NONSURGICAL TREATMENT OF

PATHOLOGICAL CYSTS OF DENTAL ORIGIN

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ABSTRACT

BACKGROUND:

Radicular cysts (RC) of dental origin are

slow-growing lesions which are asymptomatic in most of the cases.

The management of RCs is still existing over a debate. Therefore,

we present a study of nonsurgical management of pathological cysts

of dental origin.

AIM:

To study the success of non-surgical management of patients

presenting with pathological cysts of dental origin in terms of

healing and recurrence.

MATERIALS AND METHODS:

Prospective study was done

in 25 patients presenting with pain and swelling in the Department

of conservative and endodontics for a period of 2 years. The cystic

cavity was opened and drained using various methods such as

decompression, aspiration-irrigation, placement of intracanal Ca

(OH)2 and lesion sterilization.

RESULTS:

The success rate of nonsurgical treatment was 80 %

while 12% of cases presented with recurrence and 8% of cases had

delayed healing.

CONCLUSION:

Follow-up and assessment of healing are

essential after nonsurgical treatment of the cysts. The surgical

approach is used for cases which are refractory to nonsurgical

method.

KEYWORDS:

Nonsurgical method, Ca (OH)2 decompression,

aspiration-irrigation, Cyst.

JIDAM/Chennai/Volume:7/Issue:4/Pages 139 - 144/Oct-Dec 2020

139

Address for Correspondence:

Dr.Syed Manzoor ul haq Bukhari, MDS.,

Dept of conservative and endodontics,

KVG dental college,

Kurungibagh, Sullia, Dakshin kannad

Karnataka state, India

Email id: manzoorulhaq05@gmail.com

Received

: 17.10.20

Accepted

: 11.11.20

Published

: 27.12.20

ORIGINAL ARTICLE

Dr. Syed Manzoor ul haq Bukhari, *Dr. Amrita Dhakal Sharma

Dept of conservative and endodontics, KVG dental college, Kurungibagh, Sullia, Dakshin kannad,

Karnataka state, India

* KVG Medical college, Kurungibagh, Sullia, Dakshin kannad, Karnataka state, India

DOI:1.37841/jidam_2020_V7_I4_02

JIDAM/Chennai/Volume:7/Issue:4/Pages 139 - 144/Oct-Dec 2020

Syed et al :

Nonsurgical Treatment of Pathological Cysts of Dental Origin

140

Introduction :

Dental cysts are cavities containing fluid or

soft tissue material lined by epithelium¹. It can be

traced at the crown of an un-erupted tooth or at the

root tip of a necrotic tooth. Dental cysts are formed

due to repeated trauma, infections and poor dental

hygiene². It is also linked to genetic syndromes

such as Gorlin’s syndrome³. Follicular dental cyst,

keratocyst, retromolar dental cyst, eruption dental

cyst, radicular dental cyst and residual dental cyst

are the six types of dental cysts².A cyst is usually

diagnosed incidentally on radiographic examination,

however few patients present with pain or swelling⁴.

Endodontic therapy restores the involved teeth

using the nonsurgical treatment such as enucleation,

decompression, calcium hydroxide placement or

aspiration irrigation technique and repair theratpy⁵.

Hence the aim of the present study was to evaluate

the effect of nonsurgical management of patients

presenting with radicular cysts.

MATERIALS AND METHODS :

We have studied 25 patients prospectively,

who presented with swelling and pain to the

department of conservative and endodontic for a

period of 24 months in KVG medical college and

hospital.

Inclusion criteria:

Positive findings on intraoral examination.

Radiology revealing radiolucency correlating with

clinical finding.

EXCLUSION CRITERIA:

Patients having systemic diseases like

hypertension, diabetes mellitus or Immuno-

compromised. Patients not willing for non-surgical

treatment.

