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Large Periapical Lesions: How to Think Before You Treat — Transcript

by Dr. Siju jacob · 4,430 words · 644 segments · language en · Watch on YouTube

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0:00This week we are going to talk about
0:01clinical management of large periapical
0:04lesions.
0:07[music]
0:13If you're new to the channel, my name is
0:14Sidu Jacob. I've been a private
0:16practitioner for the past 25 years in
0:18Bangalore and Dubai. I've been using a
0:20surgical microscope in my private
0:22practice for more than 20 years. and
0:24I've been training dentists how to
0:26incorporate the surgical microscope in
0:28everyday clinical practice for more than
0:29a decade. If you've been here before and
0:32you found some value in the videos that
0:34I post every week, then don't forget to
0:36click on that subscribe button so that
0:38you get notified every time I upload a
0:40new video, which is usually every
0:41Sunday. You can also subscribe to my
0:43weekly newsletter. I've put the link in
0:45the description below so that you get
0:47even more useful information delivered
0:49right into your inbox every week. As
0:52clinicians, we are exposed to different
0:54kinds of parapical lesions. Fortunately,
0:57most parapical lesions can be managed
0:59inhouse in a very straightforward
1:01manner. However, there are some
1:03parapical lesions which require
1:06different kind of management than what a
1:08dentist can offer in everyday clinical
1:10practice. So, when we talk about perapal
1:12lesions, you can have a large variation.
1:14The most common ones that you see are
1:16something like this where you have a
1:17small pal leion relation to one tooth.
1:20Somebody's done an access here. So we go
1:22there, do an opturation and then one
1:24year later the lesion heals
1:26non-surgically. This is something very
1:28common and then you can have a larger
1:30lesion. The primary cause of this again
1:31is endodonontic. So once you treat this
1:33non-surgically the lesion heals a
1:36threeear recall shows the lesion heals
1:38and then on the other hand you have
1:39extreme cases like this where treatment
1:42of this lesion on the left side of the
1:44mandible involves the resection of the
1:46entire left side of the mandible. So how
1:49does one figure out whether or not an
1:51epical lesion can heal like this
1:53conservatively just by doing
1:55conventional endodontics and then which
1:57case requires resection of the entire
2:00mandible. This is something that every
2:02practitioner needs to be aware of. So
2:04this short video is my attempt to
2:06provide some sort of a guideline for a
2:08young dental practitioner or even an
2:10older dental practitioner for that
2:12matter as to what to do when faced with
2:15a parapical lesion in your clinical
2:17practice that doesn't follow what we
2:20usually see in clinical practice. The
2:22discussion points that we will cover in
2:24this lecture are the types of lesions,
2:27the differential diagnosis, when to take
2:29a biopsy and then we'll probably look at
2:30some clinical cases as well. So let's
2:32start with classifying parapical
2:34lesions. What are the common parapical
2:36lesions that we see in everyday clinical
2:38practice? Parapical lesions can be
2:40broadly classified into lesions of
2:42endodonic origin which is inflammatory.
2:45Then you have non-inflammatory cysts and
2:47then the third category is neoplasms.
2:49This is a broad classifications.
2:51Leesions of endodonic origin are the
2:53most common and the common ones are abs
2:56granola manusc. And there's no way to
2:58figure out which of these are just by
3:00looking at a radioraph. you need to take
3:02a biopsy. Then you have the fourth
3:04category which is scar tissue.
3:05Condensing oitis is not radolucent most
3:07of the time. So I put that as a separate
3:09category. Most commons are these three
3:12variations which are primary
3:13inflammatory in origin. And then you
3:15have scar tissue which some people say
3:17doesn't exist. It's just a healing
3:18lesion but some people insist that it
3:20exists but we'll leave this out of it
3:22for now. Our current dilemma is with
3:25these three variations. Then you have
3:27non-inflammatory cyst which is non
3:30odontogenic and or odontogenic cyst.
