Ultrasound real-time imaging in the differential
diagnosis of periapical lesions
E. Cotti1, G. Campisi2, R. Ambu3 & C. Dettori1
1
School of Dentistry, Department of Conservative Dentistry and Endodontics, University of Cagliari, 2Department of Radiology,
Hospital `G. Brotzu' Cagliari and 3Department of Pathologic Anatomy, School of Medicine, University of Cagliari, Cagliari, Italy
Abstract
Cotti E, Campisi G, Ambu R, Dettori C. Ultrasound real-
time imaging in the differential diagnosis of periapical lesions. Interna-
tional Endodontic Journal, 36, 556^563, 2003.
Aim To assess whether the use of real-time ultrasound
imaging (echography), together with the application of
`Colour Power Doppler', can help the di¡erential diagno-
sis of periapical lesions based on their contents.
Methodology Eleven patients diagnosed with peria-
pical lesions using conventional clinical and radio-
graphic ¢ndings and who had been scheduled for
endodontic surgery were examined using ultrasound
imaging and Colour Power Doppler at the site of the
lesions. Lesions were described in each case byan expert
echographist, together with an endodontist, according
to a scheme described previously. Information on the size
of each lesion, its content and its vascular supply was
gained and recorded by means of the ultrasound images;
then, a tentative di¡erential diagnosis between a cyst
Introduction
Imaging techniques are essential in endodontics, espe-
cially for the study of periapical lesions, and it is impor-
tant that new and more promising techniques are
constantly being evaluated (Òrstavik & Pitt-Ford 1998).
Conventional radiographic procedures have limita-
tions in that they do not reliably demonstrate the pre-
sence and size of the lesions in bone (Bender & Seltzer
1961, van der Stelt 1985). Also, they do not allow the dif-
ferential diagnosis between cystic and noncystic lesions
Correspondence: Elisabetta Cotti, via Roma149, Cagliari 09124,
Italy (Tel.: ‡39 070 662710; fax: ‡39 070 659689; e-mail:
cottiend@tin.it).
556 International Endodontic Journal, 36, 556^563, 2003
and a granuloma was made. The lesions obtained during
endodontic surgery were processed and examined with
a light microscope. The results from the biopsies were
compared with the descriptions made with the ultra-
sound images.
Results The di¡erential diagnoses between periapical
granulomas and cystic lesions, which were based on
the echograpic ¢ndings, were con¢rmed by the results
of the histopathologic examination in all the 11 cases:
four being granulomas and seven being cystic lesions.
Conclusions Ultrasound real-time imaging is a tech-
nique that may help make a di¡erential diagnosis
between cysts and granulomas by revealing the nature
of the content of a bony lesion. This technique may have
further applications in the study of other lesions of the
jaws.
Keywords: echography, endodontic diagnosis, peria-
pical lesions.
Received 3 May 2002; accepted10 April 2003
(Priebe et al. 1954). The possibility of distinguishing
between a true cyst and a granuloma may be of help in
predicting treatment outcome (Nair 1998). Direct digital
radiography is not better than conventional radiography
in the detection and measurement of periapical lesions
(Scarfe et al. 1999). Computerized tomography (CT) has
been suggested as a noninvasive method that could be
used to make a di¡erential diagnosis between a cyst
and a granuloma (Trope et al.1989) and to manage exten-
sive lesions (Cotti et al. 1999), but routine use of CT is
associated with high radiation risks (Dula et al. 1996).
Real-time ultrasound imaging (echography) is widely
used in medicine: it is based on the phenomenon of the
re£ection of ultrasound (US) waves (echoes) at the inter-
faces betweentissues that have di¡erent acoustic proper-
ties.
ß 2003 Blackwell Publishing Ltd
 Cotti et al. Echography in endodontics

