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Vol. 101 No.

2 February 2006

ENDODONTOLOGY Editor: Larz S. W. Spångberg

Epithelium and bacteria in periapical lesions

Domenico Ricucci, MD, DDS,a Elizeu A. Pascon, DDS, MSD, PhD,b Thomas R. Pitt Ford, BDS, PhD,
FDS,c and Kaare Langeland, DDS, PhD,d Rome, Italy, Toronto, Canada, London, England,
and Farmington, CT

Objective. The purpose of this study was to evaluate 50 human periapical lesions for bacteria and epithelium in a case
study in dental practice.
Study design. Specimens were obtained from the extraction of 50 untreated teeth that had lesions attached to their apices.
The specimens were histologically evaluated using serial sections.
Results. Bacteria were found in all teeth, colonizing necrotic tissue in the main canal, dentinal tubules, or apical ramifications,
and in the body of the periapical lesion in 18 abscesses or cysts. Twenty-one lesions were epithelialized; 14 abscesses, 20
granulomas, and 16 cysts were distinguished. In 18 root canals inflamed tissue was found in the apical part of the canal. A single
foramen was present in 13 cases while apical ramifications were found in 37 cases.
Conclusions. Granulomas were most common, and most epithelialized lesions were cysts. Bacteria were only detected
periapically in abscesses or cysts. Inflamed tissue was present in the apical root canal in one third of cases.
(Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:239-49)

It is generally accepted that the etiology of apical A significant controversy concerns the histo-
periodontitis is derived from the presence and colo- pathological condition of the pulp tissue in teeth with
nization of bacteria in the root canal system.1-6 The periapical lesions. It is commonly believed that in the
invasion of living bacteria cells is considered necessary radiological presence of a periapical lesion, and the
to lead to the development of a periapical lesion.7 absence of a pulpal response to clinical vitality testing,
Indeed, Kronfeld8 observed that despite the substantial the pulp tissue is totally necrotic. Based on this alone, a
amount of bacteria in the canal lumen of teeth with clear distinction is often made between cases contain-
periapical lesions, these bacteria were seen infrequently ing vital or necrotic pulp tissue. However, this is a
inside the granulomatous tissue in the periapical lesion; conceptual mistake that may lead to incorrect diagnosis
he stated that: ‘‘a granuloma is not an area in which and treatment options. There is growing evidence that
bacteria live, but in which they are destroyed.’’ More despite the presence of a periapical lesion the pulp tissue
recent investigation using electron microscopy supports in the apical part of the root may be vital.9-13
granulomas being bacteria-free. A periapical lesion consists of acute and chronic
inflammatory cells in variable concentrations and may
contain epithelial strands that may develop into a cyst
Private practice, Rome, Italy. when stimulated. Several studies using histological
Associate Professor, Department of Endodontology, Faculty of methods have reported on the prevalence of periapical
Odontology, University of Toronto, Canada.
Professor, Restorative Dentistry, GKT Dental Institute, King’s
cysts and granulomas with the frequency of periapical
College London, England. cysts varying from 6% to 55%.14-16 This broad range of
Professor Emeritus, Department of Endodontology, Faculty of frequency is due to the differences in methods of biopsy
Odontology, University of Connecticut, Farmington, Conn. collection and the histological criteria used for the
Received for publication Dec 7, 2004; returned for revision Mar 7, diagnosis of cysts.
2005; accepted for publication Mar 28, 2005.
1079-2104/$ - see front matter
When a lesion is diagnosed as a cyst, it is essential
Ó 2006 Mosby, Inc. All rights reserved. to establish its relationship to the apical foramen of the
doi:10.1016/j.tripleo.2005.03.038 involved tooth. Simon17 was the first to describe the

