a tooth with periodontal abscess is vital and does not have caries.

, presence of pocket, mobility and sensitive to percussion, while a tooth with periapical abscess is generally related with caries , the tooth usually does not shows any pocket What is the Differences between periapical abscess and periodontal abscess? What is the Differences betw A periapical abscess is the result of a chronic, localized infection located at the tip, [1] or apex, of the root of a tooth. To achieve resolution, endodontic therapy must be performed to debride the root canal or canals and remove pathogens. Tooth #4, the maxillary right second premolar (upper right 2nd bicuspid), after extraction. The two single-headed arrows point to the CEJ, which is the line separating the crown (in this case, heavily decayed) and the roots. The double headed arrow (bottom right) shows the extent of the abscess that surrounds the apex of the palatal root. periapical abscess, an infection around the root of a tooth, usually a result of spreading of dental caries. The abscess may perforate into the oral cavity or maxillary sinus; extend into nearby bone, causing osteomyelitis; or, more often, spread to soft tissues, causing cellulitis and a swollen face. There may be associated fever, malaise, and nausea. Treatment includes drilling into the pulp of the tooth to establish drainage and relieve pain, followed by antibiotics and late root canal therapy or tooth extraction. Also called dental abscess. abscess [abses] a localized collection of pus in a cavity formed by the disintegration of tissue. Abscesses are usually caused by specific microorganisms that invade the tissues, often by way of small wounds or breaks in the skin. An abscess is a natural defense mechanism in which the body attempts to localize an infection and wall off the microorganisms so that they cannot spread throughout the body. As the microorganisms destroy the tissue, an increased supply of blood is rushed to the area. The cells, bacteria, and dead tissue accumulate to form a clump of cream-colored liquid, which is the pus. The accumulating pus and the adjacent swollen, inflamed tissues press against the nerves, causing pain. The concentration of blood in the area causes redness. The abscess sometimes comes to a head by itself and breaks through the skin or other tissues, allowing the pus to drain. Local applications of heat may be used to facilitate localization and drainage.

alveolar abscess a localized suppurative inflammation of tissues about the apex of the root of a tooth. Bartholin abscess acute infection of a Bartholin gland with symptoms including pain, swelling, cellulitis of the vulva, and dyspareunia. Treatment is incision and drainage of the abscess. Cultures should be obtained to rule out infections byNeisseria gonorrhoeae or Chlamydia. . diffuse abscess an uncircumscribed abscess whose pus is diffused in the surrounding tissues. gas abscess one containing gas, caused by gas-forming bacteria such as Clostridium perfringens. Called also Welch's abscess. miliary abscess one composed of numerous small collections of pus. pancreatic abscess one that occurs as a complication of acute pancreatitis or postoperative pancreatitis caused by secondary bacterial contamination. perianal abscess one beneath the skin of the anus and the anal canal. periapical abscess inflammation with pus in the tissues surrounding the apex of a tooth. periodontal abscess a localized collection of pus in the periodontal tissue. peritonsillar abscess a localized accumulation of pus in the peritonsillar tissue subsequent to suppurative inflammation of the tonsil; called also quinsy. phlegmonous abscess one associated with acute inflammation of the subcutaneous connective tissue. stitch abscess one developed about a stitch or suture. thecal abscess one in the sheath of a tendon. wandering abscess one that burrows into tissues and finally points at a distance from the site of origin. Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health, Seventh Edition. 2003 by Saunders, an imprint of Elsevier, Inc. All rights reserved. abscess (abses), n a localized accumulation of suppuration in a confined space formed by tissue disintegration. abscess, gingival, n a superficial periodontal abscess occurring within the free gingival sulcus surrounding the tooth, frequently caused by the impaction of food. abscess, periapical n an abscess involving the apical region of the root, alveolus, and surrounding bone as a result of pulpal disease. abscess, periodontal, n an abscess involving the attachment tissues and alveolar bone as a result of periodontal disease. abscess, periradicular n an abscess involving the periradicular region of the root, alveolus, and surrounding bone as a result of pulpal disease. abscess, pulpal, n an abscess occurring within pulpal tissue.