3:32Under non-ordontogenic cyst you have
3:33nasopalatine and simple bone cyst. And
3:36then under odontogenic cyst you have
3:37kerattocyst, lateral perodontal cyst and
3:40calcifying or odontogenic cyst. Out of
3:42which keratyst is the most dangerous in
3:45terms of very very high recurrence. So
3:48the treatment forgenic kerattoyst is
3:50usually a little more aggressive than
3:52the rest. That's why I've put that in
3:54red. And then of course you have the
3:55neoplasms which are divided into benign
3:58and malignant. This is the list of
3:59neoplasms that you commonly see. And
4:02even though these two are benign jaw
4:04lesions that is central giant cell
4:06granuloma and amaloblastto I've put that
4:09in red because these have a very high
4:11rate of recurrence and the treatment for
4:13these are usually very aggressive. Then
4:15of course you have the malignant jaw
4:17lesions which obviously are malignant.
4:20that require extremely aggressive forms
4:23of treatment rather than conservative
4:24forms of treatment. So this is a broad
4:26classification. So the clinician has to
4:29do the following steps when they are
4:31faced with a case which has a parapical
4:33lesion. So step one is to establish
4:35whether it's an lesion of anodontic
4:37origin or not. If not then you have to
4:39refer. Step two if the answer to this is
4:42yes which means you're sure that it is a
4:44leion of anodontic origin then of course
4:46you have to treat this in your own
4:48clinic. You can either treat it
4:49non-surgically or surgically. There are
4:51like different methods available in your
4:52clinic itself. Then of course you can
4:55proceed provided you've established that
4:57it's a lesion of endodontic origin. And
5:00then step three after you've done
5:02treatment in your clinic you have to
5:04recall and then determine if further
5:06treatment is required. Let's say you've
5:07kind of figured out that it's leion of
5:08anodontic origin. You go ahead with some
5:10treatment then you recall the patient
5:12and you find out that the lesion is not
5:13responding. Then again you have to ask
5:16for additional help or refer the case
5:18outside. So these are the three steps
5:19that the clinician needs to do. Let's
5:21look at the first step. How do we
5:23establish whether it's a lesion of
5:24endoderonic origin or not? You have to
5:26primarily rely on history, clinical
5:29examination, radioraphs and CBCT and
5:31then of course hystopathology if a
5:33biopsy is involved. But to me the most
5:37important among all these factors is
5:39actually the clinician's experience.
5:40Because once a clinician has spent a
5:43certain number of years in clinical
5:44practice, he or she will have a much
5:46better idea as to what is normal and
5:48what is not normal. So they will
5:49immediately know when they see a lesion
5:51which doesn't follow a set trajectory of
5:54some lesion which is atypical, they are
5:57immediately able to see it. It's a
5:58little more difficult for a beginner.
6:00That's why I think people who are
6:01starting off in practice should take the
6:04opinion or take the help of someone
6:06senior who's been around for a few
6:07years, they can spot these so-called
6:09zebras or the atypical cases when they
6:12see them in clinical practice. So
6:14clinicians experience is the most
6:16important. They have a saying if it
6:18looks like a duck, swims like a duck,
6:19and quacks like a duck, then it's
6:21probably a duck. So when you see a case
6:23that follows certain set patterns, you
6:25have a non- vital tooth, you have a
6:26lesion, you could take a cone beam CD
6:28and you see a miscanal or some reason
6:29for why that root canal failed, things
6:32like these stack up and then you come to
6:34your diagnosis. So the majority of the
6:37time when you see a parapical lesion,
6:39it's usually an inflammatory lesion
6:41which can be handled in the clinic
6:42itself. The exceptions are the ones
6:45which are something else and something
6:47more severe. So example like this you
6:49see a lesion on the buckle surface of
6:51maxillary mer you put a gapa cone into
6:55the sinus tract and it leads into the
6:56misobuckle root you take a cone beam CT
6:59and then you see that there's a missed
7:00canal here so all these three factors
7:02combined together tells you that this
7:04particular lesion is probably from a
7:06mist MB2 so the treatment for this is
7:09conservative you go in there into the
7:10tooth you find the mist MB2 you clean
7:13the canals MB1's and MB2 you fill it up
7:16you opturate it that's how it looks and
7:17then the lesion disappears by itself. So
7:20this is what we usually see in routine
7:21clinical practice. However, there are
7:24some variations and this is another
7:26variation which you can see rare but it
7:28can happen. So when you see something
7:30like this you have a hard bony swelling
7:32and there's expansion of the cortical
7:34plate and then to take a radioraph this
7:36is courtesy Dr. Lance Snder and you see
7:39lesions here lesion here lession here.
