Journal of Endodontics
Volume 35, Issue 5 , Pages 607-615 , May 2009

Nonsurgical Root Canal Therapy of Large Cyst-like Inflammatory Periapical Lesions and Inflammatory Apical Cysts

  • Louis M. Lin, BDS, DMD, PhD

      Affiliations

    • Department of Endodontics, New York University College of Dentistry, New York, New York
    • Corresponding Author InformationAddress requests for reprints to Dr Louis M. Lin, Department of Endodontics, New York University College of Dentistry, 345 E 24th St, New York, NY 10010.
    • ,
  • Domenico Ricucci, MD, DDS

      Affiliations

    • Private practice, Rome, Italy
    • ,
  • Jarshen Lin, BDS, DDS

      Affiliations

    • Department of Restorative Dentistry and Biomaterial Sciences, Harvard School of Dental Medicine, Harvard University, Boston, Massachusetts
    • ,
  • Paul A. Rosenberg, DDS

      Affiliations

    • Department of Endodontics, New York University College of Dentistry, New York, New York

References 

  1. Sjogren U, Hagglund B, Sundqvist G, Wing K. Factors affecting the long-term results of endodontic treatment. J Endod. 1990;10:498–503
  2. Marquis VL, Dao T, Farzaneh M, Abitbol S, Friedman S. Treatment outcome in endodontics: the Toronto study—phase III: initial treatment. J Endod. 2006;32:299–306
  3. Lin LM, Huang GT-J, Rosenberg PA. Proliferation of epithelial cell rests, formation of apical cysts, and regression of apical cysts after periapical wound healing. J Endod. 2007;33:908–916
  4. Nair PNR, Sjogren U, Schumacher E, Sundqvist G. Radicular cyst affecting a root-filled human tooth: a long-term post-treatment follow-up. Int Endod J. 1993;26:225–233
  5. Orstavik D, Pitt Ford TR. Essential endodontology. 2nd ed. Oxford: Blackwell Science; 2008;
  6. Cohn S, Hagreaves K. Pathways of the pulp. 9th ed. St Louis: Mosby; 2006;
  7. Ingle J, Bakland L, Baugartner C. Ingle's endodontics. 6th ed. St Louis: Saunders; 2009;
  8. Natkin E, Oswald RJ, Carnes LI. The relationship of lesion size to diagnosis, incidence, and treatment of periapical cysts and granulomas. Oral Surg. 1984;57:82–94
  9. Nair PNR. New perspectives on radicular cysts: do they heal. Int Endod J. 1998;31:155–160
  10. Ten Cate AR. The epithelial cell rests of Malassez and the genesis of the dental cyst. Oral Surg Oral Med Oral Pathol. 1972;34:56–64
  11. Oehlers FAC. Periapical lesions and residusl dental cysts. Br Oral Maxillofac Surg. 1970;8:103–113
  12. Nair PNR, Sundqvist G, Sjogren U. Experimental evidence supports the abscess theory of development of radicular cysts. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008;106:294–303
  13. Harris M, Toller P. The pathogenesis of dental cysts. Br Med Bull. 1975;31:159–163
  14. Shear M. Cysts of the jaw: recent advances. J Oral Pathol. 1985;14:43–59
  15. Langeland K, Block RM, Grossman L. A histopathological, and histobacteriological study of 35 periapical endodontic surgical specimens. J Endod. 1977;3:8–33
  16. Nair PNR, Pajarola G, Schroeder HE. Types and incidence of human periapical lesions obtained with extracted teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1996;81:93–102
  17. Ricucci D, Pascon EA, Pitt Ford TR, Langeland K. Epithelium and bacteria in periapical lesions. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006;101:214–251
  18. Cawson RA, Everson JW. Oral pathology and diagnosis. Philadelphia: Saunders; 1987;
  19. Seltzer S. Endodontology. Philadelphia: Lea & Febiger; 1988;
  20. Main DMG. Epithelial jaw cysts: 10 years of WHO classification. J Oral Pathol Med. 1985;14:1–7
  21. Kramer IR, Pindborg JJ, Shear M. The WHO Histological Typing of Odontogenic Tumours: a commentary on the second edition. Cancer. 1992;70:2988–2994
  22. Barreto DC, Gomez RS, Bale AE, Boson WL, De Marco L. PTCH gene mutations in odontogenic keratocysts. J Dent Res. 2000;79:1418–1422
