Repair of large periapical radiolucent lesions of endodontic origin without surgical treatment

To report a case of conservative nonsurgical management of periapical lesions. Small periapical lesions of endodontic origin usually heal by conventional endodontic therapy alone. Larger periapical lesions presumed to be cystic may require additional treatment protocols to aid in regression. Conservative nonsurgical management of such lesions eliminates the possible complications of surgery and has wider patient compliance and acceptance. A periapical cystic lesion associated with maxillary central incisor and lateral incisor was treated conservatively using buccal aspiration decompression followed by conventional endodontic therapy employing calcium hydroxide iodoform paste as intracanal medicament is reported. The treatment was successful as evidenced by relief of symptoms and radiographic evaluation. Large periapical cyst-like lesions can resolve by nonsurgical endodontic therapy employing calcium hydroxide intracanal interappointment medicament.

The aim of this paper is to present the non-surgical management of three cases with large periapical lesions. Surgical treatment of large periapical lesions is often subject to various complications. Therefore, a non-surgical approach should be considered for the management of these lesions. The first was a maxillary lateral incisor with a periapical lesion of endodontic origin in a 19-year-old female patient, the second affected a maxillary central incisor in a 21-year-old female patient and the third was a mandibular molar in a 36-year-old male patient. The canals were prepared using crown down technique. During root canal treatment, sodium hypochlorite was used for irrigation and calcium hydroxide was used for the intra-canal dressing. Clinical evaluation was performed after 10 days. The teeth were asymptomatic and the root canals were obturated using lateral compaction technique. The patients were recalled at 3, 6 and 12 months. These radiolucent periapical lesions were treated successfully without surgical approach. 
 How to cite this article: Arslan H, Karataş E, Barutcugil Ç, Topçuoğlu HS, Aladağ H. Treatment of Large Periapical Lesions without Surgical Approach: Report of Three Cases. Int Dent Res 2012;2:17-22
 Linguistic Revision: The English in this manuscript has been checked by at least two professional editors, both native speakers of English.

To determine the types of periapical lesions associated with root filled teeth with persistent periapical pathosis that required surgical treatment based on specific inclusion and exclusion criteria. Periapical lesions from a consecutive clinical sample of 100 patients were examined histopathologically to determine a definitive diagnosis. Females were more represented (n = 56), the average age was 46.5 years and there were no age differences between gender or lesion type. A diagnosis of periapical granuloma was the most common finding with a similar number present in females (n = 40) and males (n = 37). A cyst was present in 18% of the cases with a majority of females (n = 12) represented in the sample. Evidence of foreign material, with an appearance consistent with endodontic sealer materials, was seen in 25 periapical granulomas, two cysts and one scar. Two periapical scars were seen, one had a history of apicectomy and amalgam root-end filling while the other was associated with extruded root filling material. By using defined clinical inclusion and exclusion criteria a predictable clinical diagnosis of a persistent periapical lesion due to endodontic origin can be reliably made. Periapical granulomas and cysts were the most common periapical lesions of endodontic origin associated with persistent periapical pathosis with the overall incidence of periapical cysts similar to previous studies. The presence of endodontic material in a high proportion of periapical lesions suggests a cause-effect association with the inference that clinicians should employ canal preparation techniques that limit apical extrusion of material.

Periapical lesions of endodontic origin are common pathological conditions affecting periradicular tissues. Microbial infection of pulpal tissues is primarily responsible for initiation and progression of apical periodontitis. The primary objective of endodontic therapy should be to restore involved teeth to a state of normalcy nonsurgically. Different nonsurgical management techniques, namely, conservative root canal therapy, decompression technique, method using calcium hydroxide, aspiration-irrigation technique, lesion sterilization and tissue repair therapy, active nonsurgical decompression technique, and the apexum procedure have been advocated. New techniques which use drug-loaded injectable scaffolds, simvastatin, and epigallocatechin-3-gallate have been tried. Surgical option should be considered when intra- or extra-radicular infections are persistent. Incidence of nonendodontic periapical lesions has also been reported. An accurate diagnosis of the periapical lesion whether it is of endodontic or nonendodontic origin has to be made. Surgical methods have many disadvantages, and hence should be considered as an option only in the case of failure of nonsurgical techniques. Assessment of healing of periapical lesions has to be done periodically which necessitates a long-term follow-up. Even large periapical lesions and retreatment cases where the lesion is of endodontic origin have been successfully managed nonsurgically with orthograde endodontic therapy.

