Utility of Ultrasonography for Diagnosing and Differentiating Periapical Granuloma from Radicular Cyst.

RATIONALE AND OBJECTIVES: This study aimed to investigate the reliability and accuracy of high-resolution ultrasonography (US) for diagnosing periapical lesions and differentiating radicular cysts from granulomas. MATERIALS AND METHODS: This study included 109 teeth with periapical lesions of endodontic origin from 109 patients scheduled for apical microsurgery. Ultrasonic outcomes were analyzed and categorized after thorough clinical and radiographic examinations using US. B-mode US images reflected the echotexture, echogenicity, and lesion margin, while color Doppler US assessed the presence and features of blood flow of interested areas. Pathological tissue samples were obtained during apical microsurgery and subjected to histopathological examination. Fleiss' κ was used to measure interobserver reliability. Statistical analyses were performed to assess the diagnostic validity and the overall agreement between US and histological findings. The reliability of US compared to histopathological examinations was assessed based on Cohen's κ. RESULTS: The percent accuracy of US for diagnosing cysts, granulomas, and cysts with infection based on histopathological findings was 89.9%, 89.0%, and 97.2%, respectively. The sensitivity of US diagnoses was 95.1% for cysts, 84.1% for granulomas, and 80.0% for cysts with infection. The specificity of US diagnoses was 86.8% for cysts, 95.7% for granulomas, and 98.1% for cysts with infection. The reliability for US compared to histopathological examinations was good (κ = 0.779). CONCLUSION: The echotexture characteristics of lesions in US images correlated with their histopathological features. US can provide accurate information on the nature of periapical lesions based on the echotexture of their contents and the presence of vascularity. It can help improve clinical diagnosis and avoid overtreatment of patients with apical periodontitis.

A deep learning approach for radiological detection and classification of radicular cysts and periapical granulomas.

OBJECTIVES: Dentists and oral surgeons often face difficulties distinguishing between radicular cysts and periapical granulomas on panoramic imaging. Radicular cysts require surgical removal while root canal treatment is the first-line treatment for periapical granulomas. Therefore, an automated tool to aid clinical decision making is needed. METHODS: A deep learning framework was developed using panoramic images of 80 radicular cysts and 72 periapical granulomas located in the mandible. Additionally, 197 normal images and 58 images with other radiolucent lesions were selected to improve model robustness. The images were cropped into global (affected half of the mandible) and local images (only the lesion) and then the dataset was split into 90% training and 10% testing sets. Data augmentation was performed on the training dataset. A two-route convolutional neural network using the global and local images was constructed for lesion classification. These outputs were concatenated into the object detection network for lesion localization. RESULTS: The classification network achieved a sensitivity of 1.00 (95% C.I. 0.63-1.00), specificity of 0.95 (0.86-0.99), and AUC (area under the receiver-operating characteristic curve) of 0.97 for radicular cysts and a sensitivity of 0.77 (0.46-0.95), specificity of 1.00 (0.93-1.00), and AUC of 0.88 for periapical granulomas. Average precision for the localization network was 0.83 for radicular cysts and 0.74 for periapical granulomas. CONCLUSIONS: The proposed model demonstrated reliable diagnostic performance for the detection and differentiation of radicular cysts and periapical granulomas. Using deep learning, diagnostic efficacy can be enhanced leading to a more efficient referral strategy and subsequent treatment efficacy. CLINICAL SIGNIFICANCE: A two-route deep learning approach using global and local images can reliably differentiate between radicular cysts and periapical granulomas on panoramic imaging. Concatenating its output to a localizing network creates a clinically usable workflow for classifying and localizing these lesions, enhancing treatment and referral practices.

Noninvasive Endodontic Periapical Biopsy of a Periapical Fibrous Scar: Case Report.

Postendodontic periapical fibrous scars (PFScs) comprise a type of radiolucent healing that is frequently misinterpreted as a pathological lesion. A combined clinical, radiologic, and histologic correlation is essential for a reliable diagnosis. This report presents a case of a patient with a long-term persistent asymptomatic postendodontic radiolucency that was misdiagnosed as endodontic failure and referred for endodontic retreatment and periapical surgery. To reach a definitive diagnosis, a core bone biopsy needle (CBBn) technique was performed on the area of the radiolucency. The material obtained was processed for histologic analysis and the lesion was determined to be a PFSc. In conclusion, the use of a CBBn before any invasive treatment allowed the clinician to distinguish between PFSc and other persisting pathosis, such as periapical granuloma or cystic lesions.

