Periapical Lesions: Diagnosis, Pathophysiology, and Management

Periapical Lesions: Diagnosis, Pathophysiology, and Management: Comparison

Please note this is a comparison between Version 2 by Perry Fu and Version 1 by Ivica Pelivan.

The term “periapical lesion” refers to a pathological change in the tissues surrounding the apex of a tooth root, defined by its anatomical location rather than a distinct disease entity. Periapical lesions may be of endodontic origin, most commonly resulting from microbial infection of the root canal system following pulp necrosis due to caries, trauma, or other insults, or of non-endodontic origin, such as developmental cysts, benign and malignant odontogenic and non-odontogenic tumors, and fibro-osseous lesions. Accurate diagnosis requires a systematic approach combining patient history, clinical examination, pulp vitality testing, and radiographic assessment; histopathological evaluation is indicated when clinical and radiographic findings are inconsistent or suspicious. The pathophysiology of these lesions involves dynamic interactions between root canal microorganisms and the host immune-inflammatory response. The primary management for endodontic periapical lesions is root canal treatment, which aims to reduce or eliminate root canal microorganisms through mechanical debridement and chemical disinfection. Persistent or extensive endodontic lesions and non-endodontic lesions may require surgical intervention. Molecular and inflammatory biomarkers have been investigated as adjunctive tools for assessing disease activity and prognosis; however, these remain largely investigational and are not yet part of routine clinical practice. Future developments in artificial intelligence, advanced imaging, molecular diagnostics, and personalized therapies may enhance the diagnosis and management of periapical lesions, although further clinical validation is required.

apical periodontitis
apicoectomy
biomarker
diagnostic imaging
periapical disease
periapical granuloma

Periapical lesions are pathological changes in the tissues surrounding the root apex, most commonly resulting from microbial infection of the root canal system following pulp necrosis secondary to caries, trauma, or other insults ^[1]. The inflammatory reaction in the periapical tissues is induced and maintained by microorganisms colonizing the necrotic root canal, not by the necrotic pulp tissue itself ^[2]. Additionally, benign and malignant lesions and developmental anomalies may cause periapical bone defects ^[3].

Periapical lesions are classified radiographically as radiolucent, radiopaque, or mixed, and further subdivided by odontogenic versus non-odontogenic origin ^[3].

Periapical lesions are common globally, with a notably higher prevalence in endodontically treated teeth than in untreated teeth ^[4]. Most lesions are asymptomatic and detected incidentally on radiographs, although some present with pain, swelling, or sinus tracts and can mimic other pathological conditions ^[5]. Most periapical lesions are inflammatory and arise from endodontic causes, such as granulomas, cysts, abscesses, or periapical scars. A smaller proportion are non-endodontic in origin, including benign tumors, cysts, and malignancies, which necessitate histopathological examination for accurate diagnosis and proper management [6,7]^[6][7].

Periapical lesions are the leading cause of tooth loss, often require endodontic or surgical treatment, and can significantly impact treatment planning, particularly in patients undergoing prosthetic rehabilitation or with systemic health concerns ^[6]. Misdiagnosis of non-endodontic lesions can lead to inappropriate therapy, highlighting the critical role of biopsy in atypical or suspicious cases ^[7].

Although numerous studies have investigated periapical lesions, the literature is extensive, scattered across different journals, and sometimes inconsistent. Therefore, a clear and reliable summary is needed. This Entry Paper summarizes current evidence regarding the diagnosis, pathophysiology, imaging, management, biomarkers, and future directions of periapical lesions. Relevant literature was identified through targeted searches of PubMed/MEDLINE, Scopus, and Google Scholar using terms including “periapical lesions,” “apical periodontitis,” “diagnostic imaging,” “cone-beam computed tomography,” “endodontic surgery,” “biomarkers,” and “artificial intelligence.” Priority was given to recent systematic reviews, meta-analyses, clinical studies, and other publications considered relevant to the clinical and biological aspects of periapical disease.

References

Sullivan, M.; Gallagher, G.; Noonan, V. The root of the problem: Occurrence of typical and atypical periapical pathoses. J. Am. Dent. Assoc. 2016, 147, 646–649.
Jankowska, A.; Frąckiewicz, W.; Kus-Bartoszek, A.; Wdowiak-Szymanik, A.; Jarząbek, A. Effectiveness of Treatment of Periapical Lesions in Mature and Immature Permanent Teeth Depending on the Treatment Method Used: A Critical Narrative Review Guided by Systematic Principles. J. Clin. Med. 2025, 14, 5083.
Mupparapu, M.; Shi, K.J.; Ko, E. Differential diagnosis of periapical radiopacities and radiolucencies. Dent. Clin. N. Am. 2020, 64, 163–189.
Martins, J.N.R.; GPHS Research Group; Versiani, M.A. The global periapical health study: A big data CBCT analysis of periapical pathology across 54 countries. J. Endod. 2026, 52, 740–760.
Boeddinghaus, R.; Whyte, A. The many faces of periapical inflammation. Clin. Radiol. 2020, 75, 675–687.
Boonkasemsanti, W.; Padungkarn, C.; Tewtipsakul, S.; Phattarataratip, E. Periapical lesions: Assessment of clinical diagnostic accuracy and prevalence of nonendodontic lesions mimicking endodontic pathoses. Int. Endod. J. 2025, 58, 1582–1593.
Rudman, J.; He, J.; Jalali, P.; Khalighinejad, N.; Woo, V. Prevalence of nonendodontic diagnoses in periapical biopsies: A 6-year institutional experience. J. Endod. 2022, 48, 1257–1262.

References

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