Abscess, cross section.

abscess, staphylococcal n an abscess caused by the bacteria S. aureus, an infectious agent that can be transmitted via saliva and other discharges of the body. The incubation period is 4 to 10 days; the duration of the abscess varies and is indefinite. The bacteria are communicable throughout the drainage period of the lesions and while the carrier state continues. periapical (perpik l), adj enclosing or surrounding the apical area of a tooth root. periapical abscess, n an acute or chronic inflammation of the periapical tissues characterized by a localized accumulation of suppuration at the apex of a tooth. It is generally a sequela of pulp death of the tooth. periapical granuloma, n an accumulation of mononuclear inflammatory cells with an encircling aggregation of fibroblasts and collagen at the apex of the root of a tooth caused by chronic inflammation. Also called chronic apical periodontitis. periapical radiograph (PA), n a radiograph that includes the tooth apices and surrounding periodontium in a particular intraoral area. periapical radiographic survey, n a complete series of intraoral radiographs that include the periapical portions of the tooth and its periodontium. periapical tissue, n the tissue located at the root end of a tooth. Usually consists of the connective tissue forming an attachment between the root and the alveolar bone. Mosby's Dental Dictionary, 2nd edition. 2008 Elsevier, Inc. All rights reserved. abscess a localized collection of pus in a cavity formed by the disintegration of tissue. Most abscesses are formed by invasion of tissues by bacteria, but some are caused by fungi or protozoa or even helminths, and some are sterile. Their effects are determined by their location and the pressure that they exert on nearby organs, and the degree of toxemia that they create from their bacterial content and the amount of tissue destroyed. periapical abscess Tooth abscess Dentistry A complication of caries, linked to trauma to enamel, allowing bacteria to infect pulp, and extend to the tooth root and bone, with necrosis, gum swelling, toothache, and periodontal disease. Cf Caries, Periodontal disease. McGraw-Hill Concise Dictionary of Modern Medicine. 2002 by The McGraw-Hill Companies, Inc. periapical abscess an alveolar abscess localized around the apex of a tooth root.

Synonym(s): apical abscess, apical periodontal abscess Farlex Partner Medical Dictionary Farlex 2012 periapical abscess (per-api-kl abses) Inflammation of tissues and collection of pus around a tooth apex; may result from pulp infection due to carious lesion or pulp necrosis resulting from injury. Synonym(s): apical abscess, apical periodontal abscess. Medical Dictionary for the Dental Professions Farlex 2012 Periapical cyst The periapical cyst (also termed Radicular cyst, and to a lesser extent Dental cyst) is the most common odontogenic cyst. It is caused by pulpalnecrosis secondary to dental caries or trauma. The cyst lining is derived from the cell rests of Malassez. Usually, the periapical cyst is asymptomatic, but a secondary infection can cause pain. On radiographs, it appears a radiolucency (dark area) around the apex of a tooth's root. Radicular Cyst is the most common odontogenic cystic lesion of inflammatory origin. It is also known as Periapical Cyst, Apical Periodontal Cyst, Root End Cyst or Dental Cyst. It arises from epithelial residues in periodontal ligament as a result of inflammation. The inflammation usually follows death of dental pulp. Radicular cysts are found at root apices of involved teeth. These cysts may persists even after extraction of offending tooth, such cysts are called Residual Cysts. [edit]Definition It is defined as an odontogenic cyst of Inflammatory origin that is preceded by a chronic periapical granuloma and stimulation of cell rests of malassez present in the periodontal membrane. [edit]Classification It is classified as follows: 1) Periapical Cyst: These are the radicular cysts which are present at root apex. 2) Lateral Radicular Cyst:- These are the radicular cysts which are present at the opening of lateral accessory root canals of offending tooth. 3) Residual Cyst:- These are the radicular cysts which remains even after extraction of offending tooth.

Patient of CT scan shown above [edit]Causes Dental cysts are usually caused due to root infection involving the tooth affected greatly by carious decay . The resulting pulpal necrosis causes release of toxins at the apex of the tooth leading to periapical inflammation. This inflammation leads to the formation of reactive inflammatory (scar) tissue calledperiapical granuloma further necrosis and damage stimulates the Malassez epithelial rests, which are found in the periodontal ligament, resulting in the formation of a cyst that may be infected or sterile (The epithelium undergoes necrosis and the granuloma becomes a cyst). These lesions can grow into large lesions because they apply pressure over the bone

