Periapical central giant cell granuloma: a potential endodontic misdiagnosis

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.

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.

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.

Central giant cell granuloma of the maxilla: Long-term follow-up of a patient treated with an adjuvant corticosteroid

BACKGROUND

Central giant cell granuloma (CGCG) is one of the most intriguing lesions of the jaws and its nature has not yet been fully elucidated. Clinically, some CGCG behave more aggressively, while others have an indolent course. In cases of aggressive CGCG of the maxilla, effective personalized therapies are worth understanding.

CASE REPORT

We report here a challenging case of aggressive CGCG in a 15-year-old girl which was misdiagnosed as an endodontic lesion. Radiographically, a large osteolytic lesion involving the hard palate from the central incisor to the second premolar, extending into the nasal cavity, with loss of the lamina dura and cortical resorption was observed. The lesion expanded aggressively after extensive curettage. With possible mutilation and defects due to a more radical approach to the lesion, treatment with systemic prednisone and intralesional triamcinolone hexacetonide associated with a calcitonin nasal spray was instituted. The decision in favor of this therapeutic strategy was made after careful immunohistochemical analysis of calcitonin and glucocorticoid receptors. The H-score for the staining of glucocorticoid and calcitonin receptors in multinucleated giant cells was 222 and 153.6, respectively. The lesion reduced in size, and no adverse effects associated with medications were observed. Another curettage was performed, and only fibrous connective tissue was found. The patient is in follow-up for 11 years without evidence of recurrence.

CONCLUSION

Pharmacological agents hold clinical promise in cases of aggressive CGCG affecting the maxilla of pediatric patients. Investigating the expression of calcitonin and glucocorticoid receptors in order to plan treatment is very helpful in the decision to manage aggressive CGCG.

Central giant cell granuloma mimicking a periapical lesion of endodontic origin: A case report

This paper aims to report a case in which central giant cell granuloma (CGCG) mimicked a periapical lesion of endodontic origin. An 18-year-old female patient was referred for diagnosis and treatment of extensive radiolucent periapical lesion involving 31, 32, 33, 34 and 35 teeth. Clinically, the patient presented slight facial asymmetry and healthy teeth on the affected side with positive response to thermal vitality tests. Thus, an incisional biopsy was performed, which presented a histopathological picture characteristic of a CGCG. The endodontic treatment of the involved teeth was followed by surgical curettage of the lesion. After two years of follow-up, the patient was asymptomatic, with marked improvement in mandibular symmetry and adequate healing of the lesion. Therefore, the diagnosis of radiolucent periapical lesions must include lesions of endodontic and non-endodontic origin for better treatment planning and execution.

Successful Nonsurgical Management of Periapical Lesions of Endodontic Origin: A Conservative Orthograde Approach

Periapical lesions of endodontic origin are common pathological conditions affecting periradicular tissues. Microbial infection of pulpal tissues is primarily responsible for initiation and progression of apical periodontitis. The primary objective of endodontic therapy should be to restore involved teeth to a state of normalcy nonsurgically. Different nonsurgical management techniques, namely, conservative root canal therapy, decompression technique, method using calcium hydroxide, aspiration-irrigation technique, lesion sterilization and tissue repair therapy, active nonsurgical decompression technique, and the apexum procedure have been advocated. New techniques which use drug-loaded injectable scaffolds, simvastatin, and epigallocatechin-3-gallate have been tried. Surgical option should be considered when intra- or extra-radicular infections are persistent. Incidence of nonendodontic periapical lesions has also been reported. An accurate diagnosis of the periapical lesion whether it is of endodontic or nonendodontic origin has to be made. Surgical methods have many disadvantages, and hence should be considered as an option only in the case of failure of nonsurgical techniques. Assessment of healing of periapical lesions has to be done periodically which necessitates a long-term follow-up. Even large periapical lesions and retreatment cases where the lesion is of endodontic origin have been successfully managed nonsurgically with orthograde endodontic therapy.