METHODS:

Clinical details along with all the necessary

findings were noted. Dental history of trauma,

infection with duration and progression of pain and

swelling were taken. Both extra-oral and intra-oral

examination was done, the location and the size

of the swelling were noted. Provisional diagnosis

of cyst was made. The patient was then referred

for orthopantogram, intra-oral periapical and

occlusal radiograph for the exact location, size and

confirmation of the clinical diagnosis. Cold and

electric test was done to check the pulp vitality. If

the root canal was found to be infected, access cavity

preparation was done in the involved tooth and the

pus was expressed out. Patients were counselled

regarding the merits and demerits along with the

complications of each procedure. 25 patients were

willing to opt for nonsurgical management, the

fluid was then sent to the department of pathology

for cystic diagnosis and to rule out any malignant

pathology. Cleaning and shaping of the root canals

were done using hand instrumentation K file. The

opening was sealed with an intermediate restoration.

On the second visit, the intermediate restoration was

removed and various non- surgical methods such

as aspiration and irrigation technique of draining

the cystic fluid using a bucco-palatal approach with

18 gauge needle, intra-canal placement of calcium

hydroxide beyond the apex, lesion sterilization by

using a paste of ciprofloxacin, metronidazole and

minocycline antibiotics, decompression technique by

using negative pressure created by a suction aspirator

connected to micro 22-gauge needle inserted in the

root canal were used on different patients depending

upon the location and patients compliance. After

two weeks, permanent restoration as placed and the

case was followed up with clinical and radiographic

investigation every 6 months for a period of 24

months. If pain or swelling reappeared or if there was

an increase the size of the radiolucency or if there

was radiographical evidence of root resorption then

surgical treatment was given to the patients and the

conservative or nonsurgical treatment was considered

a failure. The success of the case was determined by

comparing the apical radiolucency on the pre- and

post-operative periapical radiograph. The periapical

index (PAI) was used for scoring, single observer

was used to eliminate intra-observer variability.

All records were digitalized and radiographs were

observed under magnification. PAI scores of 1-2

were considered success and 3-5 were considered a

failure.

RESULTS:

Table no. 1. shows the distribution of cases according

to age.

Age

No. of cases

25-30

31-35

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Syed et al :

Nonsurgical Treatment of Pathological Cysts of Dental Origin

141

36-40

41-45

›45

Total

In the present study maximum number of patients were seen in the 3

-4

decade. 3 cases were seen in 25-30

years and 1 case was noted in >45 years of age.

Table no. 2. shows the distribution of cases according to symptoms.

Symptoms

No. of cases

History of pain

History of discomfort

History of swelling

Total

As shown in the above table, 12 patients presented with a history of pain and swelling respectively, while 1

patient complained of discomfort.

Table no. 3. shows the distribution of cases according to the site of the lesion.

Site

No. of cases

Mandibular anterior

Mandibular posterior

Maxillary anterior

Maxillary posterior

Total

According to table 3, the most common location or site of the cyst was anterior maxillary followed by anterior

mandible. Posterior maxilla had 5 cases. The least common location was mandibular posteriors with 2 cases.

Table no. 4. shows distribution of cases according to radiographic diagnosis.

Radiographic diagnosis

No. of cases

Cystic

Solid-cystic

Total

According to the above table, the most common

radiographic finding was cystic with 18 cases. Solid-cystic

was observed in 7 cases in the present study.

Table no. 5. shows the distribution of cases according to cytological diagnosis.

Cytological findings

No. of cases

Benign cystic lesion

Total

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Syed et al :

Nonsurgical Treatment of Pathological Cysts of Dental Origin

142

Benign cystic lesion was confirmed as the cystic diagnosis of all cases in the present study

Table no. 6. shows the distribution of cases according to treatment modalities.

Treatment modalities

No. of cases

Aspiration-irrigation

CAOH

Decompression

Lesion sterilization

Total

According to the above table, the most common treatment modality done on patient was Ca (OH)

placement,

followed by aspiration-irrigation and decompression. The least common treatment modality done was lesion

sterilization.

Table no. 7. shows no of cases with successful management of the pathological cyst of dental origin.

Follow-up of the cases

No. of cases

Percentage

Successful management

Recurrence

Delayed healing

Total

100

As shown in table no. 7, the success rate of nonsurgical treatment was 80 % while 12% of cases presented with

recurrence and 8% of cases had delayed healing.

