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Endodontic Topics 2014, 30, 2328 2014 John Wiley & Sons A/S.
All rights reserved Published by John Wiley & Sons Ltd

ENDODONTIC TOPICS
1601-1538

The incidental discovery of apical

periodontitis
PAUL R. WESSELINK

The incidental detection of asymptomatic apical periodontitis raises the question of whether or not this lesion
should be treated. Arguments favoring treatment are that the inflammation may cause pain in the future, may
enlarge, or may negatively affect the hosts resistance. Reasons for not treating may be that treatment weakens the
tooth, may cause iatrogenic damage, and that treatment is expensive and burdensome for the patient and does not
lead to complete recovery in all cases. Scientific evidence supporting either choice, whether treating the lesion or
not, is lacking. Therefore, in making such decisions, the personal judgements of the patient and the dentist
concerning the impact on the quality of life of the patient play an important role.

Received 17 March 2014; accepted 23 March 2014.

Introduction influence might a possible treatment have on the

Once the incidental discovery of apical periodontitis
has been made and ascertained to be of endodontic
origin, it raises the question of whether the dentist
should treat it immediately or if a wait-and-watch
attitude can be adopted whereby the lesion is only
treated if the condition worsens or if the patient suffers
pain or other symptoms. As more precise diagnostic
methods come into common use, such as cone beam
computed tomography, more incidental discoveries
are expected (1).
The European Guidelines recommend that dentists
should perform a root canal treatment if the pulp
status of the tooth is necrotic and without any
evidence of periapical radiolucency on the radiographs
(2). This is based on the aim of eliminating any
infection or potential source of infection, such as a
necrotic pulp. The idea is that the patient will then
not be confronted with unexpected exacerbations
associated with apical periodontitis such as pain and
occasional swelling or adverse systemic effects of local
infection and inflammation (3). The question is how
often do these exacerbations appear and how much
negative influence these relatively small inflammations
really cause to the patients general health. What
quality of life of the patient?
Case
While taking a bitewing radiograph for a new patient,
a 52-year-old male, the dentist unintentionally
captured the apex of tooth 25. This tooth showed a
periapical radiolucency (Fig. 1). The tooth did not
react to sensitivity tests, had negative percussion and
palpation tests, and there were no deep periodontal
pockets. According to the patient, a coronal
restoration was placed more than 15 years ago and
since then he had never experienced any pain in the
tooth itself or in the surrounding area.
Apparently the cause of the periapical radiolucency
was apical periodontitis as a result of a necrotic,
infected pulp. The radiolucency indicated an infection
of the pulp space (4). According to the patient, this
situation had possibly existed for a long time without
causing any problems. It is possible that this was a
balance between the bacterial load and the local
immune response that had been in existence for years.
It was therefore not clear if any change would soon
occur.

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Wesselink
a b
Fig. 1. (a) Bitewing radiograph, made for caries diagnosis, also shows the apical area of tooth 25, with a periapical
radiolucency present. (b) Periapical radiograph of tooth 25 showing the borders of the radiolucency. (c) Clinical
picture of tooth 25.
Considerations
A case of this nature raises the question of whether an
incidental discovery of a pathological condition
requires treatment or if it is better for the patient to
monitor the development until there are clear
symptoms of a disturbed balance or if it is clear that
this pathological condition negatively affects the
general health of the patient. There are several reasons
to advise the patient to get the treatment done, but at
the same time there are also other reasons to advise the
patient not to undergo the treatment.
Reasons for treatment
(i) The inflammation can exacerbate
(flare-up)
Dentists are confronted with patients who develop
sudden pain caused by a periapical inflammation on a
regular basis. This can be inconvenient both for the
patient and the dentist. That is why dentists often
prefer to treat immediately upon discovery of an
inflammation by coincidence. The question is how
great is the chance of this type of exacerbation (flare-
up) occurring and if it indeed requires direct
treatment. There is no clear evidence about how often
a chronic inflammation will flare up and cause
symptoms. Therefore, the opinion of the dentist is
purely based on experience and assumptions.
(ii) The inflammation could grow
If a dentist decides to leave a lesion untreated with the
patients agreement, it could grow so large that the
24
c
neighboring structures in the jaw and as well as the
neighboring teeth are affected. During surgical
intervention for the treatment of this lesion, other
teeth or structures from the area could be damaged.
The timely treatment of the lesion may prevent this.
How often a chronic periapical condition requires
surgical intervention is unknown, but clinical
experience suggests that it is not frequent (Fig. 2).
However, sometimes the inflammation can take on
dramatic forms (Fig. 3).
(iii) Any infection with accompanying
inflammation is a risk
In the case of long-existing, non-painful apical
periodontitis, there appears to be an equilibrium
between the bacterial attack and the local immune
system of the patient. To what extent such
inflammation threatens the health of the patient
has never been established. Some studies suggest
that there is no relationship between periapical
radiolucencies and the markers of the presence of
systemic diseases, such as a large amount of C-reactive
proteins and interleukins (5,6). There also appears to
be no clear causative correlation between periapical
inflammation and systemic disorders such as
atherosclerosis, chronic heart disease, and diabetes
mellitus (2). However, in a recent review it was
concluded that the available evidence is limited but
consistent, suggesting apical periodontitis is associated
with increased levels of systemic inflammation in
humans. Unfortunately the presented data of this
meta-analysis did not allow for conclusions regarding
 The incidental discovery of apical periodontitis

Fig. 2. Periapical radiolucency at tooth 35 seen in 2011 and 2014 showing a stable situation.

a b c

Fig. 3. (a) Periapical radiograph of tooth 21 showing a large radiolucency. (b) CBCT scan showing the borders of the
lesion. (c) 3D reconstruction of the lesion, after a CBCT scan.

