Periapical Granuloma

IJPCDR
10.5005/jp-journals-10052-0008
Periapical Granuloma
Case Report
1
Anish Sebastian, 2Prasanth Panikar, 3Kasim Kota, 4Asika Sasi
ABSTRACT lesions of periapical granuloma are discovered in routine

Periapical granuloma is a relatively common lesion or growth radiographic examination, and it is the most common
consisting of a proliferating mass of granulation tissue and bac- periapical radiolucency found in dental practice.
teria that form in response to dead tissue in the pulp chamber
of the tooth. The death of the pulp may be due to extensive CASE REPORT
decay, deep restorations, or trauma to the tooth. It is consid-
ered a reactive inflammatory process resulting from chronic An 18-year-old boy reported to the dental clinic. His chief
irritation originating from the root canal system of the affected complaint was pain and swelling in the left mandibular
root. Periapical granuloma mainly consists of granulation tissue
posterior region (Fig. 1). A pulp test indicated necrosis of
with alveolar bone loss and a large number of T lymphocytes
and monocytes/macrophages together with a small number of the pulp of the left mandibular first molar. Periapical radio-
B lymphocytes and polymorpho-nuclear leukocytes. graph showed a well-defined radiolucent lesion extending
Keywords: Dental caries, Dental granuloma, Periapical from the mesial to the distal root (Fig. 2). The widest hori-
granuloma. zontal diameter of the lesion on the film was approximately
How to cite this article: Sebastian A, Panikar P, Kota K, Sasi A. 3.2 mm. With the exception of the left mandibular first
Periapical Granuloma. Int J Prev Clin Dent Res 2016;3(1):35-37. molar, all other teeth in the area of the lesion responded
Source of support: Nil normally to the pulp tests. Root canal therapy was begun
Conflict of interest: None at this time and completed 2 weeks later. Recall radiograph
taken after 8 months showed partial resolution of the lesion
INTRODUCTION (Fig. 3) and after 18 months showed complete resolution of
the lesion (Fig. 4). The patient is asymptomatic since then.
In periapical granuloma (dental granuloma, chronic
apical periodontitis), a tooth dies and may become
HISTOPATHOLOGY
slightly tender to touch, but shows little in the way of
symptoms. The dead tooth may develop a low-grade Hyperemia and edema of the periodontal ligament with
infection around the root tip, which often follows an infiltration of the chronic inflammatory cells are seen.
acute infection that has been inadequately drained The inflammation and localized increased vascularity
and incompletely resolved.1-3 It is the most common are associated with resorption of the supporting bone
sequel of pulpitis or acute periapical periodontitis. The adjacent to this area. As the bone is resorbed, there is
spread of pulpal infection is usually but not always in a proliferation of both fibroblasts and endothelial cells with
periapical direction. The presence of lateral or accessory the formation of more tiny vascular channels and fibrils.
root canal opening on the lateral surface of the root at Swollen endothelial cells line the new capillaries. It is a
any level is a well-recognized anatomic deviation along relatively homogenous lesion composed predominantly
which the infection may spread. It will give rise to a of macrophages, lymphocytes, and plasma cells. In early
lateral granuloma or related inflammatory lesion.4,5 Most
1
Professor, 2Reader, 3Professor and Head, 4Postgraduate
Student
1,4
Department of Conservative Dentistry, Kannur Dental
College and Hospital, Kannur, Kerala, India
2
Department of Oral and Maxillofacial Surgery, Kannur Dental
3
Department of Oral Pathology, Kannur Dental College and
Hospital, Kannur, Kerala, India
4
Department of Conservative and Endodontics, Kannur Dental
Corresponding Author: Anish Sebastian, Professor
Department of Conservative Dentistry and Endodontics Kannur
Dental College and Hospital, Kannur, Kerala, India, e-mail:
[email protected]
Fig. 1: Extraoral view
International Journal of Preventive and Clinical Dental Research, January-March 2016;3(1):35-37 35

Anish Sebastian et al
Fig. 2: Preoperative view Fig. 3: Eight months postoperative
periapical granuloma, the epithelium is found close to the

periodontal ligament. In course of time the epithelium
undergoes proliferation by the inflammatory stimuli
and shows an attempt to wall off the irritant coming out
through the apical foramen, which becomes extensive
and presents as sheets of stratified squamous epithelial
cells as well as anastomosing cords.
TREATMENT AND PROGNOSIS