`Hypoechoic' or `transonic' is a given area with low
echo intensity; `anechoic' is an area where there is no
re£ection of echoes (i.e. any area ¢lled with £uids) and
`hyperechoic' is an area that shows high echo intensity.
Bone exhibits total re£ection (hyperechoic/echogenic),
and this is the reason why US imaging can only be per-
formed through bone windows/lesions. Areas that con-
tain di¡erent types of tissues show a `dishomogeneous
echo' (Auer & VanVelthoven 1990).
The application of Colour Power Doppler ultrasound
to the echography o¡ers an opportunity to evaluate
and determine the presence, direction and velocity of
blood £ow within the ultrasound image of the examined
tissue. Colour Power Doppler gives a colour-coded repre-
sentation of the Doppler signal and its time modi¢cation
(Fleischer & Emerson 1993).
The use of real-time ultrasound examination for the
evaluation of bone lesions of endodontic origin has been
assessed recently and reported (Cotti et al. 2002). The
purpose of this study was to evaluate whether it is possi-
ble to make a di¡erential diagnosis between periapical
lesions with di¡erent histopathologic features based on
echographic study.
Materials and methods
Echographic examination
Echographic examinations of periapical lesions were
completed using an Elegra Siemens apparatus with a
regular-size, linear, high-de¢nition, multifrequency
ultrasound probe (Siemens, Erlangen, Germany) at a fre-
quency of 7^9 MHz. The examinations were performed
by an expert echographist along with an endodontist.
Eleven Caucasian patients, aged between 25 and
50 years, were selected for the study. The patients had
been diagnosed with a periradicular lesion of endodontic
origin based on clinical signs and symptoms (Trope
et al. 1998) and both intraoral and panoramic radio-
graphic ¢ndings. The patients were scheduled to be trea-
ted in the Department of Conservative Dentistry and
Endodontics at the University Clinic in Cagliari, and
the treatment plan included endodontic surgery with
apicoectomy, retrograde ¢lling and biopsy for each case.
Patients who agreed to take part in the study were asked
to sign an informed consent form before undergoing
the echographic examination. The area of diagnostic
interest in the mouth was selected for the echography.
The ultrasonic probe, covered with an insulating latex
glove ¢nger, was positioned on the buccal sulcus of the
maxillary bones corresponding to the apical area of the
tooth of interest inside the mouth. Subsequently, it was
placed outside the mouth in the corresponding external
area. The tissues to be examined were covered with a
layer of echographic gel (Aquagel, HP, Palo Alto, CA,
USA). The probe was put in contact with the tissue and
then moved slightly in order to obtain an adequate num-
ber of transversal scans (approximately four) to de¢ne
the bony defect. Colour Power Doppler was applied to
each examination.
For each lesion, a representative echographic image
was selected; it was saved in a magneto-optical disk
(Eastman Kodak, Rochester, NY, USA) and analysed by
an expert echographist together with an endodontist.
A report was described in a chart (Cotti et al. 2002),
and a tentative di¡erential diagnosis between a cystic
lesion and a granuloma was agreed based on the follow-
ing principles:
 Cystic lesion: a transonic (hypoechoic) well-contoured
cavity, surrounded by reinforced bone walls, ¢lled
with £uids and with no evidence of internal vascular-
ization on Colour Power Doppler examination.

Table 1 Classi¢cation of data relative to

PT. AGE SEX TOOTH DIAG. CL ‡ RX DIAG. ECHO DIAG. HISTO
periapical lesions, clinical, radiographic,
ecographic and histopathologic 1 67 M 33 PAL PAC PAC
diagnosis 2 46 F 33 PAL PAC PAC
3 39 M 12 PAL PAC PAC
4 28 F 15 PAL PAC PAC
5 57 M 11 PAL PAC PAC
6 35 M 44 PAL PAC ‡ PAG PAC ‡ PAG
7 52 F 41^31 PAL PAC PAC
8 64 F 21 PAL PAG PAG
9 32 F 26 PAL PAG PAG
10 39 M 21 PAL PAG PAG
11 37 F 21^22 PAL PAG PAG

PT. ˆ Patient; DIAG. CL ‡ RX ˆ diagnosis: clinical and radiographic; DIAG. ECHO ˆ diagnosis:
ecographic; DIAG. HISTO ˆ diagnosis: histopathologic; PAL ˆ periapical lesion; PAC ˆ periapical
cyst; PAG ˆ periapical granuloma.

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 Echography in endodontics Cotti et al.

Figure 1 (a) Panoramic radiograph showing a lesion involving the periradicular area of the tooth 33 (arrowed). (b) Echotomogram
(ultrasound image) showing a`transonic lesion' (arrowed) with well-de¢ned and reinforced contours (the dotted line indicates the
major diameter of the lesion). (c) The microphotograph of one of the sections of the lesion shows a cystic cavity lined by epithelium
(arrowed) (H&E 2). (d) Microphotograph of a detail from the previous lesion showing the strati¢ed squamous epithelium
(arrowed) (H&E 40).

