Diagnosis and Management of Periapical granuloma
Periapical granuloma is a lesion that is round with a slow development which is located close to the apex of the tooth, usually a complication of pulpitis. Consisted of chronic inflammatory tissue mass berprolifersi between fibrous capsule which is an extension of the periodontal ligament.
Diagnosis
Most of the periapical granuloma found incidentally during a routine examination. Because of the periapical granuloma is a continuation of the pulp necrosis on physical examination will get a negative thermal test and EPT tests are negative. On radiographs of small-sized lesions that can not be separated clinically and radiographically. Periapical granuloma seen as a radiolucent image attached to the apex of the tooth root. A clear picture or a diffuse radiolucency bounded by a variety of sizes that can be observed with loss of lamina dura, with or without involvement of bone condensation.
Differential Diagnosis
Differential diagnosis includes periapical cyst and periapical abscesses.
Clinical symptoms of periapical granuloma and periapical cysts is very difficult to distinguish, patients usually do not complain of pain, and negative percussion tests. Because that has been associated with pulp necrosis, thermal stimulation would indicate a negative value. Radiographs will indicate the presence of radiolucent with clear boundaries. Although the radiographic examination is a diagnostic key, the only way to be able to distinguish them accurately is to use microscopic examination; histopathological picture of granuloma periapical previously described, while histopathological picture of periapical cysts are characterized by the presence of a cavity is covered with epithelial type of stratified squamous non-keratinizing with varying thickness, the wall can be highly proliferative epithelium and showed plexiform arrangement. Typically it can be seen the inflammatory process by the discovery of many inflammatory cells, namely lymphocytes and plasma cells in the cyst wall. Rousel eusinophilic body or round globule are found within or outside the plasma cells resulting in increased synthesis of immunoglobulin.
Patients with a periapical abscess may be with or without signs of inflammation, diffuse or localized. On percussion and palpation examination found signs of sensitivity to varying degrees. The pulp does not respond to thermal stimulation as pulp that has been associated with necrosis. radiographs can vary from the periodontal ligament up depletion radiolucency lesion with unclear boundaries.
Management
Because of the difficulty of diagnosis of periapical granuloma radiographically and had a good response to non-surgical endodontic treatment, the first choice of therapy is the conventional endodontic treatment, but also can be followed by action apicoectomy. If lesions persist after a period of more than two years, the recommended treatment is surgery.
The American Association of Endodontists defines apicectomy is that excision of the apical part of the tooth root and attach soft tissue during surgery periradikular.
Indications for apicectomy are:
1. Inability to perform conventional endodontic treatment due to anatomical defects, pathological and iatrogenic from the root canal.
2. Barriers due to the metamorphosis of calcified root canal or radicular restorations.
3. Medical reasons and time.
4. Persistent infection after conventional endodontic treatment.
5. Requires a biopsy.
6. Requires the evaluation of root canal resection for additional channels or fractures.
Prognosis
The prognosis of periapical granuloma is ad bonam
