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Prevalence of Different Periapical Lesions With Prevalence of different periapical lesions associated with human teeth and their correlation with the presence and extension of apical external root resorption F.V.Vier&J.A.P.Figueiredo Post-Graduate Program of Dentistry, ULBRA, Canoas, Brazil Abstract tion. The most prevalent diagnosis was noncystic peri- apical abscess with varying degrees of severity Vier FV, Figueiredo JAP. Prevalence of different periapical (63.7%). Periapical granuloma was not a frequent ¢nd- lesions associated with human teeth and their correlation with the ing. SEM analysis showed that 42.2% of the root apices presence and extension of apical external root resorption. International had periforaminal resorption extending over 50% of Endodontic Journal, 35, 710^719, 2002. their circumference. When the foraminal resorption Aim The aim of this study was to determine the pre- was evaluated, 28.7% had resorption a¡ecting >50% valence of various periapical pathologies and their of the periphery. Only 8.9% of the samples showed association with the presence and extent of apical no periforaminal or foraminal resorption. external in£ammatory root resorption in human Conclusions In the sample of extracted teeth inves- teeth. tigated, 24.5% of the periapical lesions were cysts. Most Methodology One hundred and four root apices periapical lesions (84.3%) displayed acute in£amma- from extracted teeth with periapical lesions were tion, whether cystic or not. Periforaminal resorption examined. Semi-serial sections of soft tissue lesions was present in 87.3% of the cases, and foraminal were stained with HE. The lesions were classi¢ed as resorption in 83.2%. Periforaminal and foraminal noncystic or cystic, each with di¡erent degrees of resorptions were independent entities. There was no acute in£ammation: 0, 1, 2 and 3, increasing in sever- association between external root resorption and the ity. The root apices were analysed by SEM. External nature of the periapical lesions. root resorption was classi¢ed according to site, as peri- Keywords: apical root resorption, diagnosis, periapi- foraminal or foraminal, and the extension of the cal pathology, SEM. resorbed area graded in increasing area as 0, 1, 2 or 3. Results Cysts accounted for 24.5% of the samples, 84% of which were associated with marked in£amma- Received 2 July 2001; accepted11February 2002 the periapical region (Yanagisawa 1980, Lin et al.1984). Introduction Chronic periapical lesionsbearingaproliferative charac- Following pulp necrosis, the root-canal system ter, represented by granulomas and periapical cysts, encourages the colonization and proliferation of are the result of this process (Leonardo et al. 1998). The microbes (Estrela & Figueiredo 1999). The low intensity, slow growth of these lesions results in bone resorption chronic stimulus provided by bacteria and their pro- that is visible radiographically. ducts allows for the maintenance of in£ammation in The precise nature of such lesions can only be deter- mined histologically (Linenberg et al. 1964). However, true prevalence of each pathological conditon is unclear. Correspondence: Jose¤ Anto“ nio Poli de Figueiredo, R. Luciana de Abreu, 20/201, Porto Alegre 90570^060, RS, Brazil (tel: þ55-51-3346 2197; Cystic lesions have been reported to account for between e-mail: endo¢[email protected]). 3.2% (Nair 1987) and 54% (Priebe et al. 1954) of apical 710 International Endodontic Journal, 35, 710^719, 2002 ß 2002 Blackwell Science Ltd Vier & Figueiredo Apical lesions and resorption lesions, and granulomas for between 45% (Lalonde & sections (0.5 m at 0.5-mm intervals) of soft periapical Luebke 1968) and 96.8% (Nair 1987). Some of this may lesions were stained with HE.The periapical lesionswere be explained bydi¡erences in sample source and histolo- classi¢ed as: gical methods. Noncystic lesions A number of chemical mediators of in£ammation, Periapical granuloma: Lesions predominantly in¢l- including the cytokynes IL-1a,IL-1b,TNFa, prostaglan- trated bylymphocytes, plasmacells and macrophages, dins and LPS, seem to be related to the pathogenesis of with or without epithelial remnants (Nair et al. 1996), periapical lesions (Schein & Schilder 1975, Schonfeld and covered by a capsule of collagen ¢bres. In these et al. 1982, Burchett et al. 1988, Wang & Stashenko lesions, neutrophils were sparse forming no abscess 1993a,b). These substances may stimulate root resorp- microcavities or concentrated in¢ltrates. tion in the same way that they stimulate bone resorption Periapical abscess: Lesions with a distinct collection of (Hammarstro« m & Lindkog1992). neutrophils in the interior of a previously existent Although radiographic examination is an important granuloma (Nair et al.1996). These were further cate- resource in clinical diagnosis, it is rarely helpful in the gorized as 1 ¼ abscess cavity occupying up to one- diagnosis of small areas of external root resorption asso- third; 2 ¼1/3^2/3; 3 2/3 of the total area of the ciated with teeth having apical periodontitis (Bhaskar visualized lesion in the histological sections. & Rappaport1971, Ferlini Filho1999, Laux