7:41This is atypical. This is not something
7:43that you see very often. So it should
7:45immediately raise a red flag and then
7:47you need to ask for a biopsy and in this
7:49case Dr. Lans has asked for a biopsy and
7:51biopsy turned out to be osteoggenic
7:53saroma which is very very different from
7:55an endodonic lesion. So that's how you
7:57go about it. So the next question is
7:59when does one ask for a biopsy? Again,
8:02the directions are not very very
8:05straightforward because on one hand, if
8:07you start doing biopsy for virtually
8:09every case that comes to your clinic,
8:10every parapal leion that you see in
8:12clinical practice, then you'll end up
8:14doing biopsy for every single case and a
8:16biopsy is a surgical procedure. So, it's
8:18not that easy to get a biopsy from a
8:20parapal leion. So, it will be a form of
8:23overt treatment if you start asking
8:24biopsy for every single case. And on the
8:27other hand, if you don't do a biopsy,
8:29then you have no accurate diagnosis. So
8:31one has to walk a fine line. So there
8:33are some guidelines which you can
8:34probably rely on. And let me show you
8:36some of those guidelines. These are just
8:39a short list. It's not an absolute list.
8:41There are other reasons as well. But by
8:43and large these are some of the
8:44guidelines you can use as to when to
8:46take a biopsy. Legion adjacent to rootex
8:49or vital teeth. So this case was
8:51referred for anodonic therapy of this
8:52tooth and once I did a cold test I found
8:55that it was responding immediately. So
8:56now you have a lesion in relation to
8:58mandibular second mer. But that tooth is
9:01vital. So that should immediately raise
9:04a red flag. In this case, we'll need a
9:05biopsy to find out why is there a lesion
9:08in a tooth which is vital. Persistent or
9:10progressively enlarging peripal lesion
9:12in relation to enderonically treated
9:14tooth or teeth. Now here's a case where
9:16on the right side multiple teeth have
9:18been endurically treated. There's a
9:19tooth which has been extracted and in
9:21spite of all that the patient has a
9:22large diffused lesion. Again, it's an
9:24indication for a biopsy because this is
9:27not something that you see in everyday
9:28clinical practice. So that should
9:29immediately raise a red flag and one
9:31should ask for a biopsy and in this
9:33particular case the biopsy turned out to
9:35be odontogenic kerattocyst which
9:37required a much more aggressive form of
9:39treatment and you can see here that's
9:42the line of treatment and this is like a
9:44three-year recall and you can see the
9:46treatment is more aggressive which
9:47involves extraction and curate of the
9:50entire leion with a fairly safe margin
9:52as well. So it's much more aggressive.
9:54Another indication is multiple lesions
9:56in the same patient. So you have a case
9:58like this. You have one large lesion
9:59here, another large lesion here. It's
10:01extremely unlikely that this is going to
10:03be something inflammatory or
10:04endodonically related. It has to be
10:06something else. And the only way to find
10:08out what that is is to do a biopsy. This
10:10is courtesy Dr. Maro. And in this case,
10:12it turned out to be calcifying orgenic
10:14cyst. And this is a pretty conservative
10:17management. It involve only extraction
10:18of one tooth and the rest were kind of
10:20conserved with anodonic therapy. Another
10:23indication for biopsy would be irregular
10:25radolucency. So when we say irregular it
10:27means something like this. You can't
10:28call this regular radolucency. The
10:30borders are kind of irregular. Again
10:32it's an indication for biopsy. Another
10:35indication is lesion in relation to a
10:36tooth teeth with minimal or no carries.