  23. Shear M. The aggressive nature of the odontogenic keratocyst: is it a benign cystic neoplasm? part 2—proliferation and genetic studies. Oral Oncology. 2002;38:323–331
  24. Agaram NP, Collins BM, Barnes L, et al. Molecular analysis to demonstrate that odontogenic keratocysts are neoplastic. Arch Pathol Lab Med. 2004;128:313–317
  25. Cotran RS, Kumar V, Robbins SL. Robbins pathologic basis of disease. 6th ed. Philadelphia: WB Saunders; 1999;
  26. Warren JR, Scarpelli DG, Reddy JK, Kanwar YS. Essential of general pathology. New York: Macmilliam; 1987;
  27. Slauson DO, Cooper BJ. Mechanisms of disease. 3rd ed. St Louis: Mosby; 2002;
  28. Wong M. Surgical fenestration of large periapical lesions. J Endod. 1991;17:516–521
  29. Enislidis G, Fok N, Sulzbacher I, Ewers R. Conservative treatment of large cystic lesions of the mandible: a prospective study of the effect of decompression. Br J Oral Maxillofacial Surg. 2004;42:546–550
  30. Sakkas N, Schoen R, Schulze D, Otten- J-E, Schmelzeisen R. Obturator after marsupialization of a recurrence of a radicular cyst of mandible. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007;103:e16–e18
  31. Toller PA. The osmolality of fluids from cysts of the jaws. Br Dent J. 1970;129:275–278
  32. Formigli L, Orlandini SZ, Tonelli P, Gianelli M, Martini M, Brandi M. Osteolytic processes in human radicular cysts. J Oral Pathol Med. 1995;24:216–220
  33. Meghji S, Qureshi W, Henderson B, Harris M. The role of endotoxin and cytokines in the pathogenesis of odontogenic cysts. Arch Oral Biol. 1996;41:523–531
  34. Teronen O, Salo T, Laitinen J, et al. Characterization of interstitial collagenases in jaw cyst wall. Eur J Oral Sci. 1995;103:141–147
  35. Birek C, Heersche JN, Jez D, Brynette DM. Secretion of a bone resorbing factor by epithelial cells cultured from porcine rests of Malassez. J Periodontal Res. 1983;18:75–81
  36. Neaverth EJ, Burg HA. Decompression of large periapical cystic lesions. J Endod. 1982;8:175–182
  37. Rees JS. Conservative management of a large maxillary cyst. Int Endod J. 1997;30:64–67
  38. Moiseiwitsch JRD, Trope M. Nonsurgical root canal therapy with apparent indications for root-end surgery. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1998;86:335–340
  39. Oztan MD. Endodontic treatment of teeth associated with a large periapical lesion. Int Endod J. 2002;35:73–78
  40. Calskan MK. Prognosis of large cyst-like peripaical lesions following nonsurgical root canal therapy: a clinical review. Int Endod J. 2004;37:408–416
  41. Lin LM, Gaengler P, Langeland K. Periradicular curettage. Int Endod J. 1996;29:220–227
  42. Trowbridge HO, Emling RC. Inflammation: a review of the process. 5th ed. Chicago: Quintessence Publishing Co, Inc; 1997;
  43. Linkhart TA, Mohan S, Baykink DJ. Growth factors for bone growth and repair: IGF, TGFβ and BMP. Bone. 1996;19:1S–12S
  44. Dimitrious R, Tsiridis E, Giannoudis PV. Current concepts of molecular aspects of bone healing. Injury. 2005;36:1392–1404
  45. Al-Aql ZS, Alagl AS, Graves DT, Gerstenfeld LC, Einvborn TA. Molecular mechanisms controlling bone formation during fracture healing and distraction osteogenesis. J Dent Res. 2008;87:107–118
  46. Raff MC. Social control on cell survival and cell death. Nature. 1992;356:397–400
  47. Collins MK, Perkins GR, Rodriguez-Tarduchy G, Nioto MA, Lopez-Rivas A. Growth factors as survival factors: regulation of apoptosis. Bioessays. 1994;16:133–138
  48. O'Connor R. Survival factors and apoptosis. Adv Biochem Eng Biotechnol. 1998;62:137–166
  49. Raff MC, Barres BA, Burne JF, Coles HS, Ishizaki Y, Jacobson MD. Programmed cell death and the control of cell survival: lessons from the nervous system. Science. 1993;262:695–700
  50. Bergmann A. Survival signaling goes BAD. Dev Cell. 2002;3:607–608
