Nonsurgical management of large periapical lesions

Dr. Fernando Noronha M.D.S

Introduction

Physiopathological relationship of pulp and

periapical tissues triggers an inflammatory response which starts a resorptive process

Immunopathological mechanisms lead to formation of abscesses, granulomas and periapical cysts

Histological analysis of 256 periapical lesions found that 35% were abscesses, 50% were granulomas,and only 15% were cysts. Nonetheless 52%of the lesions had an epithelial component

◦ Nair et al (1996). Oral surgery Oral medicine Oral pathology Oral radiology Endodontics 81, 93-102

Case 1A 18 year old female

complains of pain in the upper left molar region since the tooth was treated for root canal. She also complains of pain on biting,intermittent swelling and pus discharge.

History

The upper left 6 was root treated 4 months back,by a different dentist, because it developed acute pain,. Following the treatment the patient continued to experience pain and discomfort for which the dentist advised antibiotics and painkillers.

Differential Diagnosis

● Inadequate root canal treatment.● Cracked tooth● Periodontal abscess● Periapical lesion● Some other tooth is the focus of infection.

Examination

The patient is afebrile without any lymph node involvement.

Swelling and tenderness in the buccal aspect of upper left 6.

Draining sinus present in the same region.Mildly tender to percussion.

INVESTIGATIONS:

● Intraoral periapical radiographs.● Vitality testing of adjacent and opposing

teeth.● Cone Beam C.T.

Radiographic FindingsWe can see a solitary

discrete irregularly round in shape radiolucency of approximately 1x1.5cms in size located in the upper left first molar region (which is root treated) with epicenter at the mesio buccal root, has well defined borders and is not associated with any resorption or deviation.

Diagnosis

Periapical Inflammatory Lesion resembling a Cyst

Treatment PlanEmergency treatment-

Removal of the gp and establishing drainage through the canals.

Intracanal medication - ledermix paste and calcium hydroxide.

Changing the dressings initially weekly and subsequently once in two weeks for 3 months.

Then monthly follow up for the next 9 months and occasional calcium hydroxide dressings were given.

PRE - OP (FEB ‘13)

POST - OP ( FEB’ 14)

Effect of biomechanical preparation on the intracanal microbiota

Effect of lesion decompression by establishing apical patency

Effect of calcium hydroxide Effect of the immune system on the

epithelial component

Rationale

Case 2:

PRE - OP POST - OP

Other Treatments:

1. Conservative R.C.T2. Decompression Technique3. Active non surgical

decompression4. Aspiration and irrigation

though Root Canals.5. Using Calcium Hydroxide6. Antibiotic pastes and MTA7. Niti Ablators [Apexum

procedure]

Conclusion

Thank You!

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