causing resorption . The toxins released by the breakdown of granulation tissue is one of the common causes of bone resorption. These cysts are not true neoplasms [edit]Etiology A Radicular Cyst presupposes physical, chemical or bacterial injury resulting in death of pulp followed by stimulation of epithelial cell rests of malaseez which are present normally in periodontal ligament. [edit]Pathogenesis Pathogenesis of Radicular Cyst is conveniently considered in 3 Phases, which are as follows 1. Phase of Inititiation, 2. Phase of Cyst Formation, 3. Phase of Cyst Enlargement [edit]Phase of Initiation It is generally agreed that the epithelial lining of these cysts are derived from epithelial cell rests of malaseez in periodontal ligaments. However in some cases, epithelial lining may be derived from, Respiratory epithelium of Maxillary sinus when periapical lesion communicates with sinus wall. Oral epithelium from fistulous tract. Oral epithelium proliferating apically from periodontal pocket. The mechanism of stimulation of epithelial cells to proliferate is not clear. It may be due to inflammation in periapical granuloma or some products of dead pulp may initiate the process & at same time it evokes an inflammatory reaction. There is also evidence of local changes in supporting connective tissue which may be responsible for activating the cell rests of malaseez. [edit]Phase of Cyst Formation It is a process by which cavity becomes lined by proliferating epithelium. There are two theories regarding it which are as follows: Most widely accepted theory suggests that initial reaction leading to cyst formation is a proliferation of epithelial rests in periapical area involved by granuloma. As this proliferation continues with the epithelial mass increasing in size by division of the cells on periphery corresponding to basal layer of surface epithelium. The cells of central portion of mass become separated further & further from nutrition in comparison with basal layer due to which they fail to obtain sufficient nutrition, they eventually degenerate, become necrotic & liquify. This creates an epithelium lined cavity filled with fluid. The another theory suggest that a cyst may form through proliferation of epithelium to line a pre-existing cavity formed through focal necrosis & degeneration of connective tissue in periapical granuloma. But the finding of epithelium or epithelial proliferation near an area of necrosis is not common. [edit]Phase of Cyst Enlargement Experimental work provided evidence that osmosis makes contribution to increase in size of cyst. Investigators found that fluids of Radicular cysts

have Gamma Globulin level High by almost more than half to patients own serum. Plasma protein exudate & Hyaluronic acid as well as products of cell breakdown contribute to high osmotic pressure of cystic fluid on cyst walls which causes resorption of bone & enlargement of cyst. [edit]Microbiology Cyst may or may not be infected. Whenever an infection is present, Actinomyces organisms have been isolated from radicular cyst. Microorganisms mainly found in root canal are 75% Gram +ve & 24% Gram ve, among which Streptococci are predominant also other Gram +ve organisms like Staphylococci, Cornybacterium, yeast & others are found. Gram -ve organisms are Spirochetes, Nesseria, Bacteroids, fusobacterium, pseudomonas & others. In Periapical lesions like Radicular cysts Obligate anaerobes are found. Additionally in long-standing cases of periapical pathology a- hemolytic & non hemolytic streptococci are found along with obligate anaerobes. Medias used for Culture of Root Canal Materials - - - Brain Heart Infusion Broath with 0.1% Agar - Trylicase Soy Broath with 0.1% Agar (TSA) - Glucose Ascitis Broath [edit]Clinical features Expansion of the cyst causes erosion of the floor of the maxillary sinus. As soon as it enters the maxillary antrum the expansion starts to occur a little faster because there is space available for expansion. Tapping the affected teeth will cause shooting pain. This is virtually diagnostic of pulpal infection. A) Frequency:- It is most common cystic lesion of jaw comprising about approximately 52.3% of jaw cystic lesions B) Age:- Large no. of cases are found in 4th & 5th decades of life after which there is gradual decline. C) Sex:- It is more common in males comprising about 58% & in females comprising about 42%. D) Race:-White patients are involved with a frequency of about twice that of Black patients. E) Site:- It occurs with frequency of 60% in Maxilla. Though it may occur in all tooth bearing areas of both the jaws but preferably it occurs in maxillary anterior region. Upper lateral Incisors and dens in dente are usually the offending teeth. It occurs most commonly at apices of involved teeth. They may however be found at lateral accessory root canals. [edit]Gross Features Gross Specimen may be spheroidal or ovoid intact cystic masses, but often they are irregular & collapsed. The walls vary from extremely thin to a thickness of about 5mm. The inner surface may be smooth or corrugated yellow mural nodules of cholesterol may project into the cavity. The fluid contents are usually brown from breakdown of blood and