  51. Kvist T, Reit C. Results of endodontic retreatment: a randomized clinical study comparing surgical and nonsurgical procedures. J Endod. 1999;25:814–817
  52. Lin LM, Gaengler P, Langeland K. Periapical curettage. Int Endod J. 1996;29:220–227
  53. Willis RA. The spread of tumors in the human body. 3rd ed. London: Butterworth; 1973;
  54. Majno G, Joris I. Cell, tissues, and disease. 2nd ed. Oxford: Oxford University Press; 2004;210–9
  55. Lodish H, Berk A, Matsudaira P, et al. Molecular cell biology. 5th ed. New York: W.H. Freeman and Co; 2004;
  56. Uemura N, Okamoto S, Yamamoto S, et al. Helicobacter pylori infection and the development of gastric cancer. N Engl J Med. 2001;345:784–789
  57. Coussens LM, Werb Z. Inflammation and cancer. Nature. 2002;420:860–867
  58. Mims C, Playfair J, Roitt I, Wakelin D, Williams R. Medical microbiology. 3rd ed. Philadelphia: Mosby; 2004;
  59. Sabeti M, Simon JH, Slot J. Cytomegalovirus and Epstein-Barr virus are associated with symptomatic periapical pathosis. Oral Microbiol Immunol. 2003;17:327–328
  60. Sabeti M, Slot J. Herpesviral-bacterial coinfection in periapical pathosis. J Endod. 2004;30:69–72
  61. Slot J, Sabeti M, Simon JH. Herpes virus in periapical pathosis: an etiopathologic relationship?. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003;96:327–331
  62. Slot J, Nowzari H, Sabeti M. Cytomegalovirus infection in symptomatic periapical pathosis. Int Endod J. 2004;37:519–524
  63. Bhathal PS, Gall JA. Deletion of hyperplastic biliary epithelial cells by apoptosis following removal of the proliferative stimulus. Liver. 1985;5:311–325
  64. Bursch W, Taper HS, Lauer B, Schulte-Hermann R. Quantitative histological and histochemical studies on the occurrence and stage of controlled cell death (apoptosis) during regression of rat liver hyperplasia. Virchows Arch B Cell Pathol Mol Pathol. 1985;50:153–166
  65. Wyllie AH. Apoptosis: cell death in tissue regulation. J Pathol. 1987;153:313–316
  66. Ledda-Columbano GM, Columbano A, Coni P, Faa G, Pani P. Cell deletion by apoptosis during regression of renal hyperplasia. Am J Pathol. 1989;135:657–662
  67. Santarosa R, Colombel MC, Kaplan S, Monson F, Levin RM, Buttyan R. Hyperplasia and apoptosis: opposing cellular processes that regulate the response of the rabbit bladder to transient outlet obstruction. Lab Invest. 1994;70:503–510
  68. Ohkusa T, Takashimizu I, Fujiki K, et al. Disappearance of hyperplastic polyps in the stomach after eradication of Helicobacter pylori: a randomized, controlled trial. Ann Intern Med. 1998;129:712–715
  69. Nakajima A, Matsuhashi N, Yazaki Y, et al. Details of hyperplastic polyps of the stomach shrinking after anti-Helicobacter pylori therapy. J Gastroenterol. 2000;35:372–375
  70. Nishiyama Y, Koyama S, Andoh A, et al. Gastric inflammatory fibroid poly treated with Helicobacter pylori eradication therapy. Intern Med. 2003;42:263–267
  71. Tchen TT, Chan SW, Kuo TH, Mostafapour KM, Dezewiecki VH. Studies on the adrenal cortex of hypophysectomized rats: a model for abnormal cellular atrophy and death. Mol Cell Biochem. 1977;15:79–87
  72. Wyllie AH, Kerr JFR, Currie AR. Cell death: the significance of apoptosis. Int Revy Cytol. 1980;68:251–306
  73. Buttyan R, Ghafar MA, Shabsigh A. The effects of androgen deprivation on the prostate gland: cell death mediated by vascular regression. Curr Opin Urol. 2000;10:415–420
  74. Molyneux GS. Observations on the structure and growth of periodontal and residual cysts. Oral Surg. 1964;18:80–89
  75. High AS, Hirschmann PN. Age changes in residual radicular cysts. J Oral Pathol. 1986;15:524–528
  76. Kakehashi S, Stanley H, Fitzgerald R. The effect of surgical exposures of dental pulps in germ-free and conventional laboratory rats. Oral Surg Oral Med Oral Pathol. 1965;20:340–349