et al. 2000). Cystic lesions Irregularresorbedareasarefrequentlysituatedinsites Periapical cyst: Lesions with a layer of strati¢ed squa- that are not within the reach of root-canal instruments mous epithelium along a surface of su⁄cient quantity or medication and may act as niches for extraradicular of conjunctive tissue to indicate a delineated cavity bacterial colonization (Tronstad et al.1990,Lomc¸ali and surrounded by a slight ¢brous capsule (Patterson et al.1996), besides causing technical problems for root- etal.1964, Lalonde & Luebke1968,Lalonde1970,Nobu- canal treatment (Delzangles1989, Malueg et al. 1996). hara & Del Rio1993,White et al.1994). There are few reports correlating periapical lesions Abscessed periapical cyst: Cysts containing pus-¢lled with external in£ammatory root resorption (Delzangles cavities were classed as1,2 or 3 as above. 1989, Bohne 1990, Vier & Figueiredo 2000). The aim of The histological sections were analysed by two this study was to evaluate the prevalence of di¡erent blinded and previously calibrated observers, using 32, periapical lesions as well as to evaluate the presence 100 and 400Â magni¢cation (Zeiss microscope, Thorn- and extension of apical external resorption and its asso- wood, USA). ciation with di¡erent categories of disease. The diagnosis of each lesion was determined by con- sidering all the histological sections. The presence of epithelium delineating a pathological cavity in one or Materials and methods more sections of a lesion characterized it as a periapical The sample comprised 113 extracted human teeth with cyst. Classi¢cation of abscess severity was based on the visible periapical lesions. These extracted teeth were section showing its largest dimension. Thereafter, the obtained from the Public Dental Services in the state of periapical lesions were grouped in two subgroups: Rio Grande do Sul, Brazil, where endodontic or restora- noncystic lesions: A1 ^ with absence or with a small tive treatment is not provided. Some of the teeth were abscess (periapical granuloma and abscess degree 1); symptomatic, others were removed because the crown A2 ^ with advanced abscess (periapical abscess was completely compromised by dental caries. Care degrees 2 and 3). was taken to include only teeth with whole and intact cysticlesions: B1^withabsence or witha smallabscess periapical lesions. (periapical cyst and abscessed cyst degree1); B2^with The specimens were stored at room temperature in a advanced abscess (abscessed cysts degree 2 and 3). solution of formaldehyde (10%, w/v), and radiographed Theapicalportionof the root was cut perpendicular to to exclude previous root-canal treatment or incomplete thelongaxis withcarborundum disc to favourplacement root formation. Fifteen teeth were discarded, leaving a on stubs. The root apices were submerged in a solution ¢nal sample of 98 teeth, amongst which six presented of 2.5% sodium hypochlorite for 3 h, dehydrated in an two lesions on separate roots. Atotal of104 apical lesions ascending sequence of alcohols (70, 90 and 99.96%, for and104 root apices were analysed. 5 h ineach), attachedtothe stubs withtheapexupwards, The periapical lesions were gently removed from the and sputtered (Balzers, Liechtensten) with gold root apices and labelled before processing. Semi-serial palladium, to a thickness of 150 —. Scanning electron ß 2002 Blackwell Science Ltd International Endodontic Journal, 35, 710^719, 2002 711 Apical lesions and resorption Vier & Figueiredo microscopy was conductedusinga Philips XL 20 (Eindh- Table 1 Prevalence of di¡erent periapical lesions moven, Netherlands) microscope, operating at 15 Kv. Periapical lesion f % The areas that surrounded the apical foramina of the Noncystic lesions with absence or with 12 11. 8 apices were imaged at 100Â. The apical foramen occu- a small degree of abscess piedthe central regionof thevideoscreenandwastotally Noncystic lesions with high degree of abscess 65 63.7 surrounded by the root. If a root presented more than Cystic lesions with absence or with a 43.9 one apical foramen, more than one image was obtained, minimum degree of abscess so as to guarantee the analyses of all the foramina. Cystic lesions with high degree of abscess 21 20.6 SEM images were analysed separately by two blinded To t a l 10 2 10 0.0 and previously calibrated observers. The dental apices were classi¢ed depending on the presence orabsence of externalapical resorption, aswell as to its extent: Table 2 Periapical lesions of minor and major severity of Periforaminal resorption: Periforaminal resorptionwas abscess de¢ned as the area of resorption not comprising the out- line of the foramen, but the surrounding area. The Type of lesion f % degrees of severity 0^3 were employed when there was A1 þB11615.7 absence of resorption, resorption of up to 1/4, from 1/4 A2 þ B28684.3 to1/2 and in more than1/2 of the area that surrounded To t a l 1 0 2 10 0.0 or circumscribed the apical foramen, respectively. A1^noncystic lesions with absence or with a small degree of abscess. Foraminal resorption: De¢ned as the resorption within A2^noncystic lesions with high degree of abscess.
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