Periapical lesion without endodontic origin.
Patient sent for endodontic treatment of element 31 due to observation of periapical radiolucent image. On clinical examination, the tests revealed no different response in relation to adjacent teeth, positive in relation to the thermal test with gas and negative to percussion. Slight pain was reported in relation to the palpation test in the root region of tooth 31. On probing, periodontal pocket was revealed in the proximal regions. The presence of calculus was also observed.
The pathology was diagnosed as having a periodontal origin and the case was sent to the periodontist for treatment and orientation for possible concomitant endodontic treatment.
In: Ferrari et al. Radiology applied to Endodontics, Machado, R. Endodontia. Biological and technical principles. Ed. Gen, 2022.
Non-endodontic pathologies with periapical radiographic manifestations
Periapical pathologies or changes not caused by pulpoperirradicular involvement may present images frequently confused as such. A thorough examination of the patient, initially considering the initial complaint, the case history, and the results of a thorough clinical examination can, in most cases, provide data that allow a correct diagnosis. The absence of signs or symptoms and normal responses to vitality tests, percussion and palpation in all teeth adjacent to the lesion can already constitute a substantial indication of its non-endodontic origin.
Radiographic interpretation must be performed with attention and rigor, following specific and objective criteria, among which are: number of lesions, location, radiolucency, border characteristics, internal structures, and effects on adjacent structures and teeth. Such questions, when analyzed in order, facilitate the determination of diagnostic hypotheses.
The pathologies and changes of non-endodontic origin most commonly misdiagnosed as such are described below, according to their radiolucency.
Radiopaque
-Idiopathic osteosclerosis: single image, usually present in the periapical region of the posteroinferior teeth, with variable radiopacity, irregular borders and absence of cortical bone. It has no known etiology, nor requires treatment, and is often confused with condensing osteitis, caused by a chronic inflammatory process of endodontic origin
-Mandibular torus: external bone formations located on the mandibular lingual surface can produce radiopaque images on periapical examination with variable number and rounded shape, often overlapping the periapical region of the lower teeth. The clinical examination can confirm the suspicion by observing such formations through intraoral inspection.
Mixed
- cemento-osseous dysplasias: idiopathic lesions in which there is replacement of bone tissue by fibrous tissue. They present a mixed image, being more radiolucent in the first phase, becoming mixed and then radiopaque after maturation. They are more common in black patients, females and in adulthood, self-limiting and frequently diagnosed by means of routine radiographs. However, because they are located in the periapical region, their presence is commonly associated with unnecessary endodontic treatment. Cemento-osseous dysplasias are subdivided into periapical cemento-osseous dysplasia, more localized in only one region (often in the anteroinferior teeth), and florid cemento-osseous dysplasia, with multiple images spread throughout the arch.
-Other pathologies with mixed radiographic images that can mimic lesions of endodontic origin are odontomas and benign cementoblastoma.
Periapical lesion.