when cholesterol crystals are present they impart an orange gold or straw colour. [edit]Clinical Presentation Smaller radicular cysts are usually symptomless and may be discovered when intraoral periapical (IOPA) radiographs are taken of non-vital teeth. Larger lesions show slowly enlarging swelling. At first the enlargement is bony hard but as cyst increases in size, the covering bone becomes very thin, despite subperiosteal deposition & swelling exhibits springiness, only when cyst has become completely eroded, the bone will show fluctuation. In Maxilla, there may be buccal and palatal enlargement Whereas in mandible it is usually labial or buccal & only rarely lingual. Pain & infection are other clinical features of some radicular cysts. These cysts are painless unless infected. However, complain of pain is also observed in patient without any evidence of infection. Occasionally, a sinus may lead from cyst cavity to the oral mucosa Quite often there may be more than one radicular cyst. Scientists believe that there are cyst prone individuals who show particular susceptibility to develop radicular cysts. Radicular cysts arising from deciduous tooth are very rare.Deciduous tooth which had been treated endodontically with materials containing Formecresol which in combination with tissue protein is antigenic & may elicit a humoral or cell-mediated response like rapid buccal expansion of cyst. Rarely, parasthesia or pathologic jaw bone fracture may occur. Radiographically it is virtually impossible to differentiate granuloma from a cyst. If the lesion is large it is more likely to be a cyst. Radiographically both granuloma and cyst appear radiolucent, associated with the apex of non vital tooth. Radiographic Features:- Intra Oral Peri Apical Radiographs i.e. IOPAs are common radiographs which are used as diagnostic aid from radiological point of view. Radiographically, Radicular Cysts are round or ovoid radiolucent areas surrounded by a narrow radio-opaque margin, which extends from Lamina Dura of involved tooth. In infected or rapidly enlarging cysts, radio-opaque margins may not be seen. Root resorption is rare but may occur. It is often difficult to differentiate radiologically between radicular cysts & apical granulomas. Radiologic presentation of Radicular Cyst is given in detail as follows: Periphery & Shape--- Periphery usually have a well defined cortical border. If Cyst is secondarily infected, the inflammatory reaction of surrounding bone may result in loss of this cortex or alteration of cortex into more sclerotic border. The outline of radicular cyst usually is curved or circular unless it is influenced by surrounding structures such as cortical boundaries.

Internal structure--- in most cases, internal structure of radicular cyst is radiolucent. Occasionally, dystrophic calcification may develop in long standing cysts appearing as sparsely distributed, small particulate radioopacities. Effects on surrounding structures--- If a radicular cyst is large, displacement and resorption of roots of adjacent teeth may occur. The resorption pattern may have a curved outline. In rare cases, the cyst may resorb the roots of related non-vital teeth. The cyst may invaginate the antrum, but there should be evidence of a cortical boundary between contents of cyst and internal structure of antrum. The outer cortical plates of maxilla and mandible may expand in a curved or circular shape. Cyst may displace the mandibular alveolar nerve canal in an inferior direction. Histopathological Features:- The gross specimen may be spherical or ovoid intact cystic masses, but often they are irregular & collapsed. The walls vary from extremely thin to a thickness of about 5mm. The inner surface may be smooth or corrugated. The histopathological studies shows following features --1) Epithelial Lining :- Almost all radicular cysts are wholly or in part lined by stratified Squamous Epithelium & range in thickness from 1 to 50 cell layers. The only exception to this is in those rare cases of periapical lesions of Maxillary Sinus. In such cases, cyst is then lined with a pseudo stratified cilliated columnar epithelium or respiratory type of epithelium. Ortho or para keratinised linings are very rarely seen inradicular cysts. Secretory cells or ciliated cells are frequently found in epithelial lining. 2) Rushtons Hyaline Bodies:- In approximately 10% of cases of radicular cysts, Rushton's Hyaline bodies are found in epithelial linings. Very rarely they are found in Fibrous capsule. The hyaline bodies are tiny linear or arc shaped bodies which are amorphous in structure, eosinophillic in reaction and Brittle in nature. 3) Cholesterol Clefts:- Deposition of Cholesterol crystals are found in many radicular cysts, slow but considerable amount of cholesterol accumulation could occur through degeneration and disintegration of lymphocytes, plasma cells & macrophages taking part in inflammatory process, with consequent release of Cholesterol from their walls. 4) Fibrous Capsule:- Fibrous Capsule of Radicular Cyst is composed of mainly condensed parallel bundles of collagen fibres peripherally and a loose connective tissue adjacent to epithelial lining. 5) Inflammatory Cells:- Acute inflammatory cells are present when epithelium is proliferating. Chronic inflammatory cells are present in connective tissue immediately adjacent to epithelium. 6) Mast cells, Remnants of Odontogenic Epithelium & occasionally Satellite microcysts are also present. Some cysts are markedly vascularised. Various kinds of Calcifications are also present. Schematic Representation of Histopathological Aspects [edit]Differential Diagnosis Radicular Cyst

