Periapical granuloma, also sometimes referred to as a radicular granuloma or apical granuloma, is an inflammation at the tip of a dead (nonvital) tooth. It is a

lesion A lesion is any damage or abnormal change in the tissue of an organism, usually caused by disease or trauma. ''Lesion'' is derived from the Latin "injury". Lesions may occur in plants as well as animals. Types There is no designated classif ...

or mass that typically starts out as an

epithelial Epithelium or epithelial tissue is one of the four basic types of animal tissue, along with connective tissue, muscle tissue and nervous tissue. It is a thin, continuous, protective layer of compactly packed cells with a little intercell ...

lined

cyst A cyst is a closed sac, having a distinct envelope and division compared with the nearby tissue. Hence, it is a cluster of cells that have grouped together to form a sac (like the manner in which water molecules group together to form a bubble) ...

, and undergoes an inward curvature that results in

inflammation Inflammation (from la, inflammatio) is part of the complex biological response of body tissues to harmful stimuli, such as pathogens, damaged cells, or irritants, and is a protective response involving immune cells, blood vessels, and molec ...

granulation tissue Granulation tissue is new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process. Granulation tissue typically grows from the base of a wound and is able to fill wounds of almost any siz ...

at the root tips of a dead tooth. This is usually due to

dental caries Tooth decay, also known as cavities or caries, is the breakdown of teeth due to acids produced by bacteria. The cavities may be a number of different colors from yellow to black. Symptoms may include pain and difficulty with eating. Complicat ...

or a bacterial infection of the

dental pulp The pulp is the connective tissue, nerves, blood vessels, and odontoblasts that comprise the innermost layer of a tooth. The pulp's activity and signalling processes regulate its behaviour. Anatomy The pulp is the neurovascular bundle centr ...

. Periapical granuloma is an infrequent disorder that has an occurrence rate between 9.3 to 87.1 percent. Periapical granuloma is not a true granuloma due to the fact that it does not contain granulomatous inflammation; however, ''periapical granuloma'' is a common term used.

Symptoms

Patients who have a periapical granuloma are usually asymptomatic; however, when there is inflammation, patients could experience temperature sensitivity, pain while chewing solid foods, swelling and sensitivity to a dental percussion test. Generally, periapical granuloma is diagnosed due to

acute Acute may refer to: Science and technology * Acute angle ** Acute triangle ** Acute, a leaf shape in the glossary of leaf morphology * Acute (medicine), a disease that it is of short duration and of recent onset. ** Acute toxicity, the adverse eff ...

pain in a tooth, or during a radiographic examination in routine visits to the dentist.

Radiographic Features

When looking at the

radiographic Radiography is an imaging technique using X-rays, gamma rays, or similar ionizing radiation and non-ionizing radiation to view the internal form of an object. Applications of radiography include medical radiography ("diagnostic" and "therapeut ...

features of periapical granuloma, typically there is a

radiolucent Radiodensity (or radiopacity) is opacity to the radio wave and X-ray portion of the electromagnetic spectrum: that is, the relative inability of those kinds of electromagnetic radiation to pass through a particular material. Radiolucency or hypod ...

lesion visible at the tip of a root on a nonvital tooth. This often is associated with

root resorption Resorption of the root of the tooth, or root resorption, is the progressive loss of dentin and cementum by the action of odontoclasts. Root resorption is a normal physiological process that occurs in the exfoliation of the primary dentition. Howeve ...

. The radiolucency must correlate with the lateral root surface or the root of the tooth. The average size of radiography when looking at periapical granuloma is 7.4 millimeters (mm).

Histopathology

When examining the tissues of periapical granuloma for disease,

hyperaemia Hyperaemia (also hyperemia) is the increase of blood flow to different tissues in the body. It can have medical implications but is also a regulatory response, allowing change in blood supply to different tissues through vasodilation. Clinically, ...

oedema Edema, also spelled oedema, and also known as fluid retention, dropsy, hydropsy and swelling, is the build-up of fluid in the body's tissue. Most commonly, the legs or arms are affected. Symptoms may include skin which feels tight, the area ma ...

and chronic inflammation is observed in the

periodontal ligament The periodontal ligament, commonly abbreviated as the PDL, is a group of specialized connective tissue fibers that essentially attach a tooth to the alveolar bone within which it sits. It inserts into root cementum one side and onto alveolar b ...