Several factors influence the condition of the periapical tissues associated with root filled teeth. The primary objective of this study was to retrospectively evaluate the extent and speed of bone healing of large periapical lesions associated with nonsurgical root canal treatment or retreatment. The secondary objective was to analyse the relationship between the time to complete healing when analysed using cone beam computed tomography (CBCT) and other possible predictors that affect healing. Seventy-nine patients were treated during the years 2013-2020 with large periapical lesions of endodontic origin (10-15 mm) as observed on intraoral periapical radiographs (IOPAR) were included. IOPAR and CBCT were available before treatment and during the follow-up (IOPAR every 6 months and CBCT every 12 months). The volume of periapical lesions was calculated by OsiriX Lite software. Variables such as initial volume of the lesion, age, gender, type of treatment or type of root canal filling were compared to identify the differences between healed and unhealed lesions. Pearson's Chi-square test was used for categorical variables, the t-test for age and the Wilcoxon test for initial volume of the lesion. The association between time to healing and the variables was assessed using univariate analysis and multivariate analysis. The Wilcoxon test was used to observe the association of healing time with categorical variables and the correlation index was measured with the quantitative variables. Of the 79 cases analysed, 60 lesions (76%) were completely healed as verified by CBCT in a mean healing time of 19 months, of which 60% healed fully between 12 and 18 months. Increase in age of patient and larger initial volume of the lesion were associated with a significantly longer healing time (p < .001). Gender, filling material and type of treatment did not have a significant effect on the healing process (p > .05). Clinicians should be aware that periapical lesions in older patients and larger areas of bone loss take longer to heal. CBCT monitoring of large periapical lesions is critical and it can help clinicians in the decision-making process.

The aim of this paper is to report the healing of two large periapical lesions following non-surgical root canal treatment. The first case was a mandibular right lateral with periapical lesion of endodontic origin in a 40 year-old female patient with extra oral fistula and swelling. In the second case, a mandibular right central incisor was affected in a 22 year-old male patient. The root canals were prepared and filled with calcium hydroxide as an intra-canal medicament. The patients were recalled for clinical evaluation at intervals of 3 weeks. Root canals obturations were performed with gutta–percha and AH Plus sealer. The clinical and radiographic examination after 1 year revealed complete repair. This report confirms that large periapical lesions can respond favourably to nonsurgical treatment

Management of Large Radicular Lesions Using Decompression: A Case Series and Review of the Literature

The present study was designed to investigate the relationships between clinicopathological findings and the resorptive conditions of root apices of teeth with periodontitis. The samples included 21 root apices with large periapical radiolucent lesions. The preoperative computed tomography (CT) and intraoperative findings were correlated with the presence, extension, and the progression pattern of periapical resorption using a scanning electron microscope. The subjects' age, gender, chief complaint, type of tooth, percussion test results, size of periapical lesion using CT, and intraoperative findings were recorded. All apicoectomies were performed under an operative microscope for endodontic microsurgery. A significant large size was observed in cystic lesions compared with granulomatous lesions. The cementum surface at the periphery of the lesion was covered with globular structures (2-3 μm in diameter). Cementum resorption started as small defect formations at the surface. As the defect formation progressed, a lamellar structure appeared at the resorption area, and the size of globular structures became smaller than that of globules at the surface. Further resorption produced typical lacuna formation, which was particularly observed in fracture cases. The most morphologically severe destructive pattern of dentin resorption was observed in large cystic lesions. This study is the first report to elucidate the relationships between three clinical types of undesirable periapical lesions: (1) undertreatment, (2) periapical fracture, (3) macro-level resorption, and the microstructure of external root resorption including from small defects at the cementum surface to a significant destructive pattern inside the dentin. Microsc. Res. Tech. 79:495-500, 2016. © 2016 Wiley Periodicals, Inc.