Periapical Granuloma Traumatic Bone Cyst Periapical Scar Periapical Cemental Dysplasia Periapical Surgical Defect Globulomaxillary Cyst Aneurysmal Bone Cyst Mandibular Infected Buccal Cyst Periapical Cemento-osseous dysplasia [edit]Treatment The source (i.e., necrotic pulp) should be removed by full pulpectomy (i.e., root canal therapy) or extraction of the offended tooth, and the cyst should be enuclated. Treatment:1)Endodontic Treatment:Peripheral lesions including radicular cysts are eliminated by body once the causative agents are removed. Majority of radicular cysts can undergo resolutions following Root Canal Treatment & don't require surgical intervenation. It is suggested that insertion of file or other root canal instrument beyond the apical foramen (for 1-2mm) produces transitory acute inflammation which may destroy epithelial lining of radicular cyst & convert it in to granuloma. Thus, leading to its resolutions. 2) Surgical Treatment:a) Enucleation- The affected tooth is extracted or preserved by root canal treatment with apicocetomy. A mucoperiosteal flap over cyst is raised & a window is opened in the bone to give adequate access. The cyst is carefully separated from its bony wall. The entire cyst is removed intact. the edges of bony cavity are smoothened off, free bleeding is controlled and cavity is irrigated to remove debris. Mucoperiosteal flap is replaced back and sutured in place. b) Marsupialisation- The cyst is opened essentially as for enucleation but the epithelial lining is sutured to mucous membrane at margins of opening. The aim is to produce a self-cleansing cavity, which becomes an invagination of oral tissues. The cavity is initially packed with ribbon gauze & after margins are healed a plug or extension of denture is made to close the openings. The cavity usually closes by regrowth of surrounding tissues & restoration of normal contour of that part. However, there are always chances of closing the orifice & reformation of cyst. The main application is for temporary decompression of exceptionally large cyst where fracture of jaw is a risk factor. When enough new bone is formed, cyst can be enucleated. Prognosis:Prognosis depends on particular tooth, the extent of bone destroyed & accessibility for treatment. Expected Complications:-

1) Carcinomatous/Neoplastic Changes:Squamous Cell Carcinoma or Epidermoid Carcinoma may occasionally arise from epithelial lining of Radicular Cyst. 2) Pathologic Jaw Fracture:If Cyst have completely eroded the bone specially if it is present in posterior region which is very rare in case of Radicular Cyst it may cause pathologic jaw bone fracture. 3) Secondary Infection:Cyst may get secondarily infected and create further complications. [edit]See also Periapical cyst, Cyst Infections Due to Dental Adelia Ratnadita SKG - detikHealth Monday, 01/08/2011 9:45 PM

Periapical cyst classified in odontogenic cysts.Odontogenic cyst itself has a meaning that is caused by dental cysts, either due to inflammation of the teeth or due to malformations (abnormal formation) during tooth development. Whereas periapical cyst is a cyst that forms on the tooth root tip pulpanya tissue (nerve) is dead, which is a continuation of inflammation in dental pulp tissues (pulpitis). Diagnosis of periapical cysts can be determined through dental x-ray and histological examination. Cause Periapical cyst is a further development of dental infections due to caries (cavities). If untreated cavities allowed to continue, it will cause inflammation in dental pulp tissues (pulpitis) then there is death in the tooth nerve. After tooth nonvital (dead) over time will periapical cysts can form on the tooth root tip. Symptom Periapical cysts generally do not cause complaints or pain, except if there is an infection in the cyst (secondary infection). Treatment There are several treatment options in these cysts, among others: 1. Endodontic treatment (treatment of dental nerve) If the cyst is not too big or worse yet, it can still be done endodontic treatment. If the treatment is done, it is necessary to periodically dental x-rays to check the healing of the cyst. 2. Retrieval of cysts This treatment is most often done to deal with periapical cyst, because if the healing endodontic treatment is not necessarily successful. Cysts decision-making is sometimes also accompanied teeth involved.

