Periapical Pathology.xls - College of Diplomates by xiuliliaofz



                                                                                 Long Beach VA, Endodontic Section

                                                                    Rahim Karmali DDS, Steven Merchant DDS, Stephen Davis DDS

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Author        Date Subject        Title                   Take Away
                                                          Case report. Pulse granuloma is a foreign body rxn caused by legumes. Can occur if the pulp chamber is exposed
                                  Clinical significance   due to caries or if the tooth is left open during tx. Clinical implications: 1. Do not leave the tooth open. If you have to,
                     Periapical   of the pulse            do so for the shortest amt of time poss. 2. If the chamber is exposed for an extended amt of time, possibiliyt of a
Simon         1982   Pathology    granuloma               pulse granuloma should be considered in refractory cases.
                                                          Stained 20 PA lesions for antibodies to establish the proportions of immunoglobulin positve B lymphocytes and
                                                          plasma cells and their distribution in endo tx vs non tx teeth. 81% of the inflamm cells did not stain for
                                  Antibody producing      immunoglobulins, meaning that they were T cell or null cells. Of the 19% that did stain positive, 74% stained for IgG,
                                  cells in human          20% for IgA, 4% IgE and 2% IgM. There was no stat sig difference in teeth that were endo tx vs non-tx. Indicates
                                  periapical              that NSRCT does not alter the humoral immune responses in PA lesions. Comments: These are the normal
                     Periapical   granulomas and          proportions found in the body, so this is nothing extraordinary. This may not seem like a big deal today, but this stuff
Stern, Levy   1982   Pathology    cysts                   was only described only 20 years ago. This is realatively new stuff.
                                  Role of oral
                                  microorganisms in
                                  the pathogenesis of
                                  pericapical pathosis.
                                  I. Effect of S. mutans
                                  and its cellular
                                  constituents on the
                                  dental pulp and        Exposed cat canines to S. Mutans, either whole or fragments. Found that both induced severe PA dz. Even cell wall
                     Periapical   periapical tissue of fragments of some bacteria may cause PA dz. Comments: Even if you kill the bacteria w/ intracanal meds, have you
Stabholz      1983   Pathology    cats                   removed all the cell components?? Will these have a negative effect upon healing??
                                                         Case report of SOT-like epith proliferation in an odontogenic cyst. This looks similar histologically to a Squamous
                                  Squamous               Odontogenic Tumor but the clinical and radiographic features are different. The SOT-like cyst has an epith
                                  odontogenic tumor- proliferation that will not fill the cyst, otherwise it behaves just like an ordinary cyst. The SOT is a benign
                     Periapical   like proliferations in odontogenic tumor, causes mobility, has mulitple radiographic lesions, and has a triangular or semi-circular lucencies
Simon         1985   Pathology    periapical cysts       assoc w/ the alveolar crest.
                                 Cellulose fibers from
                                 endodontic paper
                                 points as an
                                 etiological factor in
                                 post endodontic         Post endodontic lesions frequently display foreign body reactions. Looked histologically at 8 lesions dx as having
                                 periapical              foreign bodies. Found cellulose fibers in the lesions, probably from paper points. Cellulose, even in minute amts, can
                    Periapical   granulomas and          cause vivid inflamm reactions and cellulose is not broken down by the body. Extreme caution should be used w/
Koppang      1989   Pathology    cysts                   paper points.