The treatment of periapical granuloma is extraction of the
involved teeth or, under certain conditions, root canal
therapy with or without subsequent apicoectomy. If left
untreated, periapical granuloma may ultimately undergo
transformation into an apical periodontal cyst through
Fig. 4: Eighteen months postoperative
proliferation of epithelial rests in the area. In our patient,
root canal treatment was performed.
suggested that instrumentation of root canals through the
DISCUSSION apical foramen during treatment might result in a “transi-
The treatment of periapical granuloma mainly consists of tory acute inflammation with epithelial destruction” or
root canal therapy with or without subsequent apicoec- “subepithelial hemorrhage with ulceration of the epithe-
tomy.6 If the initial conventional therapy is unsuccessful, lial lining.” He postulated that these mechanisms could
endodontic retreatment represents the best approach for destroy or disrupt the cyst epithelium, thus converting the
total elimination of bacteria and should be considered cyst to a granuloma, which could resolve without surgical
before periapical surgery. If left untreated, the periapical intervention. Thomas et al10 described two cases of peri-
granuloma may ultimately undergo transformation into an apical lesions treated by endodontic therapy. The canals
apical periodontal cyst through proliferation of epithelial were thoroughly debrided with sodium hypochlorite and
rests in the area. John et al7 evaluated periapically involved calcium hydroxide paste placed in the canals. The access
teeth treated endodontically to determine their rate of cavities were sealed with temporary restorations and
success. More important to the study, the rate of failure patients were prescribed antibiotics. Four weeks postop-
was also established, and the causes of failure were care- erative it was observed that the lesions showed complete
fully examined. Nearly 95% of all endodontically treated resolution, and it was suggested that the largeness of a
teeth were successful. Lanolde8 suggested that whether a lesion does not mandate its surgical removal and that
periapically involved tooth is affected by a granuloma or a even cyst-like lesions heal following conservative therapy.
cyst, nonsurgical endodontic therapy may be the treatment
CONCLUSION
of choice. If the periapical lesion does not heal properly,
an apicoectomy can be performed at a later date. Bhaskar9 Apical granuloma is an advanced stage of chronic
in an attempt to explain nonsurgical resolution of cysts apical periodontitis. It is the most common periapical
36
IJPCDR
radiolucency found in dental practice. If cortical plate 4. Kuntz DD, Genco RJ. Localization of immunoglobulins and
is perforated, healing begins with regeneration of the complement in persistent periapical lesions. IADR Progress
Abst 1974;53:641.
external cortical plate. It may usually show signs of 5. Miller, WD. The micro-organisms of the human mouth. Phila-
healing within 1 year of treatment and in many instances delphia (PA): White Dental MFG Co.; 1890. p. 96.
as early as 2 to 4 months. 6. Shafer, WG.; Hine, MK.; Levy, BM. A textbook of oral patho
logy. 4th ed. Philadelphia (PA): WB Saunders; 1983.
7. John I, James HS, Pierre M, Patrick B. Outcome of endodontic
REFERENCES treatment and re-treatment. Endodontics 1956;22:1-22.
8. Lanolde ER. A new rationale for the management of periapi-
1. Neville, BW.; Damn, DD.; Allen, CM.; Bouqout, JE. Pulp and
cal granulomas and cysts: an evaluation of histopathologic
periapical disease. Oral and maxillofacial pathology. 2nd ed.
and radiographic findings. J Am Dent Assoc 1970 May;80(5):
Philadelphia (PA): WB Saunders; 2002.
1056-1059.
2. Stern MH, Drezen S, Mackler BF, Selbst AG, Levy BM. Quan- 9. Bhaskar SN. Nonsurgical resolution of radicular cysts. Oral
titative analysis of cellular composition of human periapical Surg Oral Med Oral Pathol 1972 Sep;34(3):458-468.
granuloma. J Endod 1981 Mar;7(3):117-122. 10. Thomas SB, Kandari AR, Abdul AA. Healing of large periapi-
3. Willoughby DA, Ryan GB. Evidence for a possible endogenous cal lesions following calcium hydroxide endodontic therapy:
antigen in chronic inflammation. J Pathol 1970 Jul;101(3): two case reports and review of literature. Endodontology
233-239. 2000;12:32-36.
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IJPCDR

ABSTRACT lesions of periapical granuloma are discovered in routine

International Journal of Preventive and Clinical Dental Research, January-March 2016;3(1):35-37 35

Fig. 2: Preoperative view Fig. 3: Eight months postoperative

periapical granuloma, the epithelium is found close to the

TREATMENT AND PROGNOSIS

International Journal of Preventive and Clinical Dental Research, January-March 2016;3(1):35-37 37

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