Sources: MayoClinic, West Indian Medical Journal, Journal of Medical. Radicular cyst (periapical cyst) Sorry, You are incorrect! Given the radiographic findings of a unilocular and well-defined radiolucency one has to consider a cyst(s) on the differential diagnosis. Being closely associated with the apices of the central and lateral incisors, a radicular cyst would be a reasonable consideration. The associated teeth, however, are vital; this indicates that it is not a periapical cyst. The histology is also not supportive of a periapical cyst. Apical periodontal cyst, also known by a variety of other names including radicular and periapical cyst, is an inflammatory cyst and is the most common odontogenic cyst. It is the result of pulpitis/pulp necrosis, which mainly caused by a badly decayed tooth but can also be the result of tooth fracture, failed endodontic treatment or an old filling with secondary caries (1-2). It can occur at any age but is more common in adults in their fourth and fifth decade of life. It is usually present at the apex of a tooth but can be apical lateral to a tooth. It is usually asymptomatic and small (around 0.5-1.5 cm) in size but can occasionally reach large sizes. It can be symptomatic, i.e. painful and expansile, if infected. The infected cysts may break through the cortical bone in the form of a fistula, usually buccal or labial in the mandible and buccal or palatal in the maxilla. It is more common in males than females and slightly more common in the maxilla, especially the anterior maxilla (1-2). Radiographically, it presents as welldemarcated or corticated unilocular radiolucency at the apex of a tooth or apical and lateral of a tooth. Occasionally, the radicular cyst can be multilocular. It can also be associated with root resorption but rarely. Histologically, it is made up of a cystic structure lined by epithelium and supported by a connective tissue wall. The latter is usually chronically inflamed and frequently associated with abscess. Treatment ranges from conventional endodontic treatment to apicoectomy to extraction of the tooth with curettage of the cystic structure. It has a good prognosis. Radiographic features of periapical cysts and granulomas. Zain RB, Roswati N, Ismail K. Source Dental Faculty, University of Malaya. Periapical cyst repair after nonsurgical endodontic therapy - case report Caroline R.A. Valois; Edson Dias Costa-Jnior Faculty of Health Sciences, Department of Dentistry, University of Braslia (UnB), Braslia, DF, Brazil Correspondence ABSTRACT This article presents the procedures that must be considered for periapical cyst repair after nonsurgical endodontic treatment. The case of a periapical cyst associated to the left maxillary lateral incisor is reported. Nonsurgical

root canal therapy was performed and lesion healing was confirmed radiographically after 24 months. Differential diagnosis, endodontic infection control, apical foramen enlargement and filling of the cystic cavity with a calcium hydroxide paste were important procedures for case resolution. Key Words: endodontic therapy, periapical cyst, periapical pathosis. RESUMO O objetivo do presente estudo foi apresentar os procedimentos a serem considerados para o tratamento endodntico no-cirrgico de cistos periapicais. Um caso de cisto periapical associado ao incisivo lateral superior esquerdo relatado. Aps o tratamento endodntico nocirrgico, o reparo da leso foi observado radiograficamente em 24 meses. Diagnstico diferencial, controle da infeco endodntica, alargamento do forame apical e preenchimento da cavidade cstica com pasta de hidrxido de clcio foram procedimentos relevantes para a resoluo do caso.

INTRODUCTION The periapical cyst is originated from the epithelium in a granuloma and is frequently associated to an inflammatory response of the organism against a long-term local aggression due to an endodontic infection. This condition is clinically asymptomatic but can result in a slow-growth tumefaction in the affected region. Radiographically, the classic description of the lesion is a round or oval, well-circumscribed radiolucent image involving the apex of the infected tooth (1). Although it has been demonstrated that this pathologic entity can represent 40 to 50% of all apical lesions (2), it is not yet well-established in the literature whether its treatment should be surgical or non-surgical. Some authors support that if the endodontic infection is eliminated, the immune system is able to promote lesion repair, while other believe that surgical intervention is invariably necessary (1-5). In this article, a case of periapical cyst healing after nonsurgical endodontic treatment is reported. CASE REPORT A 42 year-old female patient was referred to our clinic for endodontic treatment of the left maxillary lateral incisor. Intraoral clinical examination revealed that the lateral incisor had esthetic restorations on the mesial, distal and lingual surfaces. The buccal mucosa presented normal color and appearance. There was no gingival or extraoral swelling but a volumetric increase in the palate was observed. The patient denied spontaneous pain but reported painful symptomatolgy upon percussion.