                                 Kinetics of immune
                                 cell and bone          T cells, more so than B cells, are responsible for PA lesion pathogenesis. Futhermore, T helper cells predominate in
                                 resorptive responses   actively growing lesions while T supressor cells predominate in chronic lesions. Temporally, tissue destruction is not
Stashenko,          Periapical   to endodontic          linear but happens in bursts of activity. Induced PA lesions in rats and histologically examined lesions at different
Wang         1992   Pathology    infections             time points. Comments: Stashenko and Nair are the go-to guys for mechanisms of PA pathosis .
                                                        PA lesions contain low but significant amts of bone resorptive activity. This was unaffected by Polymixin B which
                                                        nuetralizes LPS. This discounts the direct affect of LPS in forming PA lesions, suggesting the presence of protein
                                                        mediators causing resorption. Action of LPS is probably to stimulate the production of cytokines from macrophages
                                 Characterizations of and lymphocytes. IL-1B and TNF-B are also elevated in sites of resorption. TNF-B is produced by T cells (see
                                 bone resorbing         Stashenko 1992.) Comments: In the old days, literature mentioned Osteoclast Activating Factor (OAF) that
Stashenko,          Periapical   activity in human      somehow activated resorption. Today, it is found that OAF is really a combination of IL-1b, and TNF-b. These
Wang         1993   Pathology    periapical lesions     factors are host produced but stimulated by some foreign substance.
                                                        Induced PA lesions in ferrets and histologically examined them up to 12 wks out. All the RCT teeth showed a
                                                        tendency towards healing, in contrast to the non-treated controls. There was a deposition of new cellular cementum
                                                        around the PA. An abundance of vascular elements, fibroblasts and osteoblasts were also assoc w/ the treated
                                 Healing of induced teeth. There were fewer lymphocytes in the treated group as well. Expressed sealer showed signs of phagocytosis.
                    Periapical   periapical lesions in Comments: The big deal is that they found the deposition of new least in the ferret. So in healing, we
Fouad        1993   Pathology    ferret canines         are assuming that cementum regenerates around the apex.
                                                        Exposed rat molar pulps to the oral environment and measured the histometrical changes in the pulp and the PA
                                 Pulpal and periapical tissues. Necrosis increased from 1-28 days, with full necrosis at 28 days. Inflamm was already present at the PA in
                                 tissue reactions after 3 days. Abscesses formed around the PA at 21 days. As soon as bacteria and their by-products leak past the apex,
                    Periapical   experimental pulal     regardless of pulp vitality, they cause PA inflamm. This is why it is possible to have a PA lucency w/ a partially vital
Yamasaki     1994   Pathology    exposures in rats.     pulp.
                    Periapical   Squamous               Presents case reports. Rare, benign, arise from Rests of Malassez. Triangular, uni-locular expansile lucency in the
Baden        1993   Pathology    odontogenic tumor alveolar process btwn the roots of teeth. Mult sites 25% of the time.
                                                        Surgically excised 10 sinus tracts to evaluate them for the presence of epith lining. Found only one that was lined w/
                                                        eptih. Showed that it is poss for tracts to be lined w/ epith, but that it is uncommon. These are clinically
                    Periapical   The epithelized oral indistinguishable from tracts lined w/ granulation tissue there was no correlation found w/ time lesion was present
Harrison     1976   Pathology    sinus tract            and the development of epith.
                                 examination of oral
                                 sinus tracts and their Microscopic examination of 30 sinus tracts. 100% were lined w/ squamous epith at the oral interface. 67% did not
Baumgartne          Periapical   associated             exhibit epith deeper than this. 33% showed epith extending the length of the canal. Sinus tracts were usu assoc w/
r          1984     Pathology    pericapical lesions    lesions grtr than 5mm.
                                pathosis causing
                                sinus tract formation
                                through the           Case reports. Contibuting factors are root proximity, dilacerations, size/location of the lesion, virulence, preexisting
Kelly,             Periapical   periodontal ligament perio, and host defense. Proper sensitivity testing is essential for proper dx. Comments: Always trace a sinus
Ellinger    1988   Pathology    of adjacent teeth     tract!!!

                                Comparison of           Diseased cellular cementum showed more projections, more lacunae and fewer fibers when compared to healthy
                                cellular cementum in    cementum. This indicates increased calcification in the area. Resorption was also a present in diseased teeth. An
                   Periapical   normal and diseased     amorphous layer was found on the cemental surface corresponding to the outline of the lesion, but its significance is
Simon       1981   Pathology    teeth- an SEM study     unknown.

                                                     35% of infected root canals have "pathological granules" in areas near the CDJ. These areas are rich in unineralized
                                Cemental changes in collagen suggesting that microbial products dentaure this collagen and give rise to the granules. Uninfected root
                   Periapical   teeth with heavily   canals did not display this change. Pathologic granules are known to occur in exposed cementum due to perio dz,
Armitage    1983   Pathology    infected root canals now it has been shown to occur in unexposed cementum, the bacterial source being the root canal.

                                Garre's osteomyelitis
                                of the mandible: The
                                role of endodontic      Bony, hard swelling of the mandible adjacent to a non-vital posterior tooth, showing sx of PA pathosis. Usu in
Mattison,          Periapical   therapy in patient      children or young adults. DD includes Ewing's sarcoma, syphilis, and leukemia. The swelling should resolve after
Neb         1981   Pathology    management              NSRCT, if not consider a biopsy.
                                condensing osteitis     Retrospective study looking at over 1,000 roots found an incidence of 2%. 85% of these showed complete or partial
                   Periapical   and endodontic          resolution of the osteitis after NSRCT. None showed an inc in size. Condensing osteitis is the deposition of sclerotic
Eliasson    1984   Pathology    treatment               bone in response to infection.