Assessment of conformity between clinical (radiological) and histopathological diagnoses of chronic inflammatory periapical lesions treated with apicoectomy. Clinical and histopathological diagnoses of periapical lesions. Research article.

OBJECTIVES: Periapical inflammation is one of the most common pathologies within the jaws, leading to the destruction of periodontal ligaments, bone resorption and the formation of periapical granulomas or radicular cysts. The final diagnosis can be made only on the basis of histopathological examination. The aim of the study was to assess the conformity between clinical and histopathological diagnosis of inflammatory periapical lesions treated with apicoectomy. MATERIALS AND METHODS: The case histories of 52 patients subjected to surgical treatment at the Clinic of Conservative Dentistry with Endodontics between 2008 and 2018 were analyzed. Demographic data (age, gender), clinical (radiological) diagnosis, and data on the presence of sinus tracts and causal tooth were obtained from patients' records. RESULTS: In the light of clinical and radiological examination, 32 (61.5%) periapical granulomas, 18 (34.6%) radicular cysts and 2 (3.9%) periapical scars were diagnosed, whereas the result of histopathological examination revealed granuloma in 34 (65.4%) cases and in 18 (34.6%) - radicular cyst. For clinical diagnosis of granuloma, the result coincided with the result of the histopathological examination in 28 cases, and in the case of cysts in 14. The analysis showed a significant relationship between the clinical and histopathological diagnoses (p <0.05). CONCLUSIONS: The study emphasizes the importance of histopathological assessment for the proper diagnosis of periapical lesions. CLINICAL RELEVANCE: The article emphasizes the high importance of histopathological examination for the correct diagnosis of chronic inflammatory periapical lesions.

Histological and immunohistochemical study on the apical granuloma.

INTRODUCTION: Periapical granuloma is one of the most frequent periodontal pathology and belongs to the group named as apical periodontitis. MATERIALS AND METHODS: Out of 78 of diagnosed granulomas, we selected samples that we analyzed histologically and immunohistochemically. RESULTS: The histopathological aspect has been dominated by the presence of mononuclear cells of the lymphocyte and plasma cells type, showing the chronic aspect of the apical lesion. Also, we noticed that in the apical granuloma macrophages occur most often. This density of macrophages explains cellular and tissular disruption that occur in apical region of the tooth under the influence of bacterial flora that reached this area, as they have the role to phagocyte pathogens and cell and tissue residues that result from bacterial aggression. The reaction of the plasma cells, determined by their number, has been always associated with the age of the granulomas, and it is more intense in old, neglected granulomas, compared to recent granulomas. CONCLUSIONS: The number and type of immunity cells varies in the apical granuloma accordingly to the age of granuloma.

Differentiation of periapical granulomas and cysts by using dental MRI: a pilot study.

The purpose of this pilot study was to evaluate whether periapical granulomas can be differentiated from periapical cysts in vivo by using dental magnetic resonance imaging (MRI). Prior to apicoectomy, 11 patients with radiographically confirmed periapical lesions underwent dental MRI, including fat-saturated T2-weighted (T2wFS) images, non-contrast-enhanced T1-weighted images with and without fat saturation (T1w/T1wFS), and contrast-enhanced fat-saturated T1-weighted (T1wFS+C) images. Two independent observers performed structured image analysis of MRI datasets twice. A total of 15 diagnostic MRI criteria were evaluated, and histopathological results (6 granulomas and 5 cysts) were compared with MRI characteristics. Statistical analysis was performed using intraclass correlation coefficient (ICC), Cohen's kappa (κ), Mann-Whitney U-test and Fisher's exact test. Lesion identification and consecutive structured image analysis was possible on T2wFS and T1wFS+C MRI images. A high reproducibility was shown for MRI measurements of the maximum lesion diameter (intraobserver ICC = 0.996/0.998; interobserver ICC = 0.997), for the "peripheral rim" thickness (intraobserver ICC = 0.988/0.984; interobserver ICC = 0.970), and for all non-quantitative MRI criteria (intraobserver-κ = 0.990/0.995; interobserver-κ = 0.988). In accordance with histopathological results, six MRI criteria allowed for a clear differentiation between cysts and granulomas: (1) outer margin of lesion, (2) texture of "peripheral rim" in T1wFS+C, (3) texture of "lesion center" in T2wFS, (4) surrounding tissue involvement in T2wFS, (5) surrounding tissue involvement in T1wFS+C and (6) maximum "peripheral rim" thickness (all: P < 0.05). In conclusion, this pilot study indicates that radiation-free dental MRI enables a reliable differentiation between periapical cysts and granulomas in vivo. Thus, MRI may substantially improve treatment strategies and help to avoid unnecessary surgery in apical periodontitis.

