Successful Treatment of a Periapical Cyst Case at Herident Dental Clinic 

Periapical cysts are a dangerous oral condition that often develops silently and can lead to jawbone resorption, infection, and even tooth loss if not treated promptly. At Herident Dental Clinic, with a team of experienced dentists and modern equipment, we have successfully treated many complex periapical cyst cases. A recent case involved a 34-year-old patient, and with our commitment to quality care, we delivered optimal oral health outcomes for the client.

What Is a Periapical Cyst?

According to an article published in JK Science, periapical cysts are the most common type of jawbone cyst, accounting for about 50% of all jaw cysts and approximately 60% of cysts caused by tooth-related infections. These cysts usually form as a pathological sac filled with fluid located around the apex (root tip) of a tooth.

This type of cyst typically develops slowly and asymptomatically. However, if left untreated, it can enlarge, cause jawbone destruction, increase the risk of tooth loss and infection, and lead to swelling. These complications can seriously affect oral health if not managed early.

Causes of Periapical Cysts 

Periapical cysts are formed from chronic inflammation at the apex of a tooth root, particularly when the dental pulp becomes necrotic. The pulp may become necrotic due to several causes, including:

• Untreated Dental Caries (Tooth Decay):If cavities are not treated promptly, bacteria can penetrate deep into the inner layers of the tooth, leading to pulp infection and necrosis. If left untreated, this condition may persist and progress, eventually resulting in a periapical cyst. 
• Dental Trauma: Tooth trauma from physical impact or accidents can damage the pulp, leading to pulp necrosis. Traumatized teeth may not always show symptoms initially, but over time, they can become discolored or infected due to bacteria entering the pulp chamber. If not properly treated, this can lead to chronic apical periodontitis and eventually form a periapical cyst.
• Periodontitis (Gum Disease): When periodontal disease progresses, bacteria and infection can travel through periodontal pockets, bone canals, or lateral root canals, eventually reaching the pulp and causing necrosis. In some cases, infection may spread in a reverse direction—from the gum into the pulp—leading to pulp death. Over time, if not treated, it can form a periapical cyst. Risk factors include poor oral hygiene, severe tartar buildup, and bacterial biofilm that worsen inflammation.

All of the above causes can lead to chronic inflammation and infection of the dental pulp. Bacteria and the byproducts of tissue necrosis can travel down the root canal and collect at the apex, forming an abscess or granuloma. As the infection persists in the acidic environment, it stimulates the epithelial cell rests of Malassez to proliferate, forming a sac-like structure. This epithelium-lined sac gradually grows, creating a periapical cyst as a response mechanism to protect surrounding bone tissue.

As pressure builds, the cyst may draw in fluids from surrounding tissue and continue to grow. While periapical cysts can remain asymptomatic in early stages, they may eventually cause bone destruction, swelling, and pain if not treated in time.

Common Symptoms of Periapical Cysts 

In early stages, periapical cysts often present without any clear symptoms. These cysts are usually detected incidentally during routine dental check-ups or X-rays. As the cyst grows, it may persist for a long time or expand significantly without causing pain or noticeable discomfort.

As the cyst enlarges, it can lead to bone loss around the apex of the tooth or nearby areas. At this point, patients may begin to experience symptoms such as swelling, jaw pain, a feeling of pressure in the affected area, or in some cases, a soft swelling inside the mouth. In more severe cases, the cyst may become infected and cause pus discharge, pain, and fever due to secondary infection and surrounding tissue inflammation.

In rare cases, the cyst may exert pressure on adjacent nerves, causing numbness or dull pain. However, these symptoms typically do not originate from the apex and should be differentiated from other lesions within the oral cavity.

Treatment Methods for Periapical Cysts

Examination and Diagnostic Process for Periapical Cysts

1. Medical History:
   The dentist will record the patient’s dental history, including signs of swelling, pain, previous trauma, or any treatments performed. This helps assess possible causes and evaluate the duration and severity of the cyst.
2. Clinical Examination:Identify the typical clinical signs of cysts

• Palpable mass:Identify a firm or fluctuant mass in the vestibular fold or gum line. If the mass is fluctuant and shows signs of cyst formation, the dentist may perform a transillumination test or assess mucosal integrity.
• Bone loss around the root:Bone loss in the affected area may indicate erosion, especially in cases of severe trauma, allowing the dentist to observe bone structure changes.
• Tooth trauma:Look for signs of trauma such as discolored teeth or teeth with large cavities, especially in teeth with a history of pulp necrosis. Trauma or untreated caries are often related to the formation of periapical cysts.

      3. Radiographic Diagnosis:

• Panoramic Radiograph:Provides an overall view of the jaws and surrounding structures to assess possible cystic lesions.
• Cone Beam CT Scan (CBCT):Highly effective for diagnosing cysts. It offers detailed imaging for evaluating cyst position, size, and extent.
• 3D CT Imaging: Allows for a three-dimensional evaluation of the cyst, helping determine its size and anatomical relation to surrounding structures.

Typical Radiographic Findings of Periapical Cysts:

• Radiolucent area: Appears as a round or oval radiolucent area near the root apex that doesn’t attach to the periodontal ligament.
• Sclerotic border: A radiopaque rim may be present, indicating a cyst lined with epithelial tissue.
• Adjacent root resorption: Roots of nearby teeth may show signs of resorption or displacement due to the expanding cyst.

       4. Differential Diagnosis:

• Apical periodontitis:Differentiate between cysts and apical granulomas or chronic periapical abscesses based on lesion size and radiographic appearance.
• Other jaw cysts/tumors:Rule out other odontogenic cysts or benign tumors that can appear similar to periapical cysts but arise from different origins.

The diagnostic and treatment process allows dentists to accurately identify and differentiate periapical cysts, leading to the development of an appropriate and effective treatment plan.

Treatment Methods 

Endodontic Treatment (Root Canal Therapy)

This method is suitable for cases where the periapical cyst is small and has not caused significant damage to the jawbone. In this approach, the dentist performs root canal therapy to eliminate the infection and reduce pressure inside the cyst. After treatment, the inflamed fluid is drained and the root canal system is cleaned and sealed.

Endodontic Treatment Combined with Apicoectomy
When the cyst is larger, endodontic treatment alone may not be sufficient. After root canal therapy, the dentist may need to surgically remove the root tip (apicoectomy) along with the cystic tissue to prevent reinfection from the apical area and ensure complete healing.

Surgical Removal and Cyst Enucleation
This method is applied in more severe cases where the cyst is large, has caused jawbone resorption, or involves parts of the tooth that cannot be preserved. The cyst is surgically removed to prevent further damage. The procedure involves: Isolating and removing the cystic sac, thorough cleaning and debridement of the area, and tooth extraction if necessary, depending on the extent of damage.

Each treatment method will be selected based on the cyst's size, level of damage, and the dentist’s assessment to ensure effective treatment and avoid complications.

Successful Periapical Cyst Treatment Case at Herident Dental Clinic

Initial Symptoms:

The patient, a 34-year-old woman, came in with symptoms of dull pain in the upper front teeth, with occasional nasal discharge. The pain had persisted despite previous root canal therapy on the upper left central incisor.

Clinical Findings:

Upon clinical examination, the dentist discovered bone loss from the apex of tooth #11 extending to surrounding teeth. The patient reported pain radiating to the right front teeth. Radiographs confirmed a large periapical lesion extending from tooth #12 to tooth #21.

Diagnosis:

The patient underwent Panoramic X-ray and Cone Beam CT (CBCT) scans to assess the extent of the lesion. The CT images showed a well-defined radiolucent area surrounding tooth #21, clearly indicating a cystic lesion. Tooth #21 had previously received root canal treatment, and tooth #22 was found to be close to the edge of the cystic lesion.

Based on the patient’s dental history, clinical examination, and radiographic results, the dentist diagnosed a periapical cyst associated with tooth #21, with possible involvement of tooth #11.

Treatment Plan:

After a definitive diagnosis, the patient was recommended an appropriate treatment approach, which included root canal retreatment combined with apicoectomy and cyst enucleation surgery. Extraction of tooth #11 was also considered if it could not be preserved.