10:39In this case you can see the left
10:41mandibular second and third mers are
10:43both vital and there's no carries at
10:46all. There's not even a slight leion. So
10:48here you have a large lesion and there's
10:49absolutely no carries at all. So why
10:51should there be a large lesion like this
10:53in relation to a tooth with absolutely
10:55no carries at all? So obviously it can't
10:57be an andodontic lesion. There has to be
10:59some other reason. So again a good case
11:01to take a biopsy in this particular
11:03case. Another indication is the patient
11:05has sensation disorders. Patient comes
11:07to you and say doc I can't feel the
11:09right side of my face anymore. Again we
11:11take a radioraph and we find out that
11:13there's a big lesion on the left side
11:15which has led to paristhesia. So again
11:17an indication for biopsy because it's
11:20very rare that somebody just pops up one
11:22day with paristhesia and it's because of
11:24an endodonic lesion. It's usually
11:25something else some other pathology. So
11:27again a good indication for biopsy.
11:30Advanced mobility without perodontal
11:32disease. Again a good indication for
11:34biopsy. This is courtesy my friend Dr.
11:36Tin Narin. You have a case where all the
11:38mandibular teeth are mobile and all the
11:40maxillary teeth are not mobile. So again
11:42atypical right? You hardly find a
11:44situation where somebody shows up with
11:46lot of mobility in the lower teeth and
11:48absolutely no mobility in the upper
11:50teeth. So when one looks at the OPG you
11:52can see there's a big difference between
11:53the maxillary teeth and the mandibular
11:55teeth. Again this is something
11:57different. So one is able to spot a red
11:59flag and say hey this is not something
12:00that you see in everyday clinical
12:02practice. So let me look at a biopsy.
12:05Right? So these are some clues and in
12:07this particular case Dr.
12:08case it turned out to be something rare
12:10which is langahan cells hystocytosis
12:12which is very different from endodonic
12:14or inflammatory lesion let me quickly
12:16take you through a few clinical cases so
12:18you kind of have a rough idea about how
12:21the thought process works in everyday
12:22clinical practice again like I reminded
12:25this is not an absolute guideline this
12:26just a suggestion you can use clues from
12:28this video to sort of nudge you in the
12:30right direction this is a complicated
12:32topic so it's not like you should take
12:34this video as gospel one should use your
12:36own common sense to kind of nudge you
12:39along the right direction. Okay, so
12:40these are some clinical cases. Let's say
12:42you have a case like this pretty large
12:43lesion. So what are the things we look
12:45for? Is this tooth non vital? Yes, it
12:47is. It has a very deep cavity. The tooth
12:49is non vital. There's a large lesion.
12:51It's pretty well defined. It's not
12:52irregular. The adjacent teeth are both
12:55vital. So all these put together, what's
12:57the likely reason in this particular
12:59case? It's probably an enderodontic
13:00inflammatory lesion. So the treatment
13:02for this is non-surgical
13:03endoderodontics, which is what we did.
13:05You can see here there's lots of bone
13:06destruction there. We treated this case
13:08with multiple rounds of calcium
13:10hydroxide through a period and you can
13:12see here after five months of calcium
13:14hydroxide there is a dramatic reduction
13:15in the lesion here and then we obturated
13:18this tooth and you can see a three-year
13:19recall here where the lesions healed
13:21completely. So you can preop and 3 years
13:23later this lesion is healed
13:25conservatively with just endodonic
13:27therapy alone. You see the CBCT that's
13:29the preop CBCD and there's a three-ear
13:31recall CBCT. You can see the lesions
13:33healed completely. This is a case
13:35courtesy of Dr. K. Nages from Bangalore.
13:36You can see here this was referred to
13:38me. I was working in his clinic at that
13:39point in time. And the reason for
13:41referral was that the clinician felt
13:43that there's a lesion in here in
13:44relation to the mandibular second mer.