558 International Endodontic Journal, 36, 556^563, 2003 ß 2003 Blackwell Publishing Ltd
 Cotti et al. Echography in endodontics

Figure 2 (a) Panoramic radiograph showing a lesion (arrowed) in the periapical area corresponding to the teeth 42, 41and 31. (b)
Echotomogram of the same lesion showing a well-contoured transonic lesion (short arrow), containing scattered echogenic
particles (long arrow). (c) The histomorphology of this periapical lesion shows a strati¢ed squamous cyst lining with several goblet
cells (arrow) (H&E 40).

ß 2003 Blackwell Publishing Ltd International Endodontic Journal, 36, 556^563, 2003 559
 Echography in endodontics Cotti et al.
 Granuloma: a poorly de¢ned lesion, which could be
frankly corpusculated (hyperechoic/echogenic) or
could show both corpusculated and hypoechoic
areas, exhibiting a rich vascular supply on Colour
Power Doppler examination.
Surgical endodontics
In all the11clinical cases, surgical endodontics was per-
formed according to Arens et al. (1998). The lesions col-
lected were stored in 10% bu¡ered formalin and sent
for histopathologic examination.
Histopathologic examination
After ¢xation in 10% bu¡ered formalin, the surgical
specimens were routinely processed for histology
by an automated histoprocessor (Ventana Medical
Systems, AZ, USA), dehydrated through a graded
series of ethanol and in¢ltrated by para¤n. The
specimens were then embedded by an embedding
centre (Especialidades Medicas, Cunit, Tarragona,
Spain) and semiserially sectioned with a microtome
(model Top Rotary S-130, Pabish, Milano, Italy). Sections
were then mounted on glass slides, which were
stored at 36 8C for 1 h and passed through a descend-
ing concentration of alcohol in order to have the
para¤n removed. The sections were subsequently
stained with haematoxylin and eosin, covered with a
coverslip by a synthetic mounting glue (BioMount,
Byo-Optica, Milano, Italy) and observed on a light
transmission microscope (Axioskop, Zeiss, Gottingen,
Germany).
Immunohistochemistry was carried out for one of
the specimens: slides that had been pretreated with
polylysin were used; the sections were processed to test
for human polyclonal cytokeratins (Biogenex, San
Ramon, CA, USA) using a dilution of1 : 50.The immunor-
eactions were enhanced by means of the streptavidin-
biotin-peroxidase technique with a rabbit antihuman
antibody followed by a counterstaining with Mayer's
haematoxylin.
The evaluation of the histological sections was com-
pleted in a blind manner.
Figure 3 (a) Panoramic radiograph showing a lesion (arrowed) in the periapical area of the tooth12. Tooth12 was diagnosed with
vertical crown-root fracture and was extracted during the surgery. (b) Echotomogram of the same lesion (in the square) that
presents a round lesion (black arrow in the upper and lower contours), with an echogenic and mixed content (white arrow) and
vascular supply (blue spots; the yellow and red spots are the result of a twinkling artefact of the Colour Doppler). (c) The
histopathologic picture of this lesion is characterized by a highly vascular, oedematous connective tissue with abundant mixed
in£ammatory cells in¢ltrate (H&E 25).
560 International Endodontic Journal, 36, 556^563, 2003
Results
The results are summarized in Table 1.
Echographic examination
Images of the periradicular lesions were obtained easily
and identi¢ed in all the cases using both the intraoral
and extraoral procedures.
The echographic study showed the presence of seven
lesions, ¢ve of which (from 1 to 5) were frankly hypoe-
choic with well-de¢ned contours and which with Colour
Power Doppler did not show evidence of internal vascu-
larization. These cases were diagnosed as periapical
lesions with cystic appearance (Fig. 1a,b).
Of the remaining two lesions, one (lesion 6) exhibited a
round shape, with interruption of the bone pro¢le and
an echostructure that was described as `mixed' because
it showed a content that was both hypoechoic (inthe cen-
tre and toward the mesial side of the associated root)
and hyperechoic (in the surrounding areas).With Colour
Power Doppler, a rich vascularization was observed on
the external area of the lesion. This lesion was diagnosed
as a periapical granuloma with a £uid-¢lled cavity
inside. The 7th lesion showed a regular oval shape, with
well-de¢ned contours, reinforced bone walls and no evi-
dence of vascularization at the Colour Power Doppler.
The content within this lesion was mostly hypoechoic,
but, unlike the others of the same kind, it showed small,
scattered echoes as if it was a £uid with dense particles.
This lesion was diagnosed as a periapical lesion with cys-
tic appearance and a prominent secretory content
(Fig. 2a,b).
The remaining four lesions exhibited a rounded shape
only partially de¢ned. In two of the cases, an interrup-
tion of the bone pro¢le was observed on the right side;
the echostructure of these lesions showed a content that
was both hypoechoic and hyperechoic. The content of
the other two lesions was frankly echogenic (hypere-
choic). On Colour Power Doppler examination, all these
four lesions showed a vascularization that varied from
rich to scattered.
All of these were classi¢ed as periapical granulomas
(Fig. 3a,b).
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 Cotti et al. Echography in endodontics