25
Wesselink
the effectiveness of endodontic treatment in reducing
serum levels of the different biomarkers of
inflammation (7).
Nevertheless, such a connection cannot be
completely ruled out because in all investigations the
diagnosis of apical periodontitis was made on the basis
of conventional periapical radiographs. These are
known to leave a substantial number of lesions
undetected (1,8). Thus it cannot be ruled out that the
patients who are listed in these studies as without
lesions actually have small periapical inflammations.
The studies therefore fail to demonstrate such a
correlation.
Despite the lack of evidence, there is great concern
among biological medicine and dentistry about the
impact that such an inflammation might have on the
patients general health. There are cases that suggest a
relationship between this kind of inflammation and
general health but clear data are lacking (9).
There appears to be a link between severe untreated
marginal periodontitis, systemic diseases, and an
increased number of inflammatory markers in the
bloodstream. However, that does not mean that a
single periapical lesion has a similar effect (10).
Nonetheless, it cannot be ruled out that, for an
accumulation of inflammation in the mouth, e.g.
generalized gingivitis, periodontitis, and pericoronitis,
apical periodontitis may actually be the last drop that
makes the balance incline and therefore will have an
effect, especially in individuals under 50 years of age
(11). Alternatively, it can be argued that in that case,
the apical periodontitis is just a drop in the ocean and
therefore does not play a significant role compared to
the other, much more burdensome, inflammatory
processes elsewhere in the mouth or the body.
Reasons against treatment
(i) The inflammation has been present for a
long time and caused no problems
If an inflammation is present for many years, the lesion
is not large, and everything indicates that there is a
balance between attack and defense, the treatment
likely will not be of much benefit. Research has shown
that even after treatment, we cannot entirely eliminate
the bacterial infection. Modern radiographic
techniques, such as cone beam computed tomography,
have demonstrated that not all of the lesions will
completely disappear (12,13). After treatment, there is
26
indeed a substantial reduction in the number of
microorganisms. As a result, the bacterial burden on
the body is very much reduced. What this actually
means for the health and well-being of a patient and
what the gain of the treatment for the patient is
remains unknown.
(ii) The treatment is burdensome, costs money,
and can cause postoperative pain
Patients are very often opposed to root canal
treatment even though, in retrospect, it usually
appears not to have been a very bad experience (14).
Moreover, treatment costs time and money, which the
patient might prefer to spend in other ways. Finally, it
is a well-known clinical experience that occasionally
pain develops after starting treatment on an
asymptomatic tooth.
(iii) The treatment weakens the tooth
When a root canal treatment is performed, the roof of
the pulp chamber is removed, making the connection
between the vestibular and lingual/palatal portion of
the tooth disappear. Occasionally iatrogenic damage
may lead to a significant weakening of the tooth. This
weakening can be, to a large extent, recovered by
placing a good, simple restoration. Sometimes this
actually requires an expensive and complicated
restoration e.g. a crown, with or without the use of a
post and core (3).
Instrumentation of the root canal, through removal
of tooth structure, also leads to weakening of the root,
although not to a large extent. Sometimes iatrogenic
accidents, such as a root perforation or the fracture of
an instrument, can occur. Moreover, recently it has
been shown in in vitro studies that the use of root
canal instruments and the application of root canal
obturation using certain techniques (such as cold
lateral and warm vertical compaction of gutta-percha)
can lead to cracks in the root (15,16). The significance
of this is not yet understood but endodontically
treated teeth sometimes present vertical root fractures
that require extraction (4).
Concluding remarks
It is difficult to see clearly what the health benefits of
a treatment are. The dentist and/or the patient will
 The incidental discovery of apical periodontitis

place more emphasis on certain arguments and less on
others, so the decisions are totally different from one
case to the next. On the basis of unbiased and honest
information by the dentist, the patient has to make the
decision, based on the best information that best
serves his or her own health perception and wellbeing.
Ultimately, the patient is in charge of his or her
own mouth. It is clear that the above-mentioned
considerations for performing the treatment lack a
strong scientific basis and the considerations not to
perform the treatment have limited foundations. The
choice will always remain arbitrary. The effects of each

Fig. 4. (a) A radiograph taken during the instrumentation of the root canal treatment of tooth 25. (b) Radiograph of
the root canal filling. (c) Three years postoperatively, the lesion has decreased in size. Courtesy of Dr. Andreas Braun.

27
Wesselink
of the two possible decisions are as yet unknown and
could be interesting topics to be studied. The famous
Dutch Professor Backer Dirks once rightly pointed out
that every treatment is in itself an experiment.
Epilogue
The 52-year-old man in this case finally decided to let
his tooth be treated by an endodontist. The tooth had
a deep apical split in which the foramen patency was of
a size that a number 45 file could pass through it. Due
to this open foramen, the apical part of the canal was
filled with MTA. Coronally to this it was filled with
gutta-percha and AH-26 was used as a sealer (Fig. 4).
The root canal entrance was covered with a resin and
the tooth was restored with a cusp-coverage composite
restoration. Three years later the radiolucency had
decreased in size but not yet completely resolved.
Acknowledgement
Part of this article has been published in Dutch in the Ned
Tijdschr Tandheelkd 2011: 118: 205208.
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