                                Garre's osteomyelitis   Case report where Garre's Osteomyelitis was resolved w/ NSRCT vs EXT. Bony expansion had onion skin
                                of the mandible         appearance and was assoc w/ a carious, necrotic Md molar w/ a PARL. Biopsy to rule out Ewing's sarcoma, syphilis
McWalter,          Periapical   resolved by             and leukemia was not taken b/c of the appearance of association w/ a necrotic tooth. The expansion showed rapid
Schaberg    1984   Pathology    endodontic treatment    improvement and was resolved w/in a year.
                   Periapical   carcinoma arising in    Squamous cell carcinoma can occur in the stratified squamous epith of dental cyst. Rare. Usu a residual cyst is
Lavery      1987   Pathology    a dental cyst           assoc w/ malignant change. Md is affected 5X more. Illustrates the importance of submiting all cysts for biopsy.
                                Central giant cell      CGCG is a local but destructive rxn due to trauma or hemorrhage. Contains multi-nucleated giant cells. Usu in
                                granuloma               young female and predominantly in the Md. It is a well defined uni or multi locular lucency. Causes expansion and
                                associated with a       tooth displacement. Rarely assoc w/ the apex of a tooth. Illustrates a case of a necrotic Md PM w/ a large PARL and
                   Periapical   non-vital tooth: A      resorptive lesion. Did not respond to NSRCT, developed a sinus tract. Long term CaOH therapy was unsuccessful.
Glickman    1988   Pathology    case report.            Surg and biopsy revealed CGCG.

                                affecting coronally-    Premolars of dogs were RCT'd. Half the roots had a 2mm orifice plug of white MTA which was allowed to set for 1
                                inoculated dog teeth    wk. Chambers were then inoculated w/ bacteria and sealed. Block resections taken 10 mo later and evaluated.
                                with root fillings      Both groups had no to mild inflammation. No real difference. This study shows that a traditional GP seal may be
                   Periapical   augmented by White      effective against leakage if exposed up to 10 mo. Long term effectiveness of an MTA plug cannot be projected from
Friedman    2003   Pathology    MTA orifice plugs       this study.
                                 Relationship of
                                 radiologic and
                                 histologic signs of
                                 inflammation in         53 root filled teeth from cadavers were evaluated radiographically and histologically. About 50% were inflammed at
                    Periapical   human root filled       the PA. Odds ratio of finding inflamm when there was a PARL was 9.2. OR of uninflammed PA w/ tight coronal seal
Trope        2004   Pathology    teeth                   is 3.7. Trope supports his idea that the coronal seal is more important than the quality of the obturation.
                                                         75 roots were extracted w/ attached PA lesions. Classified as cystic and non-cystic, SEM was used to evaluate and
                                 Internal apical         correlate the amount of apical resorption. Non-cystic abscesses were the most common finding. PA granulomas
                                 resorption and its      were present in only 9% of the sample. 20% were cystic, but the definition would include bay cysts. Of the canals w/
                    Periapical   correlation with the PA lesions, 75% had internal apical resorption, 48% of these had a large area of resorption. There was no correlation
Figueiredo   2004   Pathology    type of apical lesion btwn the type of PA lesion and internal apical resorption.
                                                         Can CAP occur before a pulp is totally necrotic?? Histologically examined 75 pulps from cariously involoved teeth w/
                                 Pulp biopsies from      PARL. The size of the PARL was related to the amt of pulpal destruction. Teeth w/ small PARL may respond to
                                 the teeth associated sensitivity testing and usu reveal only coronal necrosis. PA inflamm changes often develop before total inflamm of
                    Periapical   w/ periapical           the pulp occurs. Intact nerve fibers can persist in pulps having severe inflamm and partial necrosis. Comments: if
Langeland    1984   Pathology    radiolucency            you see a PARL but the tooth tests pos to cold, keep this article in mind.
                                 Calculus-like deposit
                                 on the apical
                                 external root surface
                                 of teeth with post-     Presents 2 cases of refractory CSPP. Even after mult uses of CaOH, the sinus tract would not resolve. Apical surg
                                 treatment apical        or EXT was done and root surfaces were examined. Both showed evidence of an apical plaque that resembled
                    Periapical   periodotitis: report of calculus. Theorized that a bacterial plaque can form on the root surface which becomes mineralized by oral fluids
Ricucci      2005   Pathology    two cases               through the sinus tract or from the inflamm exudate around the PA lesion.

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