240 Ricucci et al. February 2006

morphological characteristics of 2 categories of cysts: The following were specifically looked for in the
true cyst when the cavity is completely surrounded by histological examination:
epithelium, and bay cyst when the cavity surrounded by
1. The presence and distribution of acute (polymor-
epithelium is connected to the apical foramen. Nair
phonuclear leukocytes) and chronic (lymphocytes,
et al.18 confirmed the existence of these 2 morphologi-
monocytes, plasma cells, macrophages, foam cells,
cal structures and renamed the cyst connected to the
mast cells, and foreign body cells) inflammatory
foramen as a pocket cyst. It is still unclear whether
the true cysts will heal after conventional root canal
2. The presence and location of bacteria related to
inflammatory cells.
The aims of this investigation of a clinical extraction
3. The presence of epithelial strands.
material were to:
4. The presence of empty spaces or spaces containing
1. Observe the presence and location of bacteria in the semi-solid material surrounded by epithelium.
root and periapical lesion; 5. The presence of cholesterol clefts.
2. Evaluate the presence of epithelium in periapical 6. A relationship between epithelium and the root.
lesions that remained attached to extracted roots; 7. A relationship between the cystic cavity and the
3. Evaluate the presence of abscess, granuloma, and foramen.
cyst in these periapical lesions; 8. The number of foramina.
4. Evaluate the condition of the connective tissue in
The lesions were diagnosed histologically according
the apical third of the canal and in the apical
to Nair et al.18 as periapical abscess (epithelialized or
ramifications of teeth with apical periodontitis; and
non-epithelialized), granuloma (epithelialized or non-
5. Study the morphology of the root canal in the apical
epithelialized), or cyst (true or pocket).
third and the presence of apical ramifications.

No specimens were lost during processing. During
The study material consisted of 50 human periapical
serial sectioning an occasional section was lost, but
lesions, attached to the apices of non-endodontically
adjacent sections enabled information on the specimens
treated extracted teeth. The patients had given consent
to be recorded.
for examination of their teeth, which had been removed
because the teeth were unrestorable or the patient did
not agree to saving the tooth. The patients had attended Bacteria in the canal, remaining pulp,
1 dental practice in Italy and their mean age was 38.16 and periapical tissue
years (range 16 to 81 years). Teeth were excluded if Bacteria were always present at some level of the root
there was a perio-endo lesion or a longitudinal fracture canal, colonizing in necrotic debris lining the walls and
or crack involving the root. infiltrating the disintegrated tissue filling the lumen
The specimens were immediately immersed in 10% (Figs. 1-3). Where there was colonization on the wall,
buffered formalin for at least 48 hours. Demineraliza- bacteria staining both gram positive and gram negative
tion followed in a solution of 22.5% (vol/vol) formic were found in the dentinal tubules and their ramifica-
acid and 10% (wt/vol) sodium citrate for a period of tions. Where necrotic tissue was observed in apical
3 to 4 weeks under constant agitation (Lipshaw bone ramifications, bacteria were also present (Fig. 4). A dense
decalcifier, Lipshaw Mfg Co, Detroit, Mich). The end accumulation of neutrophilic leukocytes was found
point was controlled radiographically. After rinsing for adjacent to the bacteria (Fig. 1 and Fig. 4), and some
24 to 48 hours in running water, the specimens were bacteria were also observed in their cytoplasm (Fig. 1).
dehydrated and processed for routine histological This occurred in both the canal and the periapical lesion.
examination. The specimen was embedded in toto and Bacteria were confined to the root canal in the
oriented parallel to the long axis of the main root canal majority of specimens diagnosed as granulomas. Only
in the apical third in order to obtain sections with root 18 cases had bacteria in necrotic areas of the periapical
canal and periapical tissue in direct continuity. Serial lesions and these were classified as abscesses or cysts
sections (150 to 600) were taken with the microtome set (Fig. 5). In 6 cases, bacterial aggregates were observed
at 4 to 5 lm until the whole specimen was cut. Every only on the periphery of the lesion, close to the often
fourth slide was stained with hematoxylin and eosin. uninflamed connective tissue of the so-called pseudo-
Selected slides were stained with the Masson’s tri- capsule, but not in the body of the lesion. In 3 cases
chrome to identify collagen and with the Taylor modi- bacterial aggregates, exhibiting a ray fungus appear-
fied Brown-Brenn stain for the presence of bacteria.19 ance surrounded by neutrophilic leukocytes, were
Volume 101, Number 2 Ricucci et al. 241