To determine the range and demographic and clinical features of radiolucent inflammatory jaw lesions. Histopathology reports were reviewed to identify radiolucent jaw lesions. There were no clinical exclusive criteria, and the samples represented a wide range of clinical presentation and treatment history from multiple providers. Data were analysed using SPSS. To evaluate concordance of clinical and histological diagnoses, the clinician's provisional diagnosis was compared with the final histopathological diagnosis. A total of 17 038 specimens were reviewed; of these, 4983 (29.2%) were radiolucent jaw lesions, of which inflammatory lesions accounted for 72.8% (n = 3626). Periapical granulomas (59.7%) were the largest group followed by radicular cysts (29.2%). The mean age was 44 years (range 2-100 years), men and women were equally represented and the anterior maxilla was the most common site for the biopsied lesions. A provisional diagnosis was correct for only 48.3% of periapical granulomas and 36% of radicular cysts. This study included all presentations of periapical radiolucent lesions and showed that the incidence of cystic change in periapical lesions of endodontic origin is high at approximately 30% of all inflammatory lesions. Notwithstanding the relative frequencies, demographics and location of radiolucent inflammatory lesions presenting in the New Zealand population are comparable to that of other populations. No inflammatory radiolucent lesion can be reliably accurately diagnosed from clinical presentation and/or radiographic appearance alone.

To report the repair of an extensive periapical lesion of endodontic origin, following nonsurgical treatment. Clinical and radiographic examination revealed an extensive periapical lesion related to tooth 22, extending from the distal surface of tooth 21 to the mesial surface of 26. The patient reported a previous history of dental trauma involving this quadrant and had been under orthodontic treatment for a year. Intraoral examination revealed an asymptomatic bony hard swelling, mainly confined to the palate. During root canal exploration irregular walls associated with 3 mm of apical calcification were noted. After apical patency was obtained 1 mL of bloody serous exudate was drained. Intracanal aspiration provided a further 2 mL of yellow serous exudate. Following biomechanical preparation, a dressing of calcium hydroxide with anaesthetic solution was applied and replaced four times over a period of 12 months. The clinical-pathological picture demonstrated resolution of the lesion during this period of time. The 14-month clinical and radiographic examinations revealed normal bony contour and a significant resolution of the maxillary radiolucency. Periapical lesions of endodontic origin may develop asymptomatically and become large. Proper biomechanical preparation followed by calcium hydroxide medication renewed periodically represents a nonsurgical approach to resolve extensive inflammatory periapical lesions.

This systematic review aims to assess the effectiveness of regenerative approaches in promoting periapical healing and restoring pulp vitality. Periapical lesions of endodontic origin (LIPOE) are a common clinical issue that can compromise the prognosis of the affected tooth. While conventional treatment focuses on infection control and periapical healing, regenerative endodontics has emerged as a promising alternative. The review protocol followed preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines and was registered on PROSPERO (ID: CRD420251046339). A comprehensive electronic and manual search was conducted in three databases-MEDLINE via PubMed, Web of Science, and Cochrane-using keywords such as "periapical lesion," "regenerative endodontics," "platelet-rich fibrin," and "endodontic periapical lesion," focusing exclusively on randomized controlled trials (RCTs). Out of 135 initially retrieved articles, 10 RCTs met the inclusion criteria. Treatment outcomes were assessed through radiographic and clinical evaluations. Revascularization was the most commonly applied technique. The studies demonstrated a significant reduction in periapical lesion size, improved pulp vitality responses, and progressive tissue healing. Risk of bias was assessed using the Cochrane Risk of Bias 2.0 tool, and all included studies were found to have a low risk of bias. The selected studies highlight the effectiveness of regenerative endodontic techniques in the treatment of LIPOE. While the overall results are encouraging, complete pulp regeneration remains limited. This review provides evidence-based information on the effectiveness of regenerative endodontic procedures (REPs) for the treatment of periapical lesions. It underscores the potential of these techniques in promoting periapical healing and partial pulp tissue regeneration, making it a valuable resource for clinicians and researchers in the field of endodontics. How to cite this article: Kawthar BS, Fatma B, Hanen B, et al. Regenerative Endodontics in the Treatment of Periapical Lesions of Endodontic Origin: A Systematic Review of Randomized Controlled Trials. J Contemp Dent Pract 2025;26(6):623-631.

Background : In most cases of large periapical radiolucent lesions of pulpal origin, we often encounter a dilemmatic situation, such as whether to either treat these cases endodontically or surgically. Development of techniques, instruments and root medicaments as well as the tendency toward minimally invasive treatment, all support dentists to treat those cases using the minimal invasive principle (i.e. endodontically instead of surgically). Purpose : The purpose of this paper is to report and discuss the managing of periapical lesions by endodontic no invasive treatment. Case management : The patient with large periapical lesions were treated with noninvasive endodontic treatment. After 6 months, patients in this report were asymptomatic and radiolucencies had disappeared. When the root canal treatment is done according to accepted clinical principles and under aseptic condition, including cleaning, shaping, abturating as well as proper diagnosis, the healing process of the infected area will occur. Conclusion : Some lesions, however, may not be treated conservatively and may require surgical treatment for total elimination of the lesions.

To investigate the diagnostic reliability and accuracy of magnetic resonance imaging (MRI) to differentiate periapical lesions of endodontic origin and to compare the results with histopathological information. The radiolucent periapical jaw lesions of 34 patients, which were surgically enucleated, were investigated by two radiologists using MRI, based on the same six criteria, to categorize the lesions as granulomas, radicular cysts or others. After apicoectomies, two oral pathologists (blinded to the radiologist's diagnoses) analysed all specimens by referring to seven specific parameters and diagnosed the specimens as granulomas, radicular cysts or other conditions. The inter-rater agreements between the radiologists and pathologists in terms of MRI and histological diagnoses, respectively, along with the discriminant power of the adopted criteria and the accuracy of the MRI assessments compared with the histopathological results, were calculated. Cohen's kappa test was adopted to examine inter-rater agreement between the two radiologists and two pathologists. Guttman's lambda coefficient (λ6 ) was used to evaluate the internal consistency of the items used for the differential diagnosis by radiologists. The accuracy resulted from a receiver operator characteristic (ROC) analysis. A strong inter-rater reliability was observed between the two radiologists (k-statistic=0.86, P = 0.0001) and the two pathologists (k-statistic=0.88, P=0.0001). The internal consistency of the diagnostic items was 0.605 for cysts and 0.771 for granulomas. The accuracy (true positives plus true negatives) of the radiologists was greater than that of the pathologists based on analysis (area under the curve=0.87 and 0.91, respectively). The reliability and accuracy of MRI were high and comparable to histopathological reliability, highlightingthe usefulness of this noninvasive technique as a pre-treatment diagnostic method for periapical endodontic lesions.

Background & Objective: Radiographic images are routinely used in the field of endodontics for the diagnosis, treatment planning and follow-up of periapical bone lesions. The possibility of making a distinction between cystic lesions and granulomas among the lesions of endodontic origin may be important in the management of periapical pathosis and in predicting endodontic treatment. Recent developments in radiovisiography (RVG) and Ultrasonography have given the dentist the ability to perform radiographic examinations with greatly reduced rates of radiation exposure. Objective of the study is to assess whether the use of real time ultrasound imaging and RVG can help in the differential diagnosis of periapical lesions of endodontic origin. Method: Ten patients diagnosed with periapical lesions using conventional radiographic findings were subjected to radiovisiography and ultrasound imaging. The comparative evaluation of reports of radiologist and echographist was done to arrive at a tentative differential diagnosis. Interpretation and conclusion: This study has shown that there was definite correlation between the echo structure of a lesion and the nature of lesion. Cystic lesion versus granuloma. The results obtained tallied 90% of the time. Based on the results we can conclude that real time ultrasound imaging and RVG can be used in the endodontic field for the study of periapical lesions.

This paper aims to report a case in which central giant cell granuloma (CGCG) mimicked a periapical lesion of endodontic origin. An 18-year-old female patient was referred for diagnosis and treatment of extensive radiolucent periapical lesion involving 31, 32, 33, 34 and 35 teeth. Clinically, the patient presented slight facial asymmetry and healthy teeth on the affected side with positive response to thermal vitality tests. Thus, an incisional biopsy was performed, which presented a histopathological picture characteristic of a CGCG. The endodontic treatment of the involved teeth was followed by surgical curettage of the lesion. After two years of follow-up, the patient was asymptomatic, with marked improvement in mandibular symmetry and adequate healing of the lesion. Therefore, the diagnosis of radiolucent periapical lesions must include lesions of endodontic and non-endodontic origin for better treatment planning and execution.