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
the pathogenesis of
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
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 cementum...at 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.
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.
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.
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.
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.