PERIAPICAL LESIONS OF THE JAWS: A REVIEW OF 104 CASES IN IBADAN

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AO Akinyamoju¹, SO Gbadebo², and BF Adeyemi¹

1. Department of Oral Pathology, Faculty of Dentistry, College of Medicine, University of Ibadan.
2. Department of Restorative Dentistry, Faculty of Dentistry, College of Medicine, University of Ibadan.

Abstract

Background: Periapical lesions (PLs) occur as a result of pulpal inflammation and may rarely be seen in the absence of pulpal diseases. They are the most common pathological lesions affecting the alveolar bone.

Objective: This study aims to describe the clinicopathological features of PLs of the jaws with emphasis on the two most common types.

Methods: Histopathology records of PLs diagnosed from January 1990 to December 2012 at the Department of Oral Pathology, University College Hospital Ibadan, were examined and categorized into periapical cysts (PCs); periapical granuloma (PGs) and others. Clinical data and histopathological features of these PLs were reviewed and analyzed.

Results: One hundred and four lesions met the criteria for this study and
consisted of PGs with 71 (68.3%) cases and PCs with 31 (29.8%) cases and one
case each of apical scar and pleomorphic adenoma. Age range of cases was 9 to 80 years (mean=35.6 ± 15.8years) with a peak at age group of 20-29 years.
Females were more frequently affected with 51.9% of cases. PLs were most
frequently diagnosed in the anterior maxillary region with 58 (56.9%) cases,
while the most frequently involved tooth was the left maxillary central incisor with 23 (22.1%) cases.

Conclusion: Findings in this study are consistent with those of previous studies. It is important for all periapical pathological specimens to be submitted for histological examination to establish an accurate diagnosis and aid in the identification of sinister lesions that may present in the Periradicular region of teeth.

Keywords: Periapical, Cyst, Granuloma, Histopathology, Jaw

Introduction

Periapical lesions (PLs) are among the most frequently occurring pathological lesions of the alveolar bone.^1-3 They occur in relation to the tissues around the apex of a tooth root, the periodontal membrane and the alveolar bone.^1,4,5 They are usually the sequelae of pulpal inflammation or necrosis with inflammatory mediators spreading through the apical foramen to initiate a periapical lesion.^1,6 Nevertheless, PLs may also be seen in rare instances unrelated to pulpal inflammation and present as a neoplasm.⁷

Subsequent to pulpal necrosis, there is colonization and proliferation of microorganisms within the root canal system with the release of bacteria toxins and inflammatory mediators into the periapical region.^6,8 These irritants initiate an inflammatory reaction in the periradicular tissues leading to the activation and proliferation of quiescent epithelial cell rests that form masses ⁹ which slowly enlarge and resorb periapical bone and can be visualized radiographically¹. The ensuing proliferative activity of these masses is influenced by the release of inflammatory mediators (interleukin 1,6; prostaglandins; epidermal growth factor) by the host periapical tissues⁹ either leading to the formation of periapical granulomas which are usually composed of soft tissue attachments, or the formation of periapical cysts that may have a semisolid or liquefied cystic area when centrally located cells of the epithelial mass lose their blood supply, undergo liquefactive necrosis and become lined by non keratinized stratified squamous epithelium.^7,9,10 (Figure 1). These features are usually seen irrespective of a previous endodontic therapy or if the tooth was extracted with the lesion undiagnosed or inadequately treated.⁴

Different pathological conditions may present as periapical radiolucencies,^3,4 however, undefined radiographic features commonly seen in both granulomas and cysts may pose some difficulty in making an accurate diagnosis.^11,12 (Figure 2). Histologically, PLs of endodontic origin consist mainly of inflammatory cysts, granulomas, abscesses or apical scar tissue.³ Periapical cysts (PCs) (Figure 3) and periapical granulomas (PGs) account for over 90% of periapical radiolucencies.¹³ Clinico-radiographic features are inadequate to diagnose these lesions making histological examination essential.³

Presently, there are a few reports on PLs in our environment in which varying parameters were studied. Sede and Omoregie ¹⁴ compared the histopathological types of PLs obtained from periapical surgery involving anterior maxillary teeth with clinico-radiologic findings and treatment outcomes, while Gbolahan et al. ¹⁵ and Omoregie et al. ¹⁶ examined the incidence of PLs from extracted teeth. However, there is a dearth of studies on specimen recovered from both periapical surgery and extracted teeth. Therefore, this study aims to describe the clinicopathological features of PLs of the jaws with emphasis on the two most common types diagnosed at the Oral Pathology Department, University College Hospital Ibadan.

MATERIALS AND METHODS
This was a retrospective study in which the records and files of the Oral Pathology Department, University College Hospital, Ibadan, were examined and data of all biopsies of the periapical regions of the jaws over a 22 year period from January 1990 to December 2012 were extracted. For the purpose of this study, they were defined as specimens obtained from the periapical region of diseased teeth either following apical surgery or tooth extraction submitted by endodontists, oral surgeons, and periodontists. The haematoxylin and eosin (H&E) stained slides of the cases were obtained and reviewed by two experienced Oral Pathologists. They were categorised into three groups; periapical cyst, periapical granuloma and others (which consisted of PLs, other than PCs and PGs). The presence of a cavity, partially or wholly lined by epithelium was diagnostic for a periapical cyst, while the presence of granulation tissue in which isolated nests of epithelium may be found, was diagnostic for periapical granuloma.¹⁷ Demographic data such as age, gender and site of lesion was also retrieved from patients’ medical record. Site of lesion was sub classified into anterior and posterior parts (the portion of the jaws anterior to the canines were considered anterior, while those posterior to the canines were referred to as posterior). Also, patients aged <15 years were categorized as children, while those aged >16 years were categorized as adults.¹⁸ Cases were analysed according to age, gender, site of the lesions and histopathological subtype using SPSS for windows (version 20.0; SPSS Inc. Chicago, IL). Level of statistical significance was set at p < 0.05.