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ORIGINAL ARTICLE
Year : 2020  |  Volume : 9  |  Issue : 1  |  Page : 235-238  

Clinical, radiographic, and histological findings of chronic inflammatory periapical lesions – A clinical study


1 Department of Conservative Dentistry, AL Rass Dental College, Qassim University, Kingdom of Saudi Arabia
2 Department of Conservative Dentistry and Endodontics, Malla Reddy Institute of Dental Sciences, Suraram, Hyderabad, Telengana, India
3 Department of Conservative Dentistry and Endodontics, Awadh Dental College and Hospital, Jamshedpur, Westbengal, India
4 Department of Prosthodontics, College of Dental Scinecs and Hospital, Rau, Indore, MP, India

Date of Submission29-Aug-2019
Date of Decision18-Nov-2019
Date of Acceptance21-Nov-2019
Date of Web Publication28-Jan-2020

Correspondence Address:
Dr. Shilpa Jain
Department of Prosthodontics, College of Dental Sciences and Hospital, Rau, Indore, MP
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jfmpc.jfmpc_715_19

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  Abstract 


Aim: The present study aimed at comparing clinical, radiographical, and histological findings in chronic periapical lesions such as cysts, granuloma, and abscess. Methodology: The present study was conducted on 148 teeth having chronic inflammatory periapical lesions with or without nonsurgical endodontic treatment. Endodontic surgery was performed by single trained endodontist. After surgical endodontic treatment, biopsy sections of teeth were assessed histologically. All slides stained with hematoxylin/eosin and Gomori trichrome for light microscopy assessment. Results: Out of 148 teeth, 41 had chronic inflammatory lesions, 34 had inflammatory cysts, and 25 had indefinite lesions. Chronic inflammatory lesions assessed histologically found chronic apical periodontitis in 86 cases and inflammatory cysts in 62 cases. The difference was significant (P < 0.05). Out of 86 cases of chronic apical periodontitis confirmed clinical radiographically, 64% found positive, whereas 36% were not histologically. Out of 62 cases of inflammatory cysts confirmed clinically and radiographically, 78% found positive while 36% were not histologically. Out of 25 indefinite lesions, 56% found chronic inflammatory lesions while 44% found inflammatory cyst. Conclusion: There was significant disagreement in clinical radiographic as well as histological diagnosis.

Keywords: Clinical, endodontics, histological, lesion radiograph


How to cite this article:
Syed Ismail PM, Apoorva K, Manasa N, Rama Krishna R, Bhowmick S, Jain S. Clinical, radiographic, and histological findings of chronic inflammatory periapical lesions – A clinical study. J Family Med Prim Care 2020;9:235-8

How to cite this URL:
Syed Ismail PM, Apoorva K, Manasa N, Rama Krishna R, Bhowmick S, Jain S. Clinical, radiographic, and histological findings of chronic inflammatory periapical lesions – A clinical study. J Family Med Prim Care [serial online] 2020 [cited 2020 Dec 3];9:235-8. Available from: https://www.jfmpc.com/text.asp?2020/9/1/235/276764




  Introduction Top


Periapical lesions are generally present and apical periodontitis, periapical granuloma, periapical abscess and periapical cysts are common one. The most commonly involved site is maxillary anterior teeth. Patients encounter pain, discomfort or sensitivity to hot or cold beverages depending upon chronicity of the lesion. There is a cascade of pathologies one giving to another one.[1] Periapical lesion usually represents sequelae of pulpitis. Reversible or irreversible pulpitis results in apical periodontitis. It is usually proceeds to periapical abscess or granuloma formation depending upon host response. Periapical or radicular cyst arises from periapical granuloma.[2]

The diagnosis of the lesion is made by clinical and radiographical assessment. Histopathological findings support the diagnosis. Sometimes, due to structural and evolutionary variations of a periapical lesions and radiographic findings may reveal different picture.[3] Studies have shown variation in clinical, radiographical, and histopathological outcomes. Basker [4] demonstrated that there are chances of disagreement between clinical and histopathological diagnosis.

The causes of periapical lesions are different which involves immunological, idiopathic, etc., Therefore, all periapical lesions may act in specific form in the evolution of inflammation. The present study aimed to compare clinical, radiographical, and histological findings in chronic periapical lesions such as cysts, granuloma and abscess.


  Materials and Methods Top


This study was conducted in the Department of Endodontics and Oral Pathology Malla Reddy Institute of Dental Sciences, Hyderabad, Telengana, India after obtaining the ethical clearance from the institutional ethical committee and informed consent from participants. The study consisted of 148 teeth having chronic inflammatory periapical lesions with or without nonsurgical endodontic treatment. Teeth were assessed clinically as well as radiographically.