Differential diagnosis between a granuloma and radicular cyst: effectiveness of magnetic resonance imaging.

AIM: To investigate the diagnostic reliability and accuracy of magnetic resonance imaging (MRI) to differentiate periapical lesions of endodontic origin and to compare the results with histopathological information. METHODOLOGY: The radiolucent periapical jaw lesions of 34 patients, which were surgically enucleated, were investigated by two radiologists using MRI, based on the same six criteria, to categorize the lesions as granulomas, radicular cysts or others. After apicoectomies, two oral pathologists (blinded to the radiologist's diagnoses) analysed all specimens by referring to seven specific parameters and diagnosed the specimens as granulomas, radicular cysts or other conditions. The inter-rater agreements between the radiologists and pathologists in terms of MRI and histological diagnoses, respectively, along with the discriminant power of the adopted criteria and the accuracy of the MRI assessments compared with the histopathological results, were calculated. Cohen's kappa test was adopted to examine inter-rater agreement between the two radiologists and two pathologists. Guttman's lambda coefficient (λ6 ) was used to evaluate the internal consistency of the items used for the differential diagnosis by radiologists. The accuracy resulted from a receiver operator characteristic (ROC) analysis. RESULTS: A strong inter-rater reliability was observed between the two radiologists (k-statistic = 0.86, P = 0.0001) and the two pathologists (k-statistic = 0.88, P = 0.0001). The internal consistency of the diagnostic items was 0.605 for cysts and 0.771 for granulomas. The accuracy (true positives plus true negatives) of the radiologists was greater than that of the pathologists based on analysis (area under the curve = 0.87 and 0.91, respectively). CONCLUSIONS: The reliability and accuracy of MRI were high and comparable to histopathological reliability, highlighting the usefulness of this noninvasive technique as a pre-treatment diagnostic method for periapical endodontic lesions.

[Progress in the diagnosis of florid cemento-osseous dysplasia].

Florid cemento-osseous dysplasia (FLCOD) is a rare, extensive bone metabolism disorder, which occurs only in the jaw bone. It is usually asymptomatic for a long time and discovered incidentally during a radiological examination. The characteristics of FLCOD in the initial stages are similar to those of periapical granuloma or jaw cyst, which may lead to misdiagnosis. After the lesion is mature, the imaging findings show that radiopaque with a thin radiolucent peripheral halo, which is crucial for the diagnosis of FLCOD, but other jaw lesions have similar imaging findings. Due to the poor blood supply of the lesion, the alveolar bone of root apices of vital teeth is slow to heal after trauma, increasing the chance of infection, which can lead to the osteomyelitis of the jaws and emerge sequestrum. This paper reviews the aspects of pathogenesis, clinical characteristics, diagnosis, differential diagnosis and treatment.

Multiple Mott Cells in Periapical Lesion of the Oral Cavity.