Fig. 1. A, Apical third of the palatal root of an extracted maxillary first molar with the lesion attached, showing a bifurcation of the
main canal and an apical foramen (hematoxylin and eosin, original magnification 325). B, Center of the lesion in A. Accumulation
of neutrophilic leukocytes and necrotic tissue (inset), but no epithelial strands (hematoxylin and eosin, original magnification
3100; circle 31000). C, No bacterial colonization in the lesion (inset) (Taylor’s modified Brown and Brenn, original magnification
325; inset 31000). D, Canal lumen 2 mm from the foramen. From bottom to top: bacterial colonies, necrotic tissue and
accumulation of PMNs (Taylor’s modified Brown and Brenn, original magnification 31000). E, E. Bacteria in the cytoplasm of
PMNs (Taylor’s modified Brown and Brenn, original magnification 31000). F, F. Bacterial colonization in necrotic tissue in the
canal lumen (Taylor’s modified Brown and Brenn, original magnification 31000).

found in the foraminal area and in the periapical lesion Periapical abscess
(Fig. 5). All the lesions classified as abscesses contained a
dense accumulation of polymorphonuclear leukocytes
Presence of epithelium (PMNs), delimited by a granulomatous tissue with
Histological examination of the 50 specimens led lymphocytes, macrophages, and plasma cells. These
to the identification of epithelium in 21 lesions, 20 lesions had the appearance of a preexisting granuloma
granulomas, 14 abscesses, and 16 cysts (Table I). with an area of acute inflammation of variable extension.
242 Ricucci et al. February 2006

Fig. 2. A, Palatal root of a maxillary first molar with the periapical lesion attached. Terminal part of the canal and its foramen are
present in this section and show vital pulp tissue in continuity with the periapical lesion. Epithelial strands are present throughout
the tissue (square) (hematoxylin and eosin, original magnification 325). B, Square in A: epithelial strand infiltrated by PMNs
(hematoxylin and eosin, original magnification 3400). C, Rectangular area in A: Granulomatous tissue with chronic inflammatory
cells and bordered by a ‘‘fibrous capsule’’ (hematoxylin and eosin, original magnification 3400). D, Another section of the
epithelial strand with infiltration of inflammatory cells (hematoxylin and eosin, original magnification 31000). E, Pulp tissue 2 mm
Volume 101, Number 2 Ricucci et al. 243