Periapical lesions are not always a sequelae of pulpal necrosis: a retrospective study of 1521 biopsies

AIM

To record the incidence of lesions that were not the sequelae of pulpal necrosis (non-SPN) amongst 1521 biopsies of periapical lesions submitted with a clinical diagnosis of a sequelae of pulpal necrosis (SPN).

METHODOLOGY

A retrospective study of 1521 biopsy request forms of specimens submitted for histopathological examination with a clinical diagnosis 'periapical inflammation', 'periapical abscess', 'periapical granuloma' or 'periapical cyst' during an arbitrarily selected 14-year period was undertaken. Gender and age of the patient, site and maximum diameter of the lesion, symptoms, inclusion of the final diagnosis in the differential diagnosis and specialty of the clinician submitting the biopsy material were recorded in each case. The final diagnosis for each case was extracted from the pathology report, and two groups were formed, SPN and non-SPN lesions. Differences between the respective features of SPN and non-SPN cases were analysed with Yate's chi-square test and t-test (significance level P < 0.05) RESULTS: In 52 of the 1521 cases examined (3.42%), the histological diagnosis was not consistent with a SPN. In most non-SPN cases, the histopathological diagnosis was not included in the differential diagnosis. The keratocystic odontogenic tumour [odontogenic keratocyst (OKC)] was the most frequent non-SPN lesion (34.62%). Other, yet less frequent, non-SPN lesions included glandular odontogenic cysts, lateral periodontal cysts, central ossifying fibromas as well as malignancies (metastatic carcinomas and Langerhans cell histiocytosis).

CONCLUSIONS

Non-SPN lesions appeared in the periapical region mimicking a SPN, although rarely. Most of them were developmental cysts, in particular OKCs, but odontogenic tumours, such as ameloblastoma, or malignant lesions were also diagnosed. Histological examination of tissue harvested from periapical lesions should be performed, in particular when those lesions are large.

Central giant cell granuloma: treatment with calcitonin, triamcinolone acetonide, and a cystic finding 3 years and 6 months after the primary treatment

BACKGROUND

Central giant cell granuloma is a benign condition of the jaws which may present an aggressive behavior.

CASE REPORT

A 9-year-old boy was complaining of swelling in the floor of the mouth. A solid swelling was observed in the area of the lower incisors. From the radiographic exam, we observed a radiolucent image in the mandibular bone with well-defined limits extending from the apical region of tooth 33 to the apical region of tooth 42.

DISCUSSION

Due to the diagnosis and the age of the patient, we chose a conservative treatment, administering subcutaneous injections of calcitonin. During this treatment, no reduction to the lesion was observed. Therefore, we chose to treat the lesion with triamcinolone acetonide. Monthly follow-ups demonstrated good lesion reduction and the absence of any clinical symptoms during the first 2 years. After a 3-year follow-up, the patient returned, presenting mobility of the lower incisors. A significant increase in the size of the lesion was observed. After a biopsy, with the removal of tissue which had the appearance of a cyst capsule, microscopic analyses were found to be compatible with a secondarily infected cyst. Two months following this procedure, the patient did not present tooth mobility anymore and the oral mucosa presented a normal aspect. Following a radiographic exam, full lesion repair was observed. These conservative treatments should be the first option in cases of central giant cell granuloma and the patient must be observed for a long period of time, until no further clinical or radiographic signs of lesions are observed.

Plexiform ameloblastoma mimicking a periapical lesion: A diagnostic dilemma

Plexiform ameloblastoma is one of the variant of ameloblastoma, with specific histopathological features. It manifests as unilocular or multilocular radiolucencies in the mandible or maxilla. In very rare cases, it can appear as a localized periradicular radiolucent area and imitate an endodontic lesion. Reported here is a rare case of plexiform ameloblastoma in an uncommon location, which was misdiagnosed as periapical lesion of inflammatory origin and treated endodontically. Surgical enucleation was followed and diagnosis of plexiform ameloblastoma was confirmed on histological grounds.

[Imaging of odontogenic tumors of the maxilla]

Odontogenic tumors of the maxilla are frequent, mainly represented by cysts of the jaw. However, this group of tumors include a large number of potentially intricate pathologies whose evolution is dominated by frequent recurrences justifying long-term follow-up. When such a lesion is discovered, evaluation of imaging features combined with an extensive knowledge of the different patterns of other lesions (particularly their potentially evolutive patterns related to growth) can often suggest the diagnosis. While definitive diagnosis frequently relies on histology, it is not rare that the patterns are so intricate that final diagnosis is based on a correlation between clinical, imaging and histological findings.

Aspectos radiológicos e epidemiológicos do granuloma central de células gigantes

OBJETIVO: Este estudo teve como objetivo avaliar os principais aspectos radiográficos e epidemiológicos das lesões de células gigantes (granulomas centrais de células gigantes e tumores marrons do hiperparatireoidismo). MATERIAIS E MÉTODOS: A amostra consistiu de 26 lesões de células gigantes diagnosticadas em 22 pacientes divididos em dois grupos, um deles composto por 17 pacientes que não tinham hiperparatireoidismo (grupo A) e o outro formado por cinco pacientes portadores de tal distúrbio (grupo B). RESULTADOS: O sexo feminino (72,7%) foi o mais acometido. As lesões ocorreram mais freqüentemente na segunda década de vida, com média de idade de 27 anos. A mandíbula (61,5%) foi o arco mais envolvido. Radiograficamente, 57,7% das lesões eram multiloculares e 42,3% eram uniloculares com limites definidos. Todas as 26 lesões provocaram expansão óssea, 15,4% produziram reabsorção radicular, 50% causaram deslocamento dentário e 11,5% produziram dor. Na mandíbula, 18,7% das lesões cruzavam a linha média. O grupo A apresentou 66,7% das lesões na mandíbula e o grupo B mostrou igualdade na distribuição das lesões entre os arcos. O grupo A apresentou 66,7% das lesões multiloculares e 33,3%, uniloculares. O grupo B apresentou 62,5% das lesões uniloculares e 37,5%, multiloculares. CONCLUSÃO: As lesões de células gigantes podem manifestar-se, radiograficamente, com um amplo espectro, desde pequenas lesões uniloculares de crescimento lento até extensas lesões multiloculares. Elas apresentam características de benignidade, embora algumas lesões possam demonstrar um comportamento localmente agressivo.

Nonendodontic periapical lesions: a retrospective study in Chile

AIM

To determine the frequency with which the histopathological diagnosis of periapical lesions contributes to a change in the clinical diagnosis.

METHODOLOGY

Cases having a clinical diagnosis of disease resulting from dental pulp necrosis were selected from the database of the Oral Pathology Reference Institute between 1975 and 2005. Cases with different histopathological diagnoses were determined and information about age and gender of the patient, location of associated tooth, pulp status and the histopathological diagnosis were recorded. The percentage of nonendodontic periapical lesions was then determined.

RESULTS

In the 30-year period, 32,423 [corrected] biopsy specimens were received. Overall 4006 (9.13%) had a clinical diagnosis of pulpal necrosis with associated pathosis in the periradicular area. Within this group, 26 cases (0.65%) had a histopathological diagnosis of nonendodontic pathology. Keratocystic odontogenic tumour was the most frequent nonendodontic lesion (11 cases) in the periradicular region followed by central giant cell granuloma (three cases), chronic sinusitis (three cases) and one case each of the following lesions: nasopalatine duct cyst, lateral periodontal cyst, calcifying cystic odontogenic tumour, ameloblastic fibroma, squamous odontogenic tumour, cemental dysplasia, haemangioma, foreign body cell granuloma and amalgam tattoo.

CONCLUSIONS

The histopathological study of periapical pathosis can occasionally reveal nonendodontic lesions. Odontogenic tumours made up the largest group.

A 10-year review of the occurrence and treatment of central giant cell granulomas, in a District General Hospital

BACKGROUND

There is considerable variation in the clinical presentation, behaviour and radiological appearance of central giant cell granulomas (CGCGs), for which multiple treatment modalities have been suggested.