An entity of bizarre plasma cells has been observed, containing spherical inclusions of immunoglobulins within the cytoplasm. These cells are termed as Mott cells and are believed to occur commonly in cases of chronic inflammation. Until now, they were reported to occur in systemic diseases, various hematolymphoid malignancies and in some syndromes; but their occurrence in chronic periapical infections of the oral cavity, given the paucity of available literature, raises questions about their obscure nature. In the present case report, a 24-year male presented with a draining sinus and periapical lesion involving the maxillary right incisors. After clinical and radiographic examination, an excisional biopsy sample of the periapical lesion was obtained. Histopathological examination revealed multiple bizarre Mott cells in the connective tissue stroma. The significance, nature or fate of these Mott cells is still unknown. Frequently overlooked or a chance occurrence, the presence of these multiple Mott cells in chronic inflammatory lesions of the oral cavity could be of some significance and demand increased awareness and further research.

Dental Implants Placed in Periodontally Infected Sites in Humans.

BACKGROUND: The purpose of the present study was to evaluate fresh socket implant outcome leaving granulomatous tissue into the bone defects. MATERIALS AND METHODS: Subjects requiring tooth extractions in periodontal infected sites were selected for this prospective study. Only patients with 4-wall defects and asymptomatic ones were included. The fresh sockets were randomly scheduled into two groups: In one group (Removal Group, RG) granulomatous tissue was removed and, in the other group (Left Group, LG) granulomatous tissue was left. Implants were positioned immediately after tooth extraction, and were loaded after 3 months in both groups. Intraoral digital radiographs were performed at temporary prosthesis placement; at 12, 24 and 36 months to evaluate marginal bone levels changes. Moreover, clinical parameters were acquired at the same time points. RESULTS: Sixty patients were included in this study. Three-hundred seventy-two implants were placed immediately after tooth extraction and, at 3-year follow-up, a survival rate of 98.66% was reported, 2 implants were lost in RG and 3 implants in LG. At 36-month follow-up, not statistically significant differences were found between RG and LG in marginal bone level changes and clinical parameters (p > 005). Moreover, not statistically significant differences were found in intragroup comparisons over time (p > 0.05). CONCLUSIONS: With the limits of this study it was concluded that granulomatous tissue left in infected fresh sockets doesn't injury dental implant outcome.

Radiological, histological and immunohistochemical evaluation of periapical inflammatory lesions.

The loss of teeth is largely caused by supporting tissue damage, because of bacterial invasion from the infected root canals. Sixty patients with periapical lesions (PLs) of endodontic origin were included in the study. Clinical and radiological examination was performed. Periapical radiographs were analyzed by two independent observers to determine the size and severity of PLs, using Periapical Index (PAI) scores. The tissue samples collected by periapical curettage during apicoectomy or after dental extractions by alveolar curettage were histologically and immunohistochemically analyzed. The PLs were histologically diagnosed as: periapical granulomas (PGs), granulomas with cystic potential and radicular cysts (RCs) with various degrees of inflammation. Capillary density was evaluated using the angiogenic index after immunohistochemical staining with CD34 monoclonal antibody. A statistically significant correlation was observed between PAI scores and the size of the lesions. 68.33% of cases were PGs, 18.33% PGs with cystic potential and 18.33% RCs with different degrees of inflammation. Seventy-five percent PLs had an angiogenic index 1 and 25% had an angiogenic index 2. Statistically significant differences were obtained between the angiogenic index and lesion size (p<0.05). Capillary density within PLs did not influence the severity scores of lesions detected on radiographs. The angiogenic index appeared not to be associated with the histological lesion type and the intensity of inflammation, but was more likely correlated with the degree of granulation tissue maturation and the size of PLs.

Noninvasive differential diagnosis of dental periapical lesions in cone-beam CT scans.