13:46So I was requested to do an endotonic
13:48therapy of this tooth. Once I did a pulp
13:51vitality testing, I found that it was
13:52vital. It was responding to cold and
13:54that again is a red flag. So I asked
13:56this patient to go in for a biopsy. The
13:58patient didn't listen. The patient
14:00wasn't convinced because he was informed
14:01by somebody else that you just need to
14:03do root canal for this tooth. So he was
14:05kind of confused and then he showed up
14:07after 6 months where it had become even
14:09more diffused by the time. So that's the
14:11problem in leaving these cases without
14:13biopsy. It can expand very fast. So we
14:15did a biopsy here and then he found out
14:16that it was a keraty. So we did
14:19aggressive treatment for this. This is
14:21the posttop of this particular case. So
14:24one has to take a biopsy when one sees
14:26something out of the ordinary and
14:28vitality is a good example. So if you
14:30see a lesion in relationship to a tooth
14:32which is like vital then immediately one
14:34has to raise a red flag and suspect
14:36something which is different from a
14:38routine aerodontic case. Here's another
14:40case courtesy who's a friend of mine
14:43classmate of mine who's currently in the
14:44US. He had a case where the patient came
14:46with a large swelling on the left side
14:48of the mandible and the OPG shows you a
14:51very large diffused lesion which is
14:53again very uncommon. You don't see this
14:55in routine clinical practice. Right? So
14:56the minute you see this you ask for a
14:58biopsy and which is what Deepuk did and
15:00it turned out to be a blastto in this
15:03case. So when you have a blasto again
15:05the treatment has to be very aggressive.
15:07In this particular case it's
15:08mandiblectomy or a partial
15:10mandiblectomy. So the entire mandible on
15:12that left side has to be prosected out
15:14which is what he did and then there's a
15:16rehabilitation uh with implants in
15:18place. So now again this is a very large
15:20lesion from canine to canine but when
15:23one looks for a cause of this you can
15:24see the location of the lesion is in the
15:26maxillary anterior age area and it's
15:29extending from the canine to canine and
15:31you have two teeth which are non vital
15:33which means the child gave a history of
15:34trauma and this tooth has become non
15:38vital over a period of time and then a
15:39lesion has formed in the central
15:41incizers and then expanded. So again you
15:43have something quite obvious there. So
15:45in this particular case the diagnosis is
15:47it is most likely an inflammatory
15:49lesion. So we go ahead with calcium
15:52hydroxide. In this case you can see
15:53these two are not formed. Apex is not
15:55yet formed. Whereas the rest of the
15:57teeth the apex is formed completely. So
15:59in this particular teeth we did
16:01long-term calcium hydroxide. You can see
16:03the adjacent teeth the apex is fully
16:04formed and these two teeth the apex is
16:06not formed. So that again gives you a
16:08clue that this is the ideology. So the
16:10treatment for this is conservative which
16:12means we did non-surgical endoderonic
16:13therapy long-term calcium hydroxide and
16:16you can see over a long period the
16:17entire lesion is healed and that's the
16:20posttop and you can see here that's the
16:23epexification in addition to the lesion
16:26healing. So that's how we started and
16:28this is how we ended in both these
16:29teeth. So the apex also has closed and
16:31the lesion is healed. So conservative
16:34management in terms of preop and the
16:35posttop. You can see the lesion healed
16:37with just anodonic therapy of these two
16:39teeth. Very different from the earlier
16:41case. This is another case which was
16:43misdiagnosed. It was sent to me for
16:45anodonic therapy of both these central
16:46incizers. The previous clinician
16:48accessed both these teeth. In one teeth
16:50they couldn't find the canal because it
16:51was calcified and another teeth they
16:53found the canal but then broke a K file.
16:55You can see here. And when you see the
16:57CBCT you can quite clearly see that this
16:59is an incive canal cyst. It's not an
17:02inflammatory lesion or an endodonic
17:03lesion. So there wasn't any need to do
17:06anodonics in any of these teeth. It was
17:08a surgical problem where this needed to
17:10be excised and both these teeth didn't
17:12need anodonic therapy. However, since
17:14the anodonic therapies has already been
17:16initiated, you can see there's almost
17:18the perforation here. So the cleion was
17:20gone in labially and this is something
17:22very easy with a microscope. By the way,
17:24if you don't have a microscope, then you
17:26don't really know which direction you're
17:27going. But with a microscope, you can
17:29clearly see the color changes here where
17:31someone has gone in labially and then
17:33there's a darken area here. So you
17:35immediately know that this is where the
17:36canal is likely to be. By the way, if
17:38you've been around in this channel, you
17:40know that this is something I stress on
17:42when you deal with calcified canals.