METHOD

A 10-year retrospective review of the clinical presentation, radiological features and treatment received was undertaken.

RESULTS

The cohort of patients included six males and three females, with an age range of 7-61 years. Six lesions were in the mandible and three in the maxilla. Eight lesions presented with swelling, three in relation to teeth. One case was an incidental finding. Six cases were confined within the cortical plates, one involved soft tissue. Radiological presentation was diverse, but within the existing confines of CGCGs. With one exception, primary treatment was surgical resection with excisional curettage of the remaining bone; to date, none have recurred.

CONCLUSION

Diagnosis relies on correct interpretation of clinical, radiographical and histopathological data. Alternative treatments are worthy of consideration, although surgical excision remains the treatment of choice.

Periapical central giant cell granuloma misdiagnosed as odontogenic cyst

AIM

To present the clinicopathological features of a series of four periapically located central giant cell granulomas (CGCGs) that were misdiagnosed and treated as being of endodontic origin.

SUMMARY

Four cases of periapical CGCGs were submitted with a clinical diagnosis of either radicular or residual cyst. In two cases, root canal treatment had been performed previously. The patients were two women and two men whose age ranged from 31 to 85 years. Two cases were located in the mandibular premolar-molar region, and two in the anterolateral region of the maxilla. Two lesions were submitted for histological examination with a diagnosis of radicular cyst whereas the remaining two were submitted with a diagnosis of residual cyst.

KEY LEARNING POINTS

Periapical giant cell lesions may be unilocular and therefore misdiagnosed as an endodontic lesion because of their radiographic similarity to an inflammatory periradicular lesion, especially if the teeth have been root filled or if the vitality is negative or doubtful. It is important to follow up the healing process of a periapical radiolucency related to a root filled tooth and, in case of persistence, to perform surgery and to submit the specimen for histological examination.

Unicystic ameloblastoma: a possible pitfall in periapical diagnosis

AIM

To report a clinical case of unicystic ameloblastoma previously misdiagnosed as radicular cyst.

SUMMARY

A 49-year-old white male was referred to a private practitioner complaining of an asymptomatic bony hard swelling of the left posterior mandible. The patient's dental history indicated that his left mandibular first molar had been extracted approximately 10 years previously. At that time, preoperative radiographic examination demonstrated a radiolucent area of 1.5 cm diameter with well-defined margins involving the distal root of tooth 36. The lesion was diagnosed as cystic and surgery for its removal was advised, but not performed. At presentation, radiography demonstrated a well-defined 3 cm diameter radiolucency extending from the second premolar to the second molar. The lesion was enucleated and histopathological examination confirmed a diagnosis of unicystic ameloblastoma.

KEY LEARNING POINTS

*Despite a clinical diagnosis of periapical disease of endodontic origin, a nonendodontic lesion may be present. *Unicystic ameloblastoma located on the periapical area of a tooth can lead to a pulp-periapical misdiagnosis, and should be considered in differential diagnosis. *All tissue specimens recovered in apical surgery should be submitted to histopathological analysis.

Periapical radiolucency mimicking an odontogenic cyst

AIM

To present a clinical case of a giant cell lesion located in an unusual site, initially misdiagnosed and treated as an odontogenic cyst.

SUMMARY

Periapical radiolucencies often suggest the presence of odontogenic pathosis, usually inflammatory granulomas or cysts. The high frequency of such lesions tends to lead clinicians to arrive at a diagnosis without completing a comprehensive assessment of the patient or carrying out the full range of available diagnostic tests. A case report of a giant cell lesion, which was misdiagnosed and treated initially as an odontogenic lesion because of its unusual location, is presented.

KEY LEARNING POINTS

Clinical signs and radiographic appearance are usually sufficient to reach a diagnosis of periapical pathosis. When traditional treatment does not lead to success, a biopsy should be considered to ascertain the diagnosis and allow the correct treatment to be provided. Histological examination of soft tissue removed during endodontic surgery is essential.