. The vascular amplification and inflammation is adjacent to the bone, and bone absorption occurs next to a large growth in fibroblast and

endothelial cells The endothelium is a single layer of squamous endothelial cells that line the interior surface of blood vessels and lymphatic vessels. The endothelium forms an interface between circulating blood or lymph in the lumen and the rest of the vessel ...

which is composed of the small fibers (fibrils) with small vascular conduits (channels of passage for fluids). The lesion is predominantly composed of

plasma cells Plasma cells, also called plasma B cells or effector B cells, are white blood cells that originate in the lymphoid organs as B lymphocytes and secrete large quantities of proteins called antibodies in response to being presented specific substan ...

that are mixed with

macrophages Macrophages (abbreviated as M φ, MΦ or MP) ( el, large eaters, from Greek ''μακρός'' (') = large, ''φαγεῖν'' (') = to eat) are a type of white blood cell of the immune system that engulfs and digests pathogens, such as cancer ce ...

and lymphocytes with endothelial cells and fibroblasts.

Treatment

Treatment for periapical granuloma is initially treated with a nonsurgical procedure. Endodontic treatments of teeth with periapical lesions (lesions that occurred as a result of dental pulp inflammation) have a success rate up to 85 percent. Other forms of nonsurgical treatments used for periapical lesions are: a

root canal A root canal is the naturally occurring anatomic space within the root of a tooth. It consists of the pulp chamber (within the coronal part of the tooth), the main canal(s), and more intricate anatomical branches that may connect the root ...

, an aspiration-irrigation technique (a technique to help minimize the force required for the removal of root canal irrigant); a decompression technique (a minimally invasive surgery that involves the placement of tubing to help maintain drainage); Lesion Sterilization and Repair Therapy (a technique that allows disinfection of pulpal (dental pulp), dentinal ( dentin) and periradicular (around a root) lesions by using a combination of antibacterial drugs; a method using calcium hydroxide and the Apexum procedure (a minimally invasive removal, through a root canal access, of periapical chronically inflamed tissue). It is essential to monitor the healing closely after treatment with frequent follow-up examinations. If nonsurgical techniques fail, surgical intervention is then recommended. There are many things to be considered prior to surgical treatment in order to decide which technique will have the best outcome. When determining an approach for surgical approaches, clinicians must establish the correct

diagnosis Diagnosis is the identification of the nature and cause of a certain phenomenon. Diagnosis is used in many different disciplines, with variations in the use of logic, analytics, and experience, to determine " cause and effect". In systems engin ...

of the lesion to make sure there isn’t treatment being done on healthy (vital) teeth. It is also important to take into consideration the distance (proximity) of the lesion to the vital teeth. If the lesion is in close proximity to the roots of vital teeth, a surgical approach may have negative outcomes that include the blood vessels and nerves of the adjacent teeth being injured, this of which would jeopardize their vitality (life). Surgical approaches increase the risk of the anatomic structures being damaged. Some of these anatomic structures include: the

nasal cavity The nasal cavity is a large, air-filled space above and behind the human nose, nose in the middle of the face. The nasal septum divides the cavity into two cavities, also known as fossae. Each cavity is the continuation of one of the two nostrils. ...

mental foramen The mental foramen is one of two foramina (openings) located on the anterior surface of the mandible. It is part of the mandibular canal. It transmits the terminal branches of the inferior alveolar nerve and the mental vessels. Structure The ...

, the

inferior alveolar nerve The inferior alveolar nerve (IAN) (also the inferior dental nerve) is a branch of the mandibular nerve, which is itself the third branch of the trigeminal nerve. The inferior alveolar nerves supply sensation to the lower teeth. Structure The in ...

and / or the

inferior alveolar artery The inferior alveolar artery (inferior dental artery) is an artery of the face. It is a branch of the first portion of the maxillary artery. Structure It descends with the inferior alveolar nerve to the mandibular foramen on the medial surface of ...

and the

maxillary sinus The pyramid-shaped maxillary sinus (or antrum of Highmore) is the largest of the paranasal sinuses, and drains into the middle meatus of the nose through the osteomeatal complex.Human Anatomy, Jacobs, Elsevier, 2008, page 209-210 Structure It i ...

. When sinus cavities or adjacent tissue spaces are involved, the nonsurgical aspiration-irrigation technique is also not advised. The patient’s cooperation and age of the patient are very important as well. Patients may experience pain or discomfort during or after treatment when taking the surgical approach which could make them uncooperative. Patients that are older may not be able to tolerate this pain or discomfort, therefore they may require nonsurgical approaches. If access to the

apical foramen In dental anatomy, the apical foramen, literally translated "small opening of the apex," is the tooth's natural opening, found at the root's very tip—that is, the root's apex—whereby an artery, vein, and nerve enter the tooth and commingle w ...

is prevented due to blockages in the root canal system, a surgical approach may be warranted. Finally, surgery is recommended in cases where patients have the presence of cholesterol crystals or inflammatory apical true cysts (the top of an enclosed space lined by the epithelium and usually contains fluid) due to the fact that these can prevent the healing of the lesions.

References

{{reflist Dentistry Anatomical pathology

Symptoms

Radiographic Features

Histopathology

Treatment

See also

References