The root of the problem: Occurrence of typical and atypical periapical pathoses

Conservative endodontic microsurgery to protect critical anatomical structures-selective curettage: a case series

BACKGROUND

Endodontic microsurgery has yielded highly successful outcomes in preserving teeth with persistent or recurrent cases of periapical periodontitis that could not be successfully treated by nonsurgical endodontic approaches. To avoid complications in conditions in which periapical lesions invade anatomical structures such as the nasopalatine nerve tube and mandibular canal, selective curettage has been proposed as an alternative choice of complete curettage in surgery.

CASE PRESENTATION

The 8 cases reported herein had undergone root canal treatment and/or retreatment but still presented with symptoms, such as recurring sinus tracts and persistent dull pain. The radiographic examination indicated a large area of radiolucency that was associated with the tooth and had invaded adjacent critical anatomical structures. The patients opted for selective curettage via endodontic microsurgery, and the lesions were histologically confirmed as periapical cysts or granulomas. The follow-up results for one year or more indicated that the affected teeth were clinically asymptomatic and exhibited complete or incomplete healing radiographically.

CONCLUSION

This case series provides clinical evidence for the feasibility of selective curettage in endodontic microsurgery, which can avoid complications caused by damage to the adjacent critical anatomical structures.

Retrospective Evaluation of Periradicular Biopsies: An 18-Year Study

INTRODUCTION

Radiographic findings in periradicular areas are repeatedly associated with infected root canal systems. Although non-odontogenic lesions in teeth are reported to be low, they often mimic periapical pathoses, and consequently, histopathologic examinations after surgical revisions are nurtured.

METHODS

Biopsies submitted to the College of Dentistry between 2003 and 2021 were reviewed. Clinicopathologic characteristics were collected, including age, sex, medical history, location, sensibility tests, and clinic impressions from each specimen. Histopathologic diagnosis and gross description were also part of our database.

RESULTS

A total of 72,055 pathology reports were reviewed, of which 10,031 lesions (13.9%) met the criterion of being intraosseous lesions at the periradicular area. Among those 10,031 lesions, 7.94% (n = 796) were of non-endodontic origin, 7153 were documented as non-vital, and 2.36% (n = 169) of these non-vital teeth were diagnosed with a non-endodontic origin. A total of 5707 lesions were obtained from surgeries within the periapical tissues, primarily performed by endodontists (94.02%). Non-endodontic lesions were reported in 1.09% of the cases. Odontogenic keratocyst was the most common non-endodontic diagnosis, followed by nasopalatine duct cyst and benign fibro-osseous lesion, respectively.

CONCLUSIONS

Pathologic findings of the periradicular tissues are not always from endodontic origin. The probability of encountering non-endodontic lesions is almost 8%. Even in clinically reported teeth with pulp necrosis, 1%-3% of biopsies were confirmed as non-endodontic lesions.

A Cone Beam CT Study on the Correlation between Crestal Bone Loss and Periapical Disease

The aim of this study was to determine whether the degree of bone loss around teeth can be linked to the loss of vitality of adjacent teeth and periapical disease, which necessitates root canal treatments. Three hundred and twenty-one full maxilla cone-beam computed tomography scans were examined. The parameters investigated included the degree of crestal bone loss in relation to the cementoenamel junction, the presence/absence of apical periodontitis, and the presence/absence of root canal treatments. Out of the 2001 teeth examined, 696 (34.8%) showed evidence of crestal bone loss. The degree of crestal bone loss was classified as mild, moderate, or severe. A significant association (p < 0.001) was found between the presence of crestal bone loss around a tooth and root canal treatment of that tooth. It was found that it is more likely for teeth with crestal bone loss to be root canal treated compared to teeth with existing root canal treatment and healthy crestal bone levels. Furthermore, teeth with buccal or lingual crestal bone loss were significantly associated with a higher rate of periapical disease than teeth without crestal bone loss (p < 0.001). CBCT identified the severity of bone loss on all surfaces of the teeth, and the most common presentation was bone loss to the mid-root level. Teeth with crestal bone loss were significantly more likely to be associated with a higher rate of periapical disease. Teeth with crestal bone loss were more likely to be root treated than teeth with healthy crestal bone levels.

Prevalence of Nonendodontic Diagnoses in Periapical Biopsies: A 6-year Institutional Experience

INTRODUCTION

The purpose of this study was to identify non-endodontic periapical lesions (NPLs) mimicking endodontic pathosis most frequently encountered by clinicians.

METHODS

A retrospective study was conducted on biopsies obtained from 2015-2020 at Texas A&M College of Dentistry oral pathology laboratory. The online database was screened for cases submitted as suspected endodontic pathology using specific keywords. Histological diagnoses were collected to determine prevalence of NPLs that were originally thought to be of endodontic origin. The frequency and percentage of endodontic pathology and NPLs were documented.

RESULTS

Among 6,704 biopsies clinically diagnosed as endodontic lesions, 190 (2.8%) were histopathologically diagnosed as NPLs. The most frequent NPLs were odontogenic keratocyst (n=70, 36.8%), cemento-osseous dysplasia (n=27; 14.2%), and dentigerous cyst (n=22; 11.6%). Of all NPLs, 3.7% were malignant neoplasms, with the most common diagnosis being squamous cell carcinoma. Of 6,514 endodontic histological diagnoses, the prevalence of periapical granulomas and cysts was 60.2% (n=3,924) and 39.1% (n=2,549), respectively.

CONCLUSIONS

While most endodontic submissions are likely to be histologically diagnosed as periapical granuloma or cyst, the clinician should be aware that a small portion of these lesions may be non-endodontic in origin and possibly neoplastic in nature. Histopathological evaluation of biopsied specimens is critical to achieve a proper diagnosis to ensure appropriate management of patients.

Langerhans cell histiocytosis simulating endodontic periapical lesion: Are we prepared to diagnose and manage it? A case report

Many aggressive non-endodontic radiolucent lesions show very similar clinical and radiographical features to periapical lesions of endodontic origin. Since the treatments of endodontic and non-endodontic lesions differ markedly, a precise diagnosis is imperative. Thus, the present study aimed at presenting a clinical case on the diagnosis and management of a Langerhans cell histiocytosis (LCH) lesion mimicking a periapical lesion of endodontic origin. A 51-year-old male patient was referred to a private dental office due to slight pain from the region of tooth 36. Although no sign of prosthetic or endodontic failure was noted, radiographical examination revealed a radiolucent image with poorly defined borders associated with the periapical region of the tooth. Apicoectomy and bone curettage were then performed and, given the clinical and laboratory features, the definitive diagnosis of solitary eosinophilic granuloma was made. The surgical treatment was sufficient for the remission of the symptoms, and recurrence was not observed. Given the current case, dentists should be aware of LCH lesions as they may mimic endodontic periapical pathoses, leading to misdiagnosis and therapeutic complications. Moreover, alveolar bone lesions may be the first or only sign of LCH in many cases.

Minimally Invasive Two-Staged Surgery in the Treatment of Large Cystic Lesions of the Jaw

Background: Cystic lesions of the jaw are commonly found in clinical practice. Large, expansive cysts raise challenges for the clinician from both diagnostic and surgical perspectives. The aim of our work is to present a combined, two-staged surgical approach in histologically confirmed non-aggressive cystic lesions of the jaw. Methods and Results: We report the case of an extensive mandibular cyst, associating a high risk of bone fracture, that is treated in the initial stage by cystic decompression through marsupialization with concomitant histological diagnostic confirmation, followed in the second stage by radical excision and mandibular reconstruction with titanium mesh, with the purpose of prevention for oro-cystic chronic fistula formation. Conclusions: Large odontogenic mandibular cysts imply a meticulously conducted assessment and treatment. Marsupialization should be taken into consideration for the treatment of large cystic lesions, followed by secondary enucleation, with minimal risks for the patient. The soft tissue healing process can be optimized with the use of titanium meshes, as an alternative for other reconstructive techniques, in the management of large cystic lesions.

Chronic apical periodontitis exacerbates atherosclerosis in apolipoprotein E-deficient mice and leads to changes in the diversity of gut microbiota

Aim

To investigate the impact of chronic apical periodontitis (CAP) on atherosclerosis and gut microbiota by establishing a Porphyromonas gingivalis (P. gingivalis)‐induced CAP in an apolipoprotein E‐deficient (apoE^−/−) mice model.

Methodology

Twenty‐eight male apoE^−/− mice were divided into two groups with 14 in each: CAP group and control group. In the CAP group, sterile cotton wool containing 10⁸ colony‐forming units of P. gingivalis was placed into the pulp chamber after pulp exposure followed by coronal resin filling in bilateral maxillary first and second molars. The mice were fed with a chow diet to induce atherosclerosis. Animals were euthanized 16 weeks after the operation, and the periapical lesions of bilateral maxillary first and second molars were assessed by micro‐CT. After collection of aortic arches, atherosclerotic lesions were measured by Oil Red O staining. Serum levels of high‐density lipoprotein cholesterol (HDL‐C), low‐density lipoprotein cholesterol (LDL‐C), total cholesterol (TC), and triglycerides (TG) were measured. Stools were collected to detect alterations in gut microbiota by 16S rRNA gene sequencing. Independent samples t‐test was used to calculate the difference between the two groups.

Results

CAP was observed in 98.2% of molars. A significant increase in atherosclerotic plaque formation in the aortic arches was found in the CAP groups (CAP: 2.001% ± 0.27%, control: 0.927% ± 0.22%, p = .005). No significant difference was observed between sevum level of HDL‐C (CAP: 2.295 ± 0.31 mmol/L, Control: 3.037 ± 0.55 mmol/L, p = .264) or LDL‐C (CAP: 17.066 ± 3.95 mmol/L, Control: 10.948 ± 1.69 mmol/L, p = .177) in CAP group and Control group. There were no significant differences in TG (CAP: 1.076 ± 0.08 mmol/L, control: 1.034 ± 0.13 mmol/L, p = .794) or TC (CAP: 6.372 ± 0.98 mmol/L, control: 6.679 ± 0.75 mmol/L, p = .72) levels between the two groups (p > .05). The alpha diversity was elevated in the CAP group. In terms of beta diversity, the CAP and control groups were clearly distinguished by the microbial community.

Conclusion

In a mouse experimental model, pulp infection with P. gingivalis ‐induced CAP, thus aggravating the development of atherosclerosis. Meanwhile, CAP increased alpha diversity and altered the beta diversity of the gut microbiota.

Nonendodontic periapical lesions: a retrospective descriptive study in a Brazilian population

Background

Several nonendodontic diseases can occur in the periapical region, resembling endodontic inflammatory conditions. Therefore, the aim of the present study was to determine the frequency of nonendodontic periapical lesions diagnosed in a Brazilian population.

Material and Methods

The files of two Oral Pathology laboratories were reviewed and all cases including at least one clinical diagnosis of endodontic periapical lesions were selected for the study. After initial selection, demographic and clinical data, clinical diagnosis and final diagnosis were reviewed and tabulated. Final diagnosis included endodontic periapical lesions, and benign and malignant nonendodontic periapical lesions. Data were descriptively and comparatively analyzed among the three groups, with a significance level of 5% (p<0.05).

Results

Nonendodontic periapical lesions were identified in 208 (19%) out of the 1.125 registries included in the final sample. Benign nonendodontic periapical lesions (200 cases, 18%) were mostly odontogenic keratocysts, ameloblastomas, nasopalatine cysts, dentigerous cysts, glandular odontogenic cysts, and benign fibroosseous lesions. Malignant nonendodontic periapical lesions (8 cases, 1%) included carcinomas, adenocarcinomas, and melanoma. In general, nonendodontic periapical lesions were more common in males and in the posterior mandible (p>0.05).

Conclusions

The frequency of nonendodontic periapical lesions was high and, although the general distribution was similar to the results from other populations, some features were probably associated with the profile of the studied populations and to the methods applied in the present study. Knowledge on differential diagnosis of endodontic and nonendodontic periapical lesions is essential to avoid unnecessary treatments and diagnostic delay in routine dental practice.

Key words:Differential diagnosis, nonendodontic, periapical lesion, pulp necrosis.

KRAS Mutation in an Implant-associated Peripheral Giant Cell Granuloma of the Jaw: Implications of Genetic Analysis of the Lesion for Treatment Concept and Surveillance

The aim of this case report was to detail diagnosis and therapy in a case of implant-associated peripheral giant cell granuloma (IA-PGCG) of the jaw. Case Report: The 41-year-old female attended the outpatient clinic for treatment of recurrent mandibular IA-PGCG. The lesion was excised and the defect was closed with a connective tissue graft of the palate. Healing of oral defects was uneventful, and no local recurrence has occurred during a follow-up of 7 months. Genetic examination of the lesion identified a somatic mutation in KRAS. Conclusion: The lesions are assessed as reactive-inflammatory changes in the mucous membrane of the oral cavity. The cause of the lesion is unknown. KRAS mutations are commonly found in various cancer tissues, but also in germline and mosaic RASopathies. Recently, KRAS mutations have been identified in several IA-PGCG. The clinical course of a frequently locally recurring lesion gives rise to the assumption that lesions of this type show characteristics known in benign neoplasms.

Non-endodontic periapical lesions clinically diagnosed as endodontic periapical lesions: A retrospective study over 15 years

Background

This study aimed to provide the frequency and demographic data of non-endodontic periapical lesions clinically misdiagnosed as endodontic periapical lesions from a Southeast Asian population over a 15-year period.

Material and Methods

A retrospective study was conducted from departmental archives between 2005 and 2019. Cases clinically diagnosed as endodontic periapical lesions were retrieved. Then, cases with a histopathological diagnosis of non-endodontic periapical lesion were selected. Demographic data of non-endodontic periapical lesions were recorded. Radiographic features of cases with available radiographs were analyzed.

Results

Of 1,566 cases clinically diagnosed as endodontic periapical lesion, 157 cases received a histopathological diagnosis of non-endodontic origin. Eighteen different histopathological diagnoses were identified. The most frequent lesion was dentigerous cyst (n= 51, 32.48%) followed by odontogenic keratocyst (n=31, 19.75%), nasopalatine duct cyst (n=18, 11.46%) and ameloblastoma (n=15, 9.56%). Three cases of malignant tumors, including adenoid cystic carcinoma, mucoepidermoid carcinoma, and metastatic papillary thyroid carcinoma were observed.

Conclusions

Non-endodontic periapical lesions constituted 10.03% of cases clinically diagnosed as endodontic periapical lesions. Histopathological examinations of non-endodontic periapical lesions revealed a variety of lesions ranging from foreign body reaction, cysts, fibro-osseous lesions, benign tumors and primary or metastatic malignant tumors. Of clinical significance is that some non-endodontic periapical lesions had different treatment modalities and prognoses compared with endodontic lesions. Therefore, dentists must be aware that periapical radiolucent lesions are not always a consequence of pulpal necrosis.

Key words:Ameloblastoma, dentigerous cyst, endodontic periapical lesions, non-endodontic periapical lesions, odontogenic keratocyst.

Malignant Lesions Mimicking Endodontic Pathoses Lesion: A Systematic Review

INTRODUCTION

Malignant nonendodontic periapical lesions represent a rare diagnosis, in which few case have been reported about this condition. Due to the low occurrence and little exploration of this subject, serious errors of diagnosis are observed in the oral medicine services. In this sense, the purpose of the present review was to integrate the information on the record published on malignant lesions that mimic endodontic pathoses into a comprehensive analysis of their clinical, radiologic, and histopathologic features.

METHODS

An online search was made in March 2020 in the following databases: Pubmed, Web of Science, and Scopus. Eligibility criteria included publications having enough clinical, radiologic, and histopathologic information to confirm the diagnosis. Data were assessed descriptively.

RESULTS

Forty-nine publications from 16 countries comprising 60 cases were included. There is a nearly equal occurrence rate between males and females (male/female ratio is 49.15%/50.84%) with a mean age of 46.56 years. The lesions were more prevalent in the posterior mandibles (40.69%), and, radiographically, they were unilocular radiolucent. Histopathologic analysis showed metastasis (26.67%) as the most prevalent lesion followed by salivary gland malignant disease (25%).

CONCLUSIONS

The present systematic review revealed several histologic types of malignant periapical lesions that could be mimicking endodontic pathoses. Because these lesions usually do not show clinical or radiologic features of malignant alteration, clinicians should consider these hypotheses in their routine.

A Retrospective Brazilian Multicenter Study of Biopsies at the Periapical Area: Identification of Cases of Nonendodontic Periapical Lesions

INTRODUCTION

The purpose of this study was to analyze the features of lesions obtained from biopsies at the periapical area of teeth with a radiographic or clinical initial diagnosis of apical periodontitis.