  77. MÖller AJR, Fabricius L, Dahlen G, Ohman AE, Heyden G. Influence on periapical tissues of indigenous oral bacteria and necrotic pulp tissue in monkeys. Scand J Dent Res. 1981;89:29–39
  78. Nair PNR, Sjogren U, Kahnberg KE, Krey G, Sundqvist G. Intraradicular bacteria and fungi in root-filled, asymptomatic human teeth with therapy-resistant periapical lesions: a long-term light and electron microscopic follow-up study. J Endod. 1990;16:580–588
  79. Lin LM, Pascon EA, Skribner J, Gangler P, Langeland K. Clinical, radiographic, and histologic study of endodontic treatment failures. Oral Surg Oral Med Oral Pathol. 1991;71:603–611
  80. Dahlen G, Haapasalo M. Microbiology of apical periodontitis. In: Essential endodontology. 2nd ed. Oxford: Blackwell Science; 2008;
  81. Nair PNR, Sjogren U, Sundqvist G. Cholesterol crystals as an etiologic factor in non-resolving chronic inflammation: an experimental study in guinea pigs. Eur J Oral Sci. 1998;106:644–650
  82. Nair PNR. Cholesterol as an aetiological agent in endodontic failures: a review. Aust Endod J. 1999;25:19–26
  83. Trott JR, Chebib F, Galindo Y. Factors related to cholesterol formation in cysts and granulomas. J Can Dent Assoc. 1973;39:550–555
  84. Tabas I. Consequences of cellular cholesterol accumulation: basic concepts and physiological implications. J Clin Invest. 2002;110:905–911
  85. Gotto AM. Cholesterol management in theory and practice. Circulation. 1997;96:4424–4430
  86. Bhaskar SN. Periapical lesions. types, incidence and clinical feature. Oral Surg Oral Med Oral Pathol. 1966;21:657–671
  87. Browne RM. The origin of cholesterol in odontogenic cysts in man. Arch Oral Biol. 1971;16:107–113
  88. Sedaghat A, Grundy SM. Cholesterol crystals and the formation of cholesterol gallstone. Arteriosclerosis. 1983;3:283–301
  89. Kruth HS, Skarlatos SI, Lilly K, Chang J, Ifrim I. Sequestration of acetylated LDL and cholesterol crystals by human monocyte-derived macrophages. J Cell Biol. 1995;129:133–145
  90. Jones NL, Willingham MC. Modified LDLs are internalized by macrophages in part via macropinocytosis. Anat Rec. 1999;255:57–68
  91. Klinkner AM, Waites CR, Kerns WD, Bugelski PJ. Evidence of foam cell and cholesterol crystal formation in macrophages incubated with oxidized LDL by fluorescence and electron microscopy. J Histochem Cytochem. 1995;43:1071–1078
  92. Vainio S, Ikonen E. Macrophages cholesterol transport: a critical player in foam cell formation. Ann Med. 2003;35:146–155
  93. Brown MS, Goldstein JL. Lipoprotein metabolism in the macrophage: implications for cholesterol deposition in artherosclerosis. Ann Rev Biochem. 1983;52:223–261
  94. Ho YK, Brown MS, Goldstein JL. Hydrolysis and excretion of cytoplasmic cholesterol esters by macrophage: stimulation by high density lipoprotein and other agents. J Lipid Res. 1980;21:391–398
  95. Bjorkhem I. Do oxysterols control cholesterol homeostasis?. J Clin Invest. 2002;110:725–730
  96. Goldstein JL, Brown MS. Familiar hypercholesterolemia: pathogenesis of a receptor disease. Johns Hopkins Med J. 1978;14:8–16
  97. Brown MS, Ho YK, Goldstein JL. The cholesterol ester cycle in macrophage foam cells: continual hydrolysis and reesterification of cytoplasmic cholesterol esters. J Biol Chem. 1980;255:9344–9352
  98. Tall AR, Coster P, Wang N. Regulation and mechanisms of macrophage cholesterol efflux. J Clin Invest. 2002;110:899–904
  99. Chang T-Y, Chang CCY, Ohgami N, Yamauchi Y. Cholesterol sensing, trafficking, and esterification. Ann Rev Cell Develop Biol. 2006;22:129–157
  100. Tabas I. Free cholesterol-induced cytotoxicity: a possible contributing factor to macrophage foam cell necrosis in advanced atherosclerosis lesions. Trends Cardiovasc Med. 1997;7:256–263