The radiographic examination showed the presence of external periapical resorption of approximately 1 mm length and a radiolucent lesion (15 x 10 mm) surrounded by a tenuous radiopaque line adjacent to the apex of tooth 22. Pulpal necrosis was confirmed by cold sensitivity testing done with Endo-Frost cold spray (Roeko, Langenau, Germany). After crown opening, a mucous and transparent exudate drained through the radicular canal. A sample of this fluid was collected for cytological examination. The canal was instrumented at 1 mm from the apical foramen according to the crown-down technique. The memory instrument was a size 60 K-file (Maillefer Instruments SA, Ballaigues, Switzerland). The canal was irrigated with HCT20, an irrigating solution composed of calcium hydroxide, tergentol and distilled water (6), and filled with a paste prepared with 9 parts of calcium hydroxide and 1 part of zinc oxide in an aqueous vehicle (HCT20), using a lentulo drill. Canal entrance was sealed with a non-eugenol, pre-mixed temporary filling material (Cimpat, Septodont, Saint Maur, France) and the access cavity was closed with a rapid-setting zinc oxide and eugenol based cement (Pulpo-san, SS White, Rio de Janeiro, RJ, Brazil). All procedures were carried out under absolute isolation. The exfoliating cytology of the lesion's fluid was compatible with periapical cyst. The patient returned for a second visit and was informed about the diagnosis, tooth conditions and treatment options. She agreed to sign an informed consent form for nonsurgical root canal therapy and documentation of her case. The provisional restoration was removed and the canal was irrigated with HCT20 and filled with intracanal medication. A size 30 K-file (Maillefer Instruments SA) was introduced 3 mm beyond the radiographic apex (Fig. 1). At this moment, an abundant serum, purulent and hemorrhagic exudate flowed through the root canal. The calcium hydroxide paste was reapplied into the canal and intentionally taken to the periapical region using a size 30 K-file as described above. All procedures were carried out under absolute isolation. During the first month, the patient returned every week for control and, after that, monthly appointments were scheduled. The intracanal medication was renewed at each visit. One month after the beginning of the treatment, the radiographic examination showed that practically all calcium hydroxide paste extruded into the periapical lesion had been resorbed. Therefore, placement of intracanal dressing beyond the tooth apex was repeated, but this time greater paste volume was used to completely fill the cystic cavity (Fig. 2).

During the following three months of treatment, renewal of intracanal medication was associated to increase of sensitivity to percussion and palate tumefaction. A fistula developed and persisted during four days. At the fifth month of follow-up, it was observed absence of sensitivity to percussion, fistula, tumefaction and exudate drainage through the canal. Therefore, at the subsequent visits, there was no longer need to take the intracanal medication to the cystic cavity by advancing the file 3 mm beyond the apical foramen. After fourteen months of treatment, periapical radiographs showed a remarkable decrease of the radiolucency of the lesion and partial resorption of the calcium hydroxide paste (Fig. 3).

The root canal was chemomechanically prepared, obturated with guttapercha cones (Dentsply Ind. Com. Ltda, Petrpolis, RJ, Brazil) and Sealer 26 cement (Dentsply Ind. Com. Ltda) using the lateral condensation technique. A definitive restoration was then placed. The patient returned for clinical and radiographic controls every 6 months during the first 2 years, and then every 12 months during the following 3 years (Fig. 4). Radiographic evidence of lesion healing was observed at the 24-month follow-up. DISCUSSION It is known that a pulpal infection originates and perpetuates periapical pathologic alterations. In addition, in the absence of aggressive agents, the immune system has mechanisms to promote the repair of tissues and structures affected by pathologic processes (3). Therefore, the elimination of harmful agents from the root canal system creates a propitious environment for repair of a cystic lesion (3,5). Parendodontic surgeries may have direct procedural consequences that make nonsurgical endodontic treatment preferable over them in cases of periapical cyst. Among the events that might be associated to periapical surgical interventions are loss of bone support, possibility of damaging blood vessels and nerves irrigating and innervating teeth adjacent to the lesion, possibility of damaging anatomic structures, such as the mental foramen, inferior alveolar nerve and/or artery, nasal cavity and the maxillary sinus, production of anatomic defects or scars, postoperative pain or discomfort, and refusal to undergo surgical procedures, especially pediatric patients (4,5). Studies have reported that periapical cysts are refractory to non-surgical endodontic therapy (7,8). Nevertheless, the fact that these findings are associated to other etiological factors, such as extraradicular infection, presence of foreign bodies and cholesterol crystals, has also been discussed in the literature (8). Furthermore, the way that the endodontic