Endodontic surgery was performed by single trained endodontist. After surgical endodontic treatment, teeth were assessed histologically. Biopsy sections were sent to the Department of Oral Pathology and Microbiology. All slides stained with hematoxylin/eosin and Gomori trichrome for light microscopy assessment.

The presence of connective tissue with variable collagen density, presence of macrophages, lymphocytes, groups of plasmocytes, polymorphonucleocytes, and giant cells, and presence of variable fibroangioblastic proliferation were indicative of periapical lesion. The lesions with variable diffuse inflammatory infiltrate and cavity formation limited by continuous or discontinuous stratified squamous epithelium were considered inflammatory cysts. The results thus obtained were subjected to statistical analysis using IBM SPSS Statistics for Windows, Version 22.0, IBM Corp., Armonk, NY, and Chi-square test, Post-hoc test was applied and Student's t- test was used with significance of P > 0.05.


  Results Top


[Table 1] shows that out of 148 teeth, 41 had chronic inflammatory lesions, 34 had inflammatory cysts, and 25 had indefinite lesions. The difference was significant (P < 0.05). [Table 2] shows that chronic inflammatory lesions assessed histologically found chronic apical periodontitis in 86 cases and inflammatory cysts in 62 cases. The difference was significant (P < 0.05). [Graph 1] shows that out of 86 cases of chronic apical periodontitis confirmed clinical radiographically, 64% found positive, whereas 36% were not histologically. [Graph 2] shows that out of 62 cases of inflammatory cysts confirmed clinically and radiographically, 78% found positive, while 36% were not histologically. [Graph 3] shows that out of 25 indefinite lesions, 56% found chronic inflammatory lesions, whereas 44% found inflammatory cyst.
Table 1: Chronic periapical lesions assessed by clinical radiographic examination

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Table 2: Chronic inflammatory lesions assessed histologically

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  Discussion Top


The commonly seen inflammatory lesions are chronic apical periodontitis, periapical cyst, and periapical granuloma. The origin of radicular cysts are from epithelial rests of Malassez' involved during the evolution of periapical granulomas, characterized by an inflammatory process associated with the central cavity formation and limited by the stratified squamous epithelium, which may be discontinuous.[5] The clinical appearance of periapical cyst is well defined swelling intraorally with carious/non vital tooth or presence of fractured tooth. Usually, radicular cysts are painless until and unless they are infected. The expansion of buccal and lingual cortical plate may be evident in severe cases. There can be egg shell crackling. However, the radiographic diagnosis with intraoral periapical radiographs confirmed the diagnosis.[6]

We observed that out of 148 teeth, chronic inflammatory periapical lesions were seen in 41 cases, inflammatory cyst in 34 cases, and 25 cases found to be indefinite which were not designated as any of above lesions.

Other reported studies has shown contradictory results for the incidence of chronic inflammatory periapical lesions such as chronic apical periodontitis, inflammatory cyst and granuloma when assessed lesions of extracted teeth with and without endodontic treatment and teeth with previous apicectomies and periapical curettage with previous root canal treatment.[1],[7]

It has been observed that the majority of these periapical granulomas and radicular cysts are occasionally found during routine examination. The most common reason behind this is the absence of pain and tooth remains asymptomatic until and unless diagnosed accidently. The smaller lesions are not discernible clinically and radiographically.[2] In case of periapical granulomas, there is well-defined periapical radiolucency size <1.6 cm, which is usually homogenous with relatively thin border. In case of cyst, there is well defined radiolucency around apex of nonvital teeth surrounded by radio-opaque sclerotic border. Periapical abscess shows irregular periapical radiolucency. In all cases, there is discontinue or complete absence of lamina dura.[3]

We observed that out of 86 cases of chronic apical periodontitis confirmed clinical radiographically, 64% found positive, whereas 36% were not histologically. We found that out of 62 cases of inflammatory cysts confirmed clinical radiographically, 78% found positive, whereas 36% were not histologically. There was significant lack of agreement in clinical radiographical and histological examination. Eesha and Jain assessed the Histopathological aspect of Chronic Inflammatory Periapical Lesions and found that there was significant disagreement in clinical radiographic as well as histological diagnosis similar to our results.[8]