Treatment Process at Herident Dental Clinic: : 

1. Evaluate and treat tooth #22: If pulp necrosis is present, perform root canal therapy prior to surgical intervention. If not, the tooth will be preserved during cyst enucleation and apicoectomy.

     2. Patient consultation: The treatment plan was explained to the patient, who then signed                  

           an informed consent form. 

3.   Preoperative monitoring: Vital signs and SpO₂ were continuously monitored to ensure the patient’s safety throughout the procedure.
4.   Aseptic preparation 

     5. Incision and flap reflection: A surgical flap was created around teeth #21 and #22 to access the cyst area. 

     6. Bone removal: A small portion of the bone was removed to access the cyst capsule. 

     7. Cyst enucleation and apicoectomy: The cystic tissue was fully excised, and the apical portion of tooth #21 was resected. 

     8. Curettage and disinfection: The surgical site was cleaned with Liderman and disinfected thoroughly. 

    9. Cavity lining: The cavity was sealed using MTA (Mineral Trioxide Aggregate). 

    10. Drain placement: A drainage strip was inserted to ensure proper postoperative fluid evacuation.

    11. Suture: The wound was sutured with sterile technique.                                                   

Postoperative Care 

• The patient was scheduled for a follow-up visit 3 days post-op to check healing and remove the drain. 
• Oral hygiene instructions: The patient was advised to rinse with warm saline water and prescribed antiseptic mouthwash to prevent infection. 
• Diet and activity guidance: The patient was advised to eat soft food, limit strenuous activity, and avoid direct pressure on the surgical site during the first few days. 

Preventive Measures Against Recurrence of Periapical Cysts

Although the recurrence rate of periapical cysts is relatively low, taking preventive measures plays a crucial role in maintaining oral health and preventing complications. Below are some practical tips:

Regular Dental Checkups

Routine dental visits help detect and treat tooth decay, periodontal disease, or pulpitis early—these are common sources of periapical cysts.

It is recommended to have checkups at least every 6 months and immediately if symptoms like toothache, gum swelling, or tooth discoloration appear.

Regular Dental Checkups Help Prevent Periapical Cyst Recurrence

Definitive Treatment of Oral Lesions

Early intervention in dental decay—such as fillings—can prevent the progression of pulp disease and subsequent cyst formation.

If pulp pathology is detected, thorough endodontic treatment is essential to ensure the root canal is completely cleaned.

Complete Removal of Cystic Tissue During Surgery

During cyst removal surgery, the dentist must ensure that all cystic and inflamed tissue is excised thoroughly.

For cases requiring apicoectomy, reverse root canal filling is necessary to prevent recurrence.

Proper Oral Hygiene Practices

Brush your teeth twice daily, use dental floss and antiseptic mouthwash to eliminate plaque and harmful bacteria.

Choose a soft-bristled toothbrush and fluoride toothpaste to protect enamel and prevent cavities.

Implementing these preventive steps not only reduces the risk of cyst recurrence but also contributes to long-term oral health, reduces treatment costs, and improves quality of life.

Frequently Asked Questions (FAQs)

How is a periapical cyst diagnosed? 

To diagnose a periapical cyst, the patient must undergo a thorough evaluation, including medical history review, clinical examination, and X-ray imaging. 

What are the treatment methods for periapical cysts? 

There are three primary treatment approaches: 

Option 1: Root canal therapy (endodontic treatment) 

Option 2: Root canal therapy combined with surgical cyst removal and apicoectomy 

Option 3: Surgical removal of the cyst, including the epithelial lining and inflamed tissue 

Depending on the size of the cyst, the amount of bone loss, and the patient's overall oral health, the dentist will determine the most suitable treatment plan. 

Postoperative care after cyst removal surgery: What to keep in mind?

After periapical cyst surgery, patients should: Maintain proper oral hygiene,, Rinse daily with antiseptic solutions, Follow a soft-food diet and Attend all scheduled follow-up appointments 

The successful treatment of this periapical cyst case at Herident Dental Clinic once again proves the exceptional capabilities of our dental team and the effectiveness of our treatment protocols. We are grateful for the trust our patients place in us and remain committed to our mission of delivering healthy smiles and lifelong happiness.

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