PURPOSE: This paper proposes a novel application of computer-aided diagnosis (CAD) to an everyday clinical dental challenge: the noninvasive differential diagnosis of periapical lesions between periapical cysts and granulomas. A histological biopsy is the most reliable method currently available for this differential diagnosis; however, this invasive procedure prevents the lesions from healing noninvasively despite a report that they may heal without surgical treatment. A CAD using cone-beam computed tomography (CBCT) offers an alternative noninvasive diagnostic tool which helps to avoid potentially unnecessary surgery and to investigate the unknown healing process and rate for the lesions. METHODS: The proposed semiautomatic solution combines graph-based random walks segmentation with machine learning-based boosted classifiers and offers a robust clinical tool with minimal user interaction. As part of this CAD framework, the authors provide two novel technical contributions: (1) probabilistic extension of the random walks segmentation with likelihood ratio test and (2) LDA-AdaBoost: a new integration of weighted linear discriminant analysis to AdaBoost. RESULTS: A dataset of 28 CBCT scans is used to validate the approach and compare it with other popular segmentation and classification methods. The results show the effectiveness of the proposed method with 94.1% correct classification rate and an improvement of the performance by comparison with the Simon's state-of-the-art method by 17.6%. The authors also compare classification performances with two independent ground-truth sets from the histopathology and CBCT diagnoses provided by endodontic experts. CONCLUSIONS: Experimental results of the authors show that the proposed CAD system behaves in clearer agreement with the CBCT ground-truth than with histopathology, supporting the Simon's conjecture that CBCT diagnosis can be as accurate as histopathology for differentiating the periapical lesions.

Immunoexpression of interleukin 17 in apical periodontitis lesions.

INTRODUCTION: Interleukin (IL)-17 expression has been detected in apical periodontitis lesions, but its role in the disease process remains unclear. The present study compared the expression of IL-17 in periradicular cysts and granulomas and evaluated the association of this cytokine with clinical and radiographic findings. METHODS: Apical periodontitis lesions (18 cysts and 20 granulomas) were obtained from 38 patients subjected to periradicular surgery. Some clinical, radiographic, and cone-beam computed tomographic features were recorded. Silanized slides containing paraffin sections were used for the immunohistochemical reactions using anti-IL-17 antibody. Image analysis was performed using an optical microscope, and each sample was divided into 5 high-power fields, which were evaluated for the expression of IL-17 in the epithelium and connective tissues. Results were evaluated for correlations with the lesion size and the occurrence of symptoms and sinus tract. RESULTS: Expression of IL-17 was significantly higher in cysts than in granulomas (P = .02). Among the periradicular cysts, a thin epithelium showed significantly increased labeling for IL-17 when compared with a hyperplastic epithelium (P = .003). IL-17 expression was usually associated with focal accumulations of polymorphonuclear leukocytes. No association of IL-17 expression with symptoms, sinus tract, or lesion size was observed (P > .05). CONCLUSIONS: The present study reinforces the notion that IL-17 may take part in the pathogenesis of apical periodontitis lesions. A role in the exacerbation of chronic inflammation and cyst formation is suspected. Further studies are required to shed light on the specific functions of IL-17 in periradicular inflammatory processes.

Evaluation of the reliability and accuracy of using cone-beam computed tomography for diagnosing periapical cysts from granulomas.

INTRODUCTION: The purpose of this study was to evaluate the reliability and accuracy of cone-beam computed tomographic (CBCT) imaging against the histopathologic diagnosis for the differential diagnosis of periapical cysts (cavitated lesions) from (solid) granulomas. METHODS: Thirty-six periapical lesions were imaged using CBCT scans. Apicoectomy surgeries were conducted for histopathological examination. Evaluator 1 examined each CBCT scan for the presence of 6 radiologic characteristics of a cyst (ie, location, periphery, shape, internal structure, effects on surrounding structure, and perforation of the cortical plate). Not every cyst showed all radiologic features (eg, not all cysts perforate the cortical plate). For the purpose of finding the minimum number of diagnostic criteria present in a scan to diagnose a lesion as a cyst, we conducted 6 receiver operating characteristic curve analyses comparing CBCT diagnoses with the histopathologic diagnosis. Two other independent evaluators examined the CBCT lesions. Statistical tests were conducted to examine the accuracy, inter-rater reliability, and intrarater reliability of CBCT images. RESULTS: Findings showed that a score of ≥4 positive findings was the optimal scoring system. The accuracies of differential diagnoses of 3 evaluators were moderate (area under the curve = 0.76, 0.70, and 0.69 for evaluators 1, 2, and 3, respectively). The inter-rater agreement of the 3 evaluators was excellent (α = 0.87). The intrarater agreement was good to excellent (κ = 0.71, 0.76, and 0.77). CONCLUSIONS: CBCT images can provide a moderately accurate diagnosis between cysts and granulomas.

Comparative analysis of accuracy of diagnosis of chronic periapical lesions made by clinical and histopatological examination.