Correa et al. evalualted the clinical, radiographic and histological characteristics of dental apical lesions correlation and observed certain clinical markers were found with the ability to predict histological manifestation of the lesions, such as dental mobility for granuloma and periapical cyst cases.[9] Croitoru et al. stated that preliminary diagnosis of chronic periapical lesions is based on the clinical symptoms and imagistic investigation, from their study, they suggested that correlation of clinical, histological and imagistic approach helps establishing accurate diagnosis for effective treatment.[10] Berar et al. from their study found statistically significant correlation between periapical index score scores and the size of the lesions.[11]

We observed that among the cases with previous non-surgical endodontic treatment, radicular cysts were more common. The persistence of periapical granuloma was also seen signifying incompetent endodontic treatment.[12] The role of iatrogenic procedures and/or apical and periapical conditions, enhancing the likelihood of not removing the apical biofilm and the existence of endogenous or exogenous foreign bodies, inducing constant reaction variables that interfere with the post-treatment repair process may be considered.[13]

We observed that out of 25 indefinite lesions which were not diagnosed clinically and radiographically, 56% found chronic inflammatory lesions whereas 44% found inflammatory cyst. Literature has revealed that persistent periradicular biofilm induces nonspecific and immunogenic reaction.

Presence or absence of periapical pathology determines prognosis of the tooth in the oral cavity. Initial radiographic diagnosis and clinical examination helps in early primary care for better prognosis. Early preventive care/surgical intervention help to prevent further spread of the inflammatoty lesion and prevent further bone destruction. The relation between the histological clinical and radiographic aspects may provide valuable data both for establishing an accurate diagnosis and for the effective treatment.

The limitation of the study is small sample size. Moreover, the disagreement in clinical radiographic as well as histological lesions was not confirmed by other endodontist as well as oral pathologists. The second opinion might result in variation of results.


  Conclusion Top


There was significant disagreement in clinical radiographic as well as histological diagnosis. This shows the importance of histological examination since all cases are not confirmed clinically and even radiographic examination.

Ethical approval

Obtained from institutional ethical committee.

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.
Patterson SS, Shafer WG, Healey HJ. Periapical lesions associated with endodontically treated teeth. J Am Dent Assoc 1964;68:191-4.  Back to cited text no. 1
    
2.
Pulver WH, Taubman MA, Smith DJ. Immune components in human dental periapical lesions. Arch Oral Biol 1978;23:435-43.  Back to cited text no. 2
    
3.
Reitschel ET, Brade H. Bacterial endotoxins. Sci Am 1992;267:26-33.  Back to cited text no. 3
    
4.
Bhaskar SN. Periapical lesion: Types, incidence, and clinical features. Oral Surg Oral Med Oral Pathol 1998;21:657-71.  Back to cited text no. 4
    
5.
Stockdale CR, Chandler NP. The nature of periapical lesion: A review of 1108 cases. J Dent 1988;16:123-9.  Back to cited text no. 5
    
6.
Trope M, Pettigrew J, Petras J, Barnett F, Tronstad L. Differentiation of radicular cysts and granulomas using computerized tomography. Endod Dent Traumatol 1989;5:69-72.  Back to cited text no. 6
    
7.
Zuolo ML, Toledo MS, Nogueira HE, Straus AH, Takahashi HK. Identification of GM3 as a marker of therapy-resitant periradicular lesions. J Endon 2001;27:107-9.  Back to cited text no. 7
    
8.
Eesha, Jain G. Histopathological assessment of chronic inflammatory periapical lesions- An in vivo study. J Adv Med Dent Scie Res 2018;6:42-5.  Back to cited text no. 8
    
9.
Correa CP, García LB, del Río EP, Caballero AD. Correlation of clinical, radiographic and histological diagnoses of apical dental lesions. Rev Odontol Mexicana 2017;21:e21-8.  Back to cited text no. 9
    
10.
Croitoru IC, Crăiţoiu S, Petcu CM, Mihăilescu OA, Pascu RM, Bobic AG. Clinical, imagistic and histopathological study of chronic apical periodontitis. Rom J Morphol Embryol 2016;57 (2 Suppl):719-28.  Back to cited text no. 10
    
11.
Berar AM, Bondor CI, Matroş L, Câmpian RS. Radiological, histological and immunohistochemical evaluation of periapical inflammatory lesions. Rom J Morphol Embryol 2016;57:419-25.  Back to cited text no. 11
    
12.
Molven O, Halse A, Grung B. Surgical management of endodontic failures: Indications and treatment results. Int Endod J 1991;41:33-42.  Back to cited text no. 12
    
13.
Molven O, Halse A, Grung B. Incomplete healing (scar tissue) after periapical surgery, radiographic findings 8 to 12 years after treatment. J Endod 1996;22:264-8.  Back to cited text no. 13
    



 
 
    Tables

  [Table 1], [Table 2]



 

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