treatment is conducted should be discussed as well. Correct planning of the intervention in cases of periapical cyst is of paramount importance for a successful therapy. The foremost step is to establish a differential diagnosis between periapical cyst and periapical granuloma. Several studies have shown the difficulty to distinguish radiographically these pathological entities (9,10). Biochemical procedures have also been described for differencial diagnosis (4,11). In the case reported in this article, exfoliating cytology was the chosen method to examine the lesion's fluid because it has a simplified technique. Endodontic infection control is another crucial point to be addressed while planning the intervention. For elimination or maximum reduction of microorganisms in the root canal system, the professional should associate debridment using endodontic files with efficient irrigating solution and intracanal medication. Moreover, patency and elargement of the canals in case of necrotic teeth with periapical lesions will help eliminating microorganisms from the apical foramen, thus preventing the inflammatory process to perpetuate. Calcium hydroxide irrigants and dressings were selected because they reportedly provide excellent clinical and laboratorial results (6,12,14,15). Calcium hydroxide was associated to an aqueous vehicle to allow rapid release of Ca++ and OH. Zinc oxide was added to the paste to allow better visualization of the medication within the canal and the cystic cavity. Overextension of calcium hydroxide paste into cystic lesions, as performed in the case reported, has been previously described (12,13,16). The benefits of this procedure include anti-inflammatory action through hygroscopic properties forming calcium proteinate bridges and inhibiting phospholipase, neutralization of acidic products such as hidrolases, which can affect the clastic activity, activation of the alkaline phosphatase, antibacterial effect and the destruction of the cystic epithelium, allowing conjunctive tissue invagination to the lesion (12,13). Bhaskar (2) suggested that, during the endodontic therapy of teeth associated with periapical cysts, root canal instrumentation must be done slightly beyond the apical foramen. According to the author, this will produce a transitory acute inflammation and destruction of the protective epithelial layer of the cyst, converting it into a granulated tissue, which has better resolution. Although there is no scientific-based evidence that support this assumption, in the case hereby presented, instrumentation beyond the apical foramen was carried out because it would help eliminating microorganisms from the apical area, thus reducing the inflammatory process. Moreover, it could also facilitate cyst resolution through the relief of the intra-cystic pressure (1). The criteria used to establish the most adequate moment for obturation of the root canal are associated with absence of spontaneous pain, sensitivity to percussion, exudate and edema, and the beginning of radiographic

regression of the lesion. Regarding the time required for considering the therapy successful, a two-year period has been considered a reasonable interval (17). In the case described in this paper, the patient was evaluated biannually and then every 12 months up to 5 years of follow-up. Differential diagnosis, endodontic infection control, apical foramen enlargement and filling of the cystic cavity with a calcium hydroxide paste were proved important procedures for successful nonsurgical endodontic treatment of periapical cysts. Correspondence: Dr. Edson D. Costa Jr., Faculdade de Odontologia, Universidade de Braslia (UnB) Campus Universitrio, Asa Norte 70910-900 Braslia, DF, Brasil Tel: +55-61-307-2632 e-mail: [email protected]/[email protected] A Periapical cyst Dr Yuranga Weerakkody and Dr Frank Gaillard et al.view revision history A periapical cyst (also known as a radicular cyst) is the most frequent cystic lesion related to teeth (see mandibular lesions). Pathology It results from infection of the tooth, which spreads to the apex and into the adjacent bone. This leads to apical periodontitis, granuloma formation and eventual cyst formation. These cysts are therefore centered on the apex of the tooth, and tend to be small, most less than 1 cm. There is also unsurprisingly usually overt evidence of caries. Epidemiology rd th 2 They are typically these are seen in middle to older age (3 to 6 decades ). Radiographic features Plain film / OPG and CT At radiography, most radicular cysts appear as round or pear-shaped, unilocular, 3 lucent lesions in the periapical region . They are usually less than 1 cm in diameter and are bordered by a thin rim of cortical bone. The associated tooth usually has a deep restoration or large carious lesion. See also