METHODS

A retrospective study was conducted on biopsies obtained from 1953-2018 at 3 Brazilian oral and maxillofacial pathology centers. Cases of endodontic and nonendodontic periapical lesions (NPLs) with a clinical diagnosis of endodontic pathoses were retrieved. Data regarding patient age, sex, and anatomic location were obtained from patients' records. The frequency and percentage of cases with clinical diagnoses of a periapical cyst, periapical granuloma, or dentoalveolar abscess were recorded, and the final histopathologic diagnosis was documented.

RESULTS

Among 66,179 oral biopsies, 7246 (10.94%) were clinically diagnosed as periapical disease, 306 (4.22%) of which were histopathologically diagnosed as NPLs. The most frequent NPLs were odontogenic keratocysts (n = 107, 34.96%) followed by dentigerous cysts (n = 48, 15.68%). The mean age at diagnosis was 39.68 years with a range of 6-80 years. A total of 159 (51.96%) cases occurred in females and 147 (48.03%) in males (female to male ratio = 1.08:1). Most lesions (137, 44.77%) were located in the posterior mandible.

CONCLUSIONS

A wide variety of histopathologic diagnoses, including benign odontogenic and nonodontogenic cystic and tumorous lesions, infectious diseases, and malignant neoplasms, was reported in the present survey. The features presented in this study were consistent with previous findings reported in the literature.

Increased interleukin 1α and interleukin 1β expression is involved in the progression of periapical lesions in primary teeth

BACKGROUND

Interleukin 1 (IL-1) is involved in bone resorption. However, the role of IL-1 in periapical lesions characterized by periapical bone destruction in primary teeth has not yet been fully elucidated. This study aimed to detect the distribution and expression of IL-1 in periapical lesions in primary teeth and assess the relationship between the cytokines and the degree of inflammatory cell infiltration.

METHODS

A total of 106 chronic periapical lesions in primary teeth were harvested. Haematoxylin and eosin (H&E) staining was used to determine the histological type and the inflammatory cell infiltration grade (mild, moderate, and severe), and immunohistochemistry and enzyme-linked immunosorbent assay (ELISA) were used to detect the distribution and expression of IL-1α and IL-1β.

RESULTS

Of the 106 chronic periapical lesion samples, there were 85 cases of periapical granuloma, accounting for 80.19% of the total samples, and 21 cases of radicular cysts, accounting for 19.81%; no cases of abscess were detected. Immunohistochemistry results showed that both IL-1α and IL-1β were expressed in periapical granulomas and cysts. ELISA results showed that IL-1α and IL-1β levels were higher in the periapical granuloma group than in the radicular cyst and normal control groups (P < 0.05). In the periapical granuloma group, IL-1α and IL-1β were detected at higher levels in the severe inflammatory cell infiltration subgroup than in the mild-inflammatory cell infiltration subgroup (P < 0.05), and IL-1β expression was also higher in the moderate inflammatory cell infiltration subgroup than in the mild inflammatory cell infiltration subgroup (P < 0.01). A significant positive correlation was observed between the protein expression levels of IL-1α and IL-1β and the inflammation grade in periapical granulomas from primary teeth (P < 0.05).

CONCLUSION

Expression levels of the cytokines IL-1α and IL-1β in periapical granulomas from primary teeth increased with increasing inflammatory severity and appeared to be a contributing factor to the progression of periapical lesions.

Binary Decision Trees for Preoperative Periapical Cyst Screening Using Cone-beam Computed Tomography

INTRODUCTION

Cone-beam computed tomographic (CBCT) analysis allows for 3-dimensional assessment of periradicular lesions and may facilitate preoperative periapical cyst screening. The purpose of this study was to develop and assess the predictive validity of a cyst screening method based on CBCT volumetric analysis alone or combined with designated radiologic criteria.

METHODS

Three independent examiners evaluated 118 presurgical CBCT scans from cases that underwent apicoectomies and had an accompanying gold standard histopathological diagnosis of either a cyst or granuloma. Lesion volume, density, and specific radiologic characteristics were assessed using specialized software. Logistic regression models with histopathological diagnosis as the dependent variable were constructed for cyst prediction, and receiver operating characteristic curves were used to assess the predictive validity of the models. A conditional inference binary decision tree based on a recursive partitioning algorithm was constructed to facilitate preoperative screening.