ß 2003 Blackwell Publishing Ltd International Endodontic Journal, 36, 556^563, 2003 561
 Echography in endodontics Cotti et al.
Histopathologic report
The results from the histopathologic examination con-
¢rmed the echographic observations: the lesions from 1
to 5 were diagnosed as cystic lesions and showed the pre-
sence of a cavity lined with strati¢ed squamous epithe-
lium. Within the lumen of the cavity, necrotic debris
and numerous impressions from cholesterin crystals
were seen (Fig. 1c,d).
The histopathologic examination of lesion 6 showed a
widespread granulomatous tissue containing an area
of strati¢ed squamous epithelium that lined a lumen.
The immunohistochemical staining for cytokeratins
applied to this case con¢rmed the previous observations
on the epithelial lining.
The examination of lesion 7 showed a cavity with a
lumen lined by a squamous epithelium presenting areas
of cylindrical ciliated cells and several goblet cells
(Fig. 2c).
The histopathologic reports on lesions 8^11 consis-
tently described a typical granulomatous appearance:
connective tissue with widespread areas of PMNs, lym-
phocytes, monocytes and newly formed blood vessels
(Fig. 3c).
Discussion
The results from preliminary investigations sugges-
ted that ultrasound real-time imaging was an easy
and reproducible examination that could become a
useful adjunct to conventional radiography in the
management of extensive periapical lesions, as it
provides speci¢c information on the size of the lesion
(Cotti et al. 2002), it has few risks and the images are
obtained in digital form that are easy to read, store and
reproduce.
From a biological standpoint, in experimental and
clinical studies, no adverse e¡ects of ultrasound waves
have been shown to occur in the tissues as a conse-
quence of echographic examination (Baker & Dalrymple
1978, Fleischer & Emerson 1993), and even if the e¡ect
of repeated ecographic examinations is less certain,
the risks entailed by radiography are much greater
(Liebeskind et al. 1981, Martin 1984).
In the present study, the potential of ultrasound ima-
ging to describe the di¡erent content of periapical lesions
and their vascularization was evaluated. The results
obtained on 11 lesions showed that there was a de¢nite
correlation between the echostructure of a lesion, its
vascular supplyand the nature of the lesion: cystic lesion
versus granuloma (Nair 1998).
562 International Endodontic Journal, 36, 556^563, 2003
All six cases in which the ultrasound images showed a
well-contoured area with a transonic content and where
the Colour Power Doppler did not show the presence of
vascularization were described as epithelial lined cav-
ities following histopathologic observations. The four
cases in which the ultrasound images displayed lesions
in which contours were not regular with an echogenic
or mixed content and a widespread blood £ow were
described as periapical granulomas from a histological
standpoint. Two cases demonstrated the sensitivity of
this diagnostic technique. In lesion 6, the ultrasound
examination with Colour Power Doppler displayed all
possible elements: echogenic content, rich vascular sup-
ply and a transonic area. The tentative diagnosis of a
mixed cystic and granulomatous lesion was supported
by the histopathologic report that showed an extensive
granulomatous lesion containing a smallercavity, which
was completely lined by epithelium. The lesion in case
7 exhibited a well-contoured shape, and its content
appeared to be hypoechoic as if ¢lled with a £uid that
had some small particles inside. During the surgical exci-
sion of this lesion, there was a dense, yellowish secretion.
The histomorphology of this periapical lesion showed a
cavity lined by a secretory epithelium, which was an
unusual occurrence.
Conclusions
Based on the results of this and previous work (Cotti et al.
2002), real-time ultrasound imaging can be considered
a new imaging technique that can be used in the
endodontic ¢eld for the study of periapical lesions.With
real-time ultrasound observation, it is also possible to
determine the histopathologic nature of the lesion: cystic
versus granulomatous by examining its shape and its
echo content, and by applying Colour Power Doppler to
provide evidence of its vascularization. Future research
in the multiple di¡erential diagnoses of bone lesions of
the jaws is suggested.
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