17:44It's much much easier to do it under a
17:46microscope. And what you see here on the
17:48screen is something that any general
17:49dentist can do. So if you are a general
17:52dentist and you're someone who's curious
17:53about bringing in a surgical microscope
17:55in your own practice, then do check out
17:57my online course microscopic dentistry
17:59simplified. It's very easy. I've
18:01designed it specifically for general
18:03dentists. You can buy a microscope,
18:05bring it in your practice and then learn
18:08how to use a surgical microscope so that
18:09you can handle calcified canals like
18:11this in your own practice. Do have a
18:13look. I've put the link in the
18:14description below. What we did, we knew
18:16that this is where the canal is going to
18:18be and I found out the calcified canal
18:20there and then you can see here we
18:22obturated that tooth and then we moved
18:24on to the next tooth and in this case
18:26the instrument fractured way towards the
18:28apex. So that it would probably be a bit
18:30of an overkill to remove this. The
18:32easier thing to do was to bypass this
18:33and I managed to bypass this very easily
18:36and then opturated that tooth as well.
18:39Now once that is done, this is a preop
18:41and that's the posttop. The initial
18:42problem of the patient is the cyst
18:44itself, right? It's an incessive canal
18:46cyst. So it's a surgical problem. So
18:48this is something I don't want to do it
18:49in my practice. So I bring in an oral
18:51surgeon. I referred this case to my
18:53friend Dr. Anjan Sha who's an oral
18:55surgeon in Bangalore. And Anjan sent me
18:57this picture from his clinic. And you
18:59can see here that's an incipive canal
19:01cyst which needs to be dealt with
19:03surgically. So in summary, what are the
19:06things that you as a dentist as a
19:08general dentist can do in your own
19:10practice when you get a case which has a
19:12parapical lesion? Well, if there is an
19:15obvious anodontic cause for the epical
19:17pathology, then treat it anodontically.
19:20And the good thing is that most clinical
19:22cases will fall in the above category.
19:25Just remember when something out of
19:28routine shows up, involve an oral
19:30surgeon and an oral pathologist. Ask
19:33them, especially if you're a young
19:35graduate or even an established one for
19:37that matter, if something feels
19:39different, if something shows up in your
19:42clinic and some sort of instinct tells
19:44you that this is not something common,
19:46this is something different from what
19:47you see normally, then don't be afraid
19:49to ask for additional help. And it's
19:52extremely important for the endodontist
19:54to work closely with an oral surgeon.
19:56The oral surgeon needs to be aware of
19:58what is possible endodontically.
20:00Similarly, the enderontis 2 needs to
20:03know what is possible surgically. So
20:06both of them need to work in tandem. You
20:08have surgeons on one side who want to
20:10treat every lesion surgically and on the
20:12other hand you have general dentists and
20:13enderodontists who want to treat every
20:16lesion enderodontically. So one needs to
20:18have a balance. One needs to understand
20:20the surgeons needs to understand what
20:22can be done anodontically conservatively
20:25for large lesions. On the other hand,
20:27the endodontist and the general dentist
20:28as well need to be aware when they see a
20:31case, they need to be aware which cases
20:33don't follow a set pattern and when you
20:35need to involve the oral surgeon. So
20:37it's it sort of should be a teamwork
20:39rather than sticking to their own
20:41corners. And as I keep stressing the
20:44most critical factor in recognizing the
20:46outlier is often the experience of the
20:48clinician. So a clinician who has been
20:51around for a few years will be able to
20:53spot these outliers far more easily than
20:56a beginner who's just starting to work
20:58in clinical practice. So one needs to
21:00always ask for additional help if you
21:02see something which is beyond the scope
21:04of your expertise or your experience.
21:07That in a nutshell is the purpose of
21:08this short video. If you enjoyed that
21:11content then maybe you would enjoy my
21:12weekly newsletter which is a short email
21:15that I send out every Wednesday. is
21:17usually filled with some useful dental
21:19and non-dental information. I've put the
21:22link in the description below. Do have a
21:24look and subscribe to my weekly
21:25newsletter called Wisdom Wednesdays.
21:27Don't forget to click on that subscribe
21:28button so that you get notified every
21:30time I upload a new video, which is
21:31usually every Sunday. And if you enjoy
21:34content like this, then maybe you should
21:35check out some of my other videos on
21:37this channel coming up over here. I'll
21:39see you next week with another video.
21:41Till then, take care. Thanks for
21:42watching.

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