Introduction
Inflammatory changes in the periapical tissues may be acute, chronic, or chronic exacerbated processes. Although such inflammation can occur in different forms, all derive from pulp necrosis. If the pulp dies and proper root canal treatment is not performed in a timely manner, the tissues surrounding the tooth root may become inflamed.1 The patients may remain asymptomatic for many years or may manifest itself as pain, swelling, or a fistula. When these symptoms develop, the patient will typically seek treatment before large inflammatory changes and extensive bone destruction occur. However, in other situations, alterations in the periapical tissues can only be seen during periodic intraoral radiograph, and these are frequently substantial and have a poor prognosis. Even extensive bone destruction in the form of granulomas or cysts may result in no clinical symptoms for many years. 1, 2 It is estimated that the incidence of periapical granulomas ranges from 9.3–87.1%, and cysts (within periapical lesions) –6–55%. 2, 3 As the size of the periapical lesions increases, the proportion of root cysts increases. However, it should be remembered that not all extensive inflammatory changes in the periapical tissues are cysts.4 The final, decisive differential diagnosis should be preceded by a histopathological diagnosis. However, this is not frequently performed. The indications that the lesion is a cyst rather than a granuloma are as follows in a clinical trial, during treatment: straw amber fluid leaking through the canal and/or during aspiration from the lesion in the radiological examination: lesion larger than 200 mm2, with an osteosclerotic rim. 3, 4
The following case reports describe the management of a particularly large mandibular periapical lesion involving the posterior teeth by nonsurgical endodontic treatment using radiovisiography.
Case Presentation
A 21-year-old male presented to the Department of conservative dentistry and Endodontics with a chief complaint of pain and food lodgement in the left lower back tooth region for 2 months. Clinical and intraoral periapical radiograph revealed a deep carious lesion in the mandibular first molar, and a periapical radiolucency was observed around the apices of both roots with furcation bone loss and sinus tract associated with mesial and distal root on the radiograph. The patient reported tenderness to percussion and palpation in the region of the mandibular first molar. Two sinus openings were observed, one from the lingual side and the other from the buccal side, involving both roots separately. Based on clinical and radiographic findings, a diagnosis of pulp necrosis with chronic peri apical abscess was established.
Figure 1
a: Showing Preoperative clinical picture of involved tooth; b: Preoperative radiograph showing large peri apical lesion involving both roots; c: Clinical image of sinus tracing with gattapercha; d-e: Radiographs of sinus tracing in both root.
Treatment
The treatment plan involved root canal therapy of the mandibular first molar. Following administration of local anesthesia (1:80000) and rubber dam placement, access cavity preparation was performed, and a K-file ISO No -10 was used to explore the root canals; the working length was determined on the apex locator and confirmed on radiographs. The cleaning and shaping was done using a combination of stainless steel K files till size #20 for glidepath and Pro Taper gold rotary files (Dentsply, Switzerland) in all the canals with intermittent irrigation using 5% sodium hypochlorite (Deepak Dental Products, Delhi, India), normal saline, and 17% EDTA (Dental Avenue Pvt Limited, Mumbai, India) solution with sonic activation by Endoactivator (Dentsply Tulsa Dental specialites, OK, USA). Calcium hydroxide used as intracanal medicament was placed, and the access cavity was temporized.
Figure 2
f: Intraoral radiograph of placement Calcium hydroxide intracanal medicament; g: Intraoral radiograph of showing mastercone selection
At the subsequent visit, the calcium hydroxide medicament was removed, and the canals were obturated using gutta-percha and a bio-ceramic sealer. In addition to root canal therapy, the patient was prescribed non-steroidal anti-inflammatory drugs to manage the periapical inflammation.
Follow-Up
The patient was followed up at regular intervals, and a radiographic examination at 6 months revealed a significant reduction in the size of the periapical lesion. The patient reported complete resolution of pain and tenderness in the treated tooth. One year post-treatment, a radiograph demonstrated complete healing of the periapical lesion, with evidence of bone regeneration in the furcal region.
Discussion
Inflammatory periapical lesions induced by endodontic conditions are commonly 5 - 8 mm in size. 5, 6 Historically, periapical lesions up to 10 mm in size have been defined as periapical granulomas, whereas greater lesions have been designated as periapical cysts. 7, 8 Epithelial cell remains of Malassez in the periodontal membrane are responsible for creating the epithelial lining of cysts. Radicular cysts may form by a number of processes, including the proliferation of epithelial cells as well as osmotic enhancement 9. According to the above-mentioned criteria, the present instance had a substantial periapical lesion that was most likely a periapical cyst. The presence of straw-coloured exudate, the magnitude of the lesion in conjunction with one non-vital tooth, the radiopaque border, and the divergence of adjacent dental roots10, 11 all clearly suggested a radicular cyst. However, only histopathologic examinations can provide a definite diagnosis. Various therapeutic options provided for big periapical lesions may range from root canal treatments to other surgical techniques. 12, 13 Sufficient chemomechanical cleaning of the root canal system and proper microbiological elimination are the most crucial criteria for getting a favorable outcome. Previous research has shown that nonsurgical RCT should be done at first;14 documents have shown that 42% to 74% of such lesions are healed with RCT.15, 16, 17 However, there is debate concerning the differences between the outcomes of traditional RCT of large and smaller lesions. 15, 18
An antibacterial calcium hydroxide-based compound dressing was applied in this instance. The entire mechanism of action of this drug is currently unclear. It is shown that calcium hydroxide paste may improve periapical healing and eradicate residual infections by controlling inflammation, encouragement of calcification, eliminating alkaline products of osteoclasts, & endotoxin suppression. 19, 20, 21, 22 In addition, it has been demonstrated that calcium hydroxide dressing greatly enhances periapical healing, specifically in young people. 23, 24 By previous research, periapical bone healing commenced 3 months after endodontic treatment in this case and persisted for the next 6 months. Radiographic evaluations indicated bone regeneration according to increasing density, trabecular repair, and lamina dura formation.
In this situation, bioceramics were utilized as a sealer, which exhibits excellent biocompatibility features due to their similarities to the biological process of hydroxyapatite production and the capacity to promote a regeneration response. They show osteoinductive capacity as they absorb osteoinductive compounds when in contact with the bone healing process. 25
The advantages of less intrusive nonsurgical treatment for massive periapical lesions include less psychological impact and are more suitable for patients. It appears that the periapical lesion was totally healed owing to a sufficient blood supply, abundant undifferentiated cells, and drainage via the lymphatic system. Thus, the lesion was cured to remove the causative causes by endodontic treatment and the regenerating capability of peri apical tissues.
The effective healing of a significant periapical lesion linked with the mandibular first molar teeth was obtained with diligent root canal therapy and adjuvant procedures. The use of an intraoral periapical radiograph allowed for a better assessment of the periapical lesion and the quality of the root canal treatment. This example shows the necessity of comprehensive cleanliness of the root canal system, proper obturation, and suitable treatment to aid the healing of periapical lesions.
Conclusion
This case report highlights the successful management and healing of a large periapical lesion in the mandibular first molar through root canal therapy and adjunctive procedures. Clinicians should consider thorough disinfection of the root canal system and appropriate follow-up to assess the healing of periapical lesions.
Article DOI
