Periapical granuloma

It manifests as a small pea-sized formation wrapped in a fibrous layer surrounding the root of the tooth. During the inflammatory process, the pulp tissue of the tooth undergoes a change and becomes granular. It is sometimes noticeable on palpation of the gum at the tip of the tooth as a soft, painful ball .

What is periapical granuloma?

Teeth are the strongest part of the body next to the bones, but they can be affected by diseases and disorders just like other parts of the body. One of them is dental granuloma, also called apical or periapical granuloma.

It is a chronic inflammation of the apex of the tooth, the part closest to the jaw or maxillary bone, generally caused by a bacterial infection that insinuates itself in the root and spreads through the surrounding tissues inside the tooth. The tissue inside the tooth - which contains a part formed by soft tissues, called pulp - protects the tooth itself from bacteria, whose presence in the mouth is constant.

In its simple form, periapical granuloma goes unnoticed by the patient because it is asymptomatic; in fact, the infection becomes chronic immediately, without giving rise to any acute episode. However, if neglected, the granuloma in the tooth - which can reach the size of a lentil - can lead to complications such as pulpitis and necrosis of the affected tissues, and if not treated in time can result in the loss of the tooth. This type of lesion occurs mainly as a consequence of an untreated caries or a devitalized tooth due to trauma. In both cases the bacteria spread inside the tooth, to the point of destroying the pulp cells.

Within the symptomatology of periapical granuloma, 2 phases can be identified:

• At the beginning of its development, the area surrounding the apex of the tooth will be inflamed and may be painful to the touch.
• When the acute phase of inflammation occurs, there may be pus production and the presence of an abscess.

It is not always necessary to extract the tooth with an ongoing granuloma: in most cases, if the state of infection permits, the tooth is devitalized. However, even a devitalized tooth can be affected by a granuloma over the years.

Causes and symptoms

The most common form of periapical granuloma can remain silent for a long time (even years), without showing any symptoms.

However, when in the acute phase, the granuloma presents symptoms such as:

• Toothache.
• General malaise.
• Inflammation of the gums.

If left untreated, periapical granuloma can create fistulas that cause more pain.

In severe cases, periapical granuloma also presents symptoms affecting other parts of the face, such as:

• Eye pain.
• Headache.
• Enlarged lymph nodes in the neck.

The causes leading to the appearance of granuloma may be:

• An untreated cavity.
• A fractured or broken tooth.
• Untreated pulpitis (an inflammation of the pulp).
• Untreated pulp necrosis.
• The consequence of periodontitis.
• An incorrect dental extraction.
• Incorrect devitalization.
• The use of materials that are not completely sterilized for a filling procedure.

Consequences and risks of periapical granuloma

Consequences

Periapical granulomas should always be treated, even if they do not cause symptoms, because they can increase in size. In these cases, their presence is usually detected through periodic diagnostic examinations, such as radiography or orthopantomography, performed for other causes. In severe cases, it can even cause resorption of the bone in which it is located, as if it were an inflamed cyst.

Particular care should be taken by people who have undergone a heart valve transplant, or who suffer from mitral prolapse or a heart valve problem as the bacteria present in the granuloma can penetrate the blood barrier and thus infect these areas.

Risks

In addition to the health consequences, if periapical granuloma is ignored or not treated in time, the most "immediate" risk is the possible loss of the affected tooth itself due to inflammation. And while it is true that modern implantology has made great advances, it is also true that there is nothing more functional and durable than a healthy tooth.

The loss of a tooth also has health consequences, such as the displacement of neighboring teeth. This can affect chewing and create a malocclusion, i.e. a misalignment between the upper and lower dental arch.

Treatment

To treat a granuloma, it is first necessary to reach a correct diagnosis: to do so, it is essential to identify the exact location of the granuloma and its type. The most immediate way to do this is through radiographic examinations or a dental check-up, which are non-invasive and painless examinations aimed at detecting cavities, granulomas, cysts and other problems.

Although this is an inflammation, with a periapical granuloma, antibiotics will not always be effective because they cannot treat a deep infection such as the one present in this case.

There are different treatments for granuloma:

• Endodontic treatment: in this type of treatment, the total removal of the dental pulp, preparation and disinfection of the root canals of the tooth must be performed, and then sealed with a special material called gutta percha.
• Apicoectomy: this is a surgical procedure that consists of removing the apex of the tooth and in this case, the granuloma. It is not always possible to perform this type of surgery.
• Dental extraction: this procedure is only performed in the most severe cases where there are continuous recurrences in spite of previous treatments.

It is the specialist dentist, once the appropriate diagnostic tests have been carried out, who will determine how to treat a granuloma in the most effective way, taking into account the patient's personal condition.

How is a granuloma resorbed?

Generally, a periapical granuloma is cured by simply devitalizing the tooth, but if the tooth has already been devitalized, it is necessary to restart the process. A new endodontic treatment must be performed; the tooth is reopened, the previously used material is removed, the canals are cleaned, disinfected and resealed.