RESULTS

Interobserver agreement was excellent for volume and density, but it varied from poor to good for the radiologic criteria. Volume and root displacement were strong predictors for cyst screening in all analyses. The binary decision tree classifier determined that if the volume of the lesion was >247 mm³, there was 80% probability of a cyst. If volume was <247 mm³ and root displacement was present, cyst probability was 60% (78% accuracy).

CONCLUSIONS

The good accuracy and high specificity of the decision tree classifier renders it a useful preoperative cyst screening tool that can aid in clinical decision making but not a substitute for definitive histopathological diagnosis after biopsy. Confirmatory studies are required to validate the present findings.

Retrospective analysis of jaw biopsies in young adults. A study of 1599 cases in Southern Brazil

BACKGROUND

To evaluate the prevalence and the characteristics of jaw lesions diagnosed in young adults aged 20 to 30 years in a southern Brazil reference center, over a period of 25 years. And to analyze the concordance between clinical and histological diagnosis.

MATERIAL AND METHODS

In this cross-sectional retrospective study, the biopsies files from this center were retrieved and data regarding sex, age, bone localization, clinical and histological diagnosis were collected. The histological diagnosis were grouped into the categories Cystic lesions of odontogenic origin, Periapical inflammation, Odontogenic tumors, Bone diseases, Health tissue and Nonspecific diagnostic. Absolute and relative frequencies were estimated with descriptive analysis. The agreement between clinical and histological diagnosis was measured through Kappa statistic.

RESULTS

A total of 18,181 histopathological analysis were performed during the period of the study, registering 1,599 jaw lesions in young adults. The average age of individuals was 24,59 years (SD 3,1). Nine hundred ninety-one (62%) lesions were found in females and 608 (38%) in males. More than half of pathologies were cystic lesions of odontogenic origin (822/51.4%), followed by periapical inflammation (282/17.6%). Regarding the site of lesions, more than half occurred in posterior mandible (877/54.8%), followed by posterior maxilla (339/21.2%). The most frequent entities were periapical cyst, chronic periapical granuloma, dental follicle and paradental cyst, corresponding to a total of 1,202 (75.2%) evaluated cases. In relation to the analysis of concordance between clinical and histological diagnosis the general Kappa index was 0.5, which is considered moderate. Finally, the findings confirm data from literature about the most frequent jaw pathologies in young adults and serve as aid for preventive measures of some entities. Additionally, they can improve the formulation of differential diagnosis and the patient management.

Radiologic assessment of quality of root canal fillings and periapical status in an Austrian subpopulation - An observational study

Background/Objective

Progress in endodontic techniques and methodological advances have altered root canal therapy over the last decades. These techniques and methods need periodical documentation. This observational study determined the current prevalence of endodontic treatments, and investigated the relationship of various factors with the periapical status in a Lower Austrian subpopulation.

Methodology

One thousand orthopantomograms of first-time university adult patients radiographed at an outpatient clinic were evaluated. For each tooth, the presence of periradicular pathosis and/or endodontic treatment was recorded, as was the quality of (post-)endodontic treatment (homogeneity and length of root canal fillings; preparation failures; posts/screws; apicoectomies; coronal restorations). Two evaluators, blinded to each other, scored all teeth. In cases of disagreement, they joined for a consensus score.

Results

In all, 22,586 teeth were counted. Of these, 2,907 teeth (12.9%) had periapical pathosis, while 2,504 teeth had undergone root canal treatment. Of the endodontically treated teeth, 52% showed no radiographic signs of apical periodontitis, while 44.9% had overt apical lesions, and 3,1% revealed widened periodontal ligament space. The majority of the root canal fillings was inhomogeneous (70.4%); 75.4% were rated too short, and 3.8% too long. The presence of apical pathosis was significantly correlated (odds ratio (OR) 2.556 [confidence interval (CI) 2.076–3.146]; P<0.0001) with poor root canal fillings (length and homogeneity). Posts or screws positively affected periapical status (OR 1.853 [CI 1.219–2.819]; P = 0.004), but endodontically treated posterior teeth were infrequently restored (posts, 7.5%; screws, 2.7%). Best results were found for teeth with both appropriate endodontic treatment and adequate coronal restoration.

Conclusion

A high prevalence of periradicular radiolucencies was observed with root canal filled teeth, along with high numbers of unmet treatment needs. Periapical health was associated with adequate root canal obturation and high-grade postendodontic restorations, and quality regarding these latter aspects is considered mandatory to promote periapical health.