INTRODUCTION: The preliminary diagnosis of chronic periapical lesions is made on the basis of clinical symptoms and radiographs, which is a reliable diagnostic tool, but it has only a subsidiary role since histopathological verification is essential for the definitive diagnosis. This study was aimed at diagnosing removed chronic periapical lesions and classifying them by size as well as at comparing the clinical diagnoses with histipathological results. MATERIAL AND METHODS: The study included 34 patients diagnosed with chronic periapical process by applying clinical examination and radiography. The removed chronic periapical lesions were processed according to classical histological technique and analyzed by hematoxylin and eosin staining protocol. RESULTS: According to histopathological analysis 53% of chronic periapical lesions were periapical granulomas and 47% were radicular cysts. The size of the lesions ranged from <9 mm (70% of lesions), 9 to 20 mm (18% of lesions) and >20 mm (12% of lesions).The histopathological examination revealed that clinical diagnosis was wrong in 26% of cases. CONCLUSION: A statistically significant difference between clinical and histopathological diagnosis has been found. The histopathological findings strongly suggest the necessity of complete curettage of lesions sizing >20 mm in order to prevent recurrences.

Differential diagnosis of apical periodontitis and nasopalatine duct cyst.

INTRODUCTION: An accurate differential diagnosis of apical periodontitis (AP) and nasopalatine duct cyst (NPDC) should be established to define the best treatment for endodontically treated maxillary anterior teeth with apical periodontitis. Three-dimensional cone beam computed tomography (CBCT) images help to plan treatment and to define an initial diagnostic hypothesis. However, endodontic treatment or retreatment may be unnecessarily prescribed when radiographs show a superimposition of the incisor foramen over the apex of maxillary central incisors, mimicking AP. Diseases of nonendodontic origin that affect the tooth apex, such as NPDC, should be included in the differential diagnosis. METHODS AND RESULTS: Four clinical cases of patients with large periapical radiolucencies and similar radiographic features are described. AP is usually a consequence of endodontic infection; in cases of NPDC, however, spontaneous epithelial proliferation, in addition to bacterial infection and trauma, may also contribute to cyst formation. The frequency and recurrence rates of NPDC are low, and its behavior is less aggressive. Surgical enucleation of the periapical lesion is recommended after nonsurgical treatment does not heal AP. CONCLUSIONS: The use of new diagnostic tools, such as CBCT imaging, may provide detailed high-resolution images of oral structures, which help to make an initial diagnostic hypothesis and to plan surgery. Histopathology is mandatory for the differential diagnosis.

Symptoms before periapical surgery related to histologic diagnosis and postoperative healing at 12 months for 178 periapical lesions.

PURPOSE: To compare the preoperative signs and symptoms with the histologic diagnosis and postoperative healing at 12 months for 178 periapical lesions. MATERIALS AND METHODS: A total of 152 patients who had undergone periapical surgery from 2005 to 2008 were studied. The study included patients presenting with signs and symptoms before periapical surgery with a sufficient tissue sample (periapical lesion) for histologic analysis and a minimal follow-up of 12 months. The signs and symptoms present in the soft tissues at the initial examination were recorded. The histologic analysis established the diagnosis as granuloma, cyst, or scar tissue. The postoperative healing at 12 months was evaluated according to the criteria of von Arx and Kurt. RESULTS: Of the 152 patients, 147, with 178 periapical lesions, were included in the present study. No significant relationship was found between the preoperative signs and symptoms, lesion type, and evolution. However, scar tissues were asymptomatic in 78.1%, and 36.4% of granulomas were painful. Of the 8 cysts, 50% were asymptomatic and 50% caused pain. Fibrous scars created no soft tissue alterations in 68.7%. Granulomas had fistulized in 31.7%, and 75% of cysts had produced no alterations. The lesions with swelling had worse healing, and those with no soft tissue alterations had better postoperative healing. CONCLUSIONS: Chronic periapical lesions (granuloma, cyst, and scar tissue) are usually asymptomatic and do not create soft tissue alterations. However, they can deteriorate, producing pain and fistulization. Worse postoperative healing was observed for lesions with swelling, although the difference was not significant.