DISCUSSION:

Pathological dental cyst treatment is

conundrum⁶. Nonsurgical treatment is not a recent

discovery, it started in 1952 when Summer, Ostrander

and Crowley introduced I shaped rubber dam wick

in the periapical region which was to be changed

every 2 weeks. The main aim of this procedure was

to initiate the healing process by relieving the cavity

pressure of the cyst⁷.Bhaskar et al 1972 description of

the nonsurgical method for the treatment of the dental

cysts (RC) has undergone changes and it has shown

massive success in the treatment of radicular cysts⁸.

Reit and Goran-Grondahl in their study reported

that nonsurgical endodontic treatment modality

was more preferred than periapical surgery⁹. In the

present study, most of the cases were in the 3

-4

decade with 8 cases. 3 cases were seen in 25-30 years

and 1 case was noted in >45 years of age which is in

contrast to a study done by Shah Naseem¹º, where

he observed a maximum number of cases in 10-20

years of age. In the present study, most of the patients

presented with pain and swelling while in a study by

Shah Naseem¹º most patients presented with painless

gumboil. The most common location or site of the

cyst was maxillary anteriors followed by mandibular

anteriors in the present study, the findings are in

line with the study done by Shah Naseem¹º, where

he reported maxillary anteriors as the most common

teeth affected followed by mandibular anteriors.

In the present study, definitive diagnosis was based

on radiographic examination where most cases

showed radiolucency due to cystic nature of the fluid

and cytological evidence of benign cystic lesion.

Shah Naseem¹º in their study reported radiolucency

of various sizes in the periapical region. The

treatment choice is determined by various factors

such as origin, characteristics and the extent of the

lesion, relationship with the structures of origin and

the surroundings and the compliance of the patients.

In the present study, the most common treatment

modality done on patients was the placement

of Ca (OH)

followed by aspiration-irrigation.

The least common treatment modality done was

lesion sterilization. Previous Case reports¹¹ have

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Syed et al :

Nonsurgical Treatment of Pathological Cysts of Dental Origin

143

used similar treatment modalities in their study.

Ca (OH)

has antibacterial action as it acts on the

cytoplasmic membranes of the bacteria and it also

damages bacterial DNA¹². Decompression is a

procedure which can remove the cystic content which

has microbial load by creating negative pressure and

enhances the process of healing. Due to the decrease

in inflammatory mediators, the cells are deprived

of growth factors which leads to programmed cell

death known as apoptosis which leads to regression

of the cyst/lesion¹³. In aspiration and irrigation

technique 18-gauge needle was used and the cystic

fluid was aspirated using the bucco-palatal approach.

Lesion sterilization was done by using a paste of

ciprofloxacin, metronidazole and minocycline. In

the present study, the criteria for success after 2 years

of follow-up every 6 months was as follows:

1. Absence of pain, swelling and discomfort.

2. Proper healing and repair process.

3. Radiographic evidence of the healing process.

The success rate of nonsurgical treatment

was 80% while 12% cases presented with recurrence

and 8% of cases had delayed healing. Studies have

shown that nonsurgical management of periapical

lesion/cyst has a success rate of upto 85% which

is similar to our study. Murphy WK¹⁴ in their study

after nonsurgical management has reported 94.4%

complete and partial healing of the periapical

lesion. Shah Naseem¹º reported 84.4% successful

conservative treatment and 15.6% patients had to

undergo surgery. He also reported 50% failure at or

after 1-year treatment. Wound healing is a complex

process; thus, healing of the lesion was assessed in

this study by using the periapical index¹⁵. Wound

healing after nonsurgical treatment of the dental cysts

follows the principles of connective tissue wound

healing of the body.

CONCLUSION:

The blood supply and the nerve supply may

get damaged with a larger cyst, if treated surgically.

Therefore, nonsurgical management, is unavoidable

in such cases. Most of the cysts resolve and heal

following the conservative method. However,

follow-up and assessment of healing are essential.

The surgical approach is used for cases which are

refractory to the nonsurgical method.

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