In some cases, this concentration of PMNs was observed in thickness and was always infiltrated by neutrophilic
in various micro-cavities (Fig. 1). Sometimes, in analyz- leukocytes. The internal layer of cells in the cystic
ing continuous serial sections, the micro-cavities be- wall showed signs of desquamation—they stained less
came larger and contained debris. At the edge of the well and their nuclei were indistinct (Fig. 4). Collagen
lesion, collagen fibers were present. Out of 14 observed fibers organized in pseudo-capsule form surrounded
periapical abscesses only 1 showed the presence of the cyst wall. Chronic inflammatory cells were
epithelial strands. observed among the collagen fibers at the border of
the lesion.
Periapical granuloma
All the 20 lesions classified as periapical granulomas Pocket cyst
contained chronic inflammatory cells. Every type of The lesions classified as pocket cysts showed a cystic
chronic inflammatory cell was observed in variable space surrounded by an epithelial wall that joined the
number and distribution inside the granuloma: lym- external root surface forming ‘‘a sac,’’ insulating the
phocytes, plasma cells, foam cells, macrophages, foramen from the rest of the lesion. The cystic cavity
and foreign body cells. A fibrous tissue with a lower had a direct opening into the canal lumen. The stratified
concentration of inflammatory cells was present at the squamous epithelial wall showed signs of cell desqua-
periphery (Fig. 2 and Fig. 3). Neutrophilic leukocytes mation and was infiltrated by PMNs. Debris was present
always infiltrated the epithelial tissue strands present inside the cystic lumen and the cavity was surrounded
in the 4 epithelialized lesions (Fig. 2). Occasionally, by inflamed connective tissue.
when the epithelium was present near the foramen it
was also observed in the canal (Fig. 2). The epithelial Apical anatomy
strands were generally organized as islands con- The anatomy of the apical third of the canal showed
taining granulomatous tissue with neutrophilic leuko- the presence of a single apical foramen in 13 cases (one
cytes, lymphocytes, plasma cells, and a rich vascular of these was a maxillary second premolar with 2 canals
network. ending in 2 single foramina, and a mesial root of a
mandibular first molar with 2 canals merging in 1 canal
Periapical cyst in the apical third, and ending in a single foramen)
Sixteen lesions were classified as cysts because a (Fig. 3). In the remaining 37 cases, apical ramifications
cavity was observed surrounded by epithelium. Seven in variable numbers were present and each one ended
had the morphological characteristics of a true cyst, independently at the root surface (one of these was the
8 had those of a pocket cyst, and 1 lesion contained mesial root of a mandibular first molar with 2 canals
2 distinct cysts, 1 true and 1 pocket (Fig. 4). In 2 lesions merging in 1 canal in the apical third and numerous
on maxillary molars the epithelial wall exhibited in apical ramifications, and 10 roots with 2 canals and
some areas the characteristics of respiratory epithelium. ramifications in the apical third). These ramifications
The epithelial cells showed distinct cilia on the cystic contained tissue in continuity with the periapical lesion
side and several mucous caliciform cells were present (Fig. 1, Fig. 2, and Fig. 4).
among epithelial cells.
Histology of the remaining apical pulp
True cyst In 18 of the 50 roots, there was vital tissue in the
The lesions classified as true cyst were character- apical part of the canals showing varying degrees of
ized by the presence of a cavity bordered by an inflammation. The coronal side presented an accumu-
epithelial wall that was not continuous with the canal lation of PMNs in direct contact with the bacterial
lumen in any of the serial histological sections. The invasion (Fig. 1), adjacent to a transition zone contain-
cystic cavity contained a mass of cells in varying ing nerves and vessels (Fig. 2) and infiltrated by chronic
stages of decomposition, necrotic debris, and some inflammatory cells (Fig. 3). In some cases, this tissue
cholesterol crystals surrounded by neutrophilic leuko- was only slightly inflamed and retained normal pulp
cytes (Fig. 4). The epithelial wall of the cavity varied architecture (Fig. 2 and Fig. 3). In the remaining 32

from the apex showing few chronic inflammatory cells and resorption on canal walls (hematoxylin and eosin, original
magnification 3400). F, Several sections away from the section in A: large canal ramification showing disintegrating tissue, the
foramen and periodontal tissue. Vital tissue in the foraminal area and absence of bacteria (insert) (Taylor’s modified Brown and
Brenn, original magnification 325, insert 31000). G, From area in F (arrow): necrotic debris colonized by bacteria (Taylor’s
modified Brown and Brenn, original magnification 31000).
244 Ricucci et al. February 2006

Fig. 3. A, Mesial root of a mandibular first molar with its periapical lesion: large area of resorption at the foramen. The pulp tissue
is vital and in direct contact with the periapical lesion. Calcifications in the coronal part of the canal (hematoxylin and eosin,
original magnification 325). B, Adjacent section stained for bacteria: these have colonized coronal to remaining pulp. Upper
insert: bacteria in necrotic pulp tissue. Middle insert: in the area apical to the calcification, no bacterial colonization. Lower insert:
in area of resorption, no bacterial colonization (Taylor’s modified Brown and Brenn, original magnification 325, inserts 31000).
C, Concentration of acute and chronic inflammatory cells in pulp tissue coronally in the canal, near the necrotic debris (upper arrow
in A) (hematoxylin and eosin, original magnification 31000). D, Area of pulp tissue, apical to calcification (middle arrow in A),
inflammation is chronic; fibers and fibroblasts present (hematoxylin and eosin, original magnification 31000). