, and an
increased number of inflammatory markers in the When a root canal treatment is performed, the roof of
bloodstream. However, that does not mean that a the pulp chamber is removed, making the connection
single periapical lesion has a similar effect (10). between the vestibular and lingual/palatal portion of
Nonetheless, it cannot be ruled out that, for an the tooth disappear. Occasionally iatrogenic damage
accumulation of inflammation in the mouth, e.g. may lead to a significant weakening of the tooth. This
generalized gingivitis, periodontitis, and pericoronitis, weakening can be, to a large extent, recovered by
apical periodontitis may actually be the last drop that placing a good, simple restoration. Sometimes this
makes the balance incline and therefore will have an actually requires an expensive and complicated
effect, especially in individuals under 50 years of age restoration e.g. a crown, with or without the use of a
(11). Alternatively, it can be argued that in that case, post and core (3).
the apical periodontitis is just a drop in the ocean and Instrumentation of the root canal, through removal
therefore does not play a significant role compared to of tooth structure, also leads to weakening of the root,
the other, much more burdensome, inflammatory although not to a large extent. Sometimes iatrogenic
processes elsewhere in the mouth or the body. accidents, such as a root perforation or the fracture of
an instrument, can occur. Moreover, recently it has
Reasons against treatment been shown in in vitro studies that the use of root
canal instruments and the application of root canal
(i) The inflammation has been present for a obturation using certain techniques (such as cold
long time and caused no problems lateral and warm vertical compaction of gutta-percha)
If an inflammation is present for many years, the lesion can lead to cracks in the root (15,16). The significance
is not large, and everything indicates that there is a of this is not yet understood but endodontically
balance between attack and defense, the treatment treated teeth sometimes present vertical root fractures
likely will not be of much benefit. Research has shown that require extraction (4).
that even after treatment, we cannot entirely eliminate
the bacterial infection. Modern radiographic
Concluding remarks
techniques, such as cone beam computed tomography,
have demonstrated that not all of the lesions will It is difficult to see clearly what the health benefits of
completely disappear (12,13). After treatment, there is a treatment are. The dentist and/or the patient will

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The incidental discovery of apical periodontitis

place more emphasis on certain arguments and less on Ultimately, the patient is in charge of his or her
others, so the decisions are totally different from one own mouth. It is clear that the above-mentioned
case to the next. On the basis of unbiased and honest considerations for performing the treatment lack a
information by the dentist, the patient has to make the strong scientific basis and the considerations not to
decision, based on the best information that best perform the treatment have limited foundations. The
serves his or her own health perception and wellbeing. choice will always remain arbitrary. The effects of each

Fig. 4. (a) A radiograph taken during the instrumentation of the root canal treatment of tooth 25. (b) Radiograph of
the root canal filling. (c) Three years postoperatively, the lesion has decreased in size. Courtesy of Dr. Andreas Braun.

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of the two possible decisions are as yet unknown and 5. Buttke TM, Shipper G, Delano EO, Trope M.
could be interesting topics to be studied. The famous C-reactive protein and serum amyloid A in a canine
model of chronic apical periodontitis. J Endod 2005:
Dutch Professor Backer Dirks once rightly pointed out
31: 728732.
that every treatment is in itself an experiment. 6. Frisk F, Hakeberg M, Ahlqwist M, Bengtsson C.
Endodontic variables and coronary heart disease. Acta
Odontol Scand 2003: 61: 257262.
Epilogue 7. Gomes MS, Blattner TC, SantAna Filho M, Grecca FS,
Hugo FN, Fouad AF, Reynolds MA. Can apical
The 52-year-old man in this case finally decided to let periodontitis modify systemic levels of inflammatory
his tooth be treated by an endodontist. The tooth had markers? A systematic review and meta-analysis. J Endod
2013: 39: 12051217.
a deep apical split in which the foramen patency was of 8. Petersson A, Axelsson S, Davidson T, Frisk F, Hakeberg
a size that a number 45 file could pass through it. Due M, Kvist T, Norlund A, Mejre I, Portenier I, Sandberg
to this open foramen, the apical part of the canal was H, Tranaeus S, Bergenholtz G. Radiological diagnosis
filled with MTA. Coronally to this it was filled with of periapical bone tissue lesions in endodontics: a
systematic review. Int Endod J 2012: 45: 783801.
gutta-percha and AH-26 was used as a sealer (Fig. 4).
9. Murray CA, Saunders WP. Root canal treatment and
The root canal entrance was covered with a resin and general health: a review of the literature. Int Endod J
the tooth was restored with a cusp-coverage composite 2000: 33: 118.
restoration. Three years later the radiolucency had 10. Paraskevas S, Huizinga JD, Loos BG. A systematic
review and meta-analyses on C-reactive protein in
decreased in size but not yet completely resolved.
relation to periodontitis. J Clin Periodontol 2008: 35:
277290.
11. Mattila KJ, Asikainen S, Wolf J, Jousimies-Somer H,
Acknowledgement Valtonen V, Nieminen M. Age, dental infections, and
coronary heart disease. J Dent Res 2000: 79: 756760.
Part of this article has been published in Dutch in the Ned 12. Wu MK, Shemesh H, Wesselink PR. Limitations of
Tijdschr Tandheelkd 2011: 118: 205208. previously published systematic reviews evaluating the
outcome. Int Endod J 2009: 42: 656666.
13. Patel S, Wilson R, Dawood A, Foschi F, Mannocci F.
The detection of periapical pathosis using digital
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