  101. Druilhet RE, Traxler RW, Sobek JM. Bacterial utilization of cholesterol. Antonie van Leewenhoek. 1968;34:315–325
  102. Imshenetskii AA, Nikitin LE, Nazarova TS, Efimochkina EF. Activities of cholesterol degrading microorganisms. Mikrobiologiya. 1975;44:210–213
  103. Sjogren U, Figdor D, Persson S, Sundqvist G. Influence of infection at the time of root filling on the outcome of endodontic treatment of teeth with apical periodontitis. Int Endod J. 1997;30:297–306
  104. Brain SD. Sensory peptides: their role in inflammation and wound healing. Immunopharmacology. 1997;37:133–152
  105. Greenhalgh DG. The role of apoptosis in wound healing. Int J Biochem Cell Biol. 1998;30:1019–1030
  106. Steed DL. The role of growth factors in wound healing. Surg Clin North Am. 1997;77:575–586
  107. Werner S, Grose R. Regulation of wound healing by growth factors and cytokines. Physiol Rev. 2003;83:835–870
  108. Andreasen JO, Rud J. Modes of healing histologically after endodontic surgery in 70 cases. Int Oral Surg. 1972;1:149–162
  109. Leonardo MR, Silva LAB, Utrilla LS, Assed S, Ether SS. Calcium hydroxide root canal sealers: histologic evaluation of apical and periapical repair after endodontic treatment. J Endod. 1997;23:428–432
  110. Leonardo MR, Hemandez MEFT, Silva LAB, Tanomaru-Filho M. Effect of a calcium hydroxide-based root canal dressing on periapical repair in dogs: a histological study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006;102:680–685
  111. Harrison JW, Jurosky KA. Wound healing in the tissue of periodontium following periradicular surgery: II—the dissectional wound. J Endod. 1991;17:544–552
  112. Harrison JW, Jurosky KA. Wound healing in the tissue of the periodontium following periradicular surgery: III—the osseous excisional wound. J Endod. 1992;18:76–81
  113. Ten Cate R. Oral histology. 5th ed. St Louis: Mosby; 1998;
  114. MacNeil RL, Somerman MJ. Development and regeneration of the periodontium: parallels and contrast. Periodontol. 1999;19:8–20
  115. Sonoyama W, Seo B-M, Yamaza T, Shi S. Human Hertwig's epithelial root sheath cells play crucial roles in cementum formation. J Dent Res. 2007;86:594–599
  116. Grzesik WJ, Narayanan AS. Cementum and periodontal wound healing and regeneration. Crit Rev Oral Biol Med. 2002;13:474–484
  117. Seo B-M, Miura M, Gronthos S, et al. Investigation of multipotent postnatal stem cells from human periodontal ligament. Lancet. 2004;364:149–155
  118. Al-Aql ZS, Alagl AS, Graves DT, Gerstenfeld LC, Einborn TA. Molecular mechanisms controlling bone formation during fracture healing and distraction osteogenesis. J Dent Res. 2008;87:107–118
  119. Linkhart TA, Mohan S, Baylink DJ. Growth factors for bone growth and repair: IGF, TGF β and BMP. Bone. 1996;19:S1–12
  120. Valderhaung J. A histologic study of experimentally induced periapical inflammation in primary teeth in monkeys. Int J Oral Surg. 1974;3:111–123
  121. Simon JHS, Enciso R, Malfaz JM, Roges R, Bailey-Perry M, Patel A. Differential diagnosis of large periapical lesions using cone-beam computed tomography measurements and biopsy. J Endod. 2006;32:833–837
  122. Rosenberg PA, Frisbie J, Lee J, Lee KE. Evaluation of pathologists (histopathology) and radiologists (cone beam computed tomography) differentiating periapical cysts from granulomas. J Endod (in press).
  123. Siqueira JF, Rocas IN. Clinical implications and microbiology of bacterial persistence after treatment procedures. J Endod. 2008;34:1291–1301
  124. Ricucci D, Siqueira JF. Anatomic and microbiologic challenges to achieving success with endodontic treatment: a case report. J Endod. 2008;34:1249–1254

PII: S0099-2399(09)00134-4

doi: 10.1016/j.joen.2009.02.012

Journal of Endodontics
Volume 35, Issue 5 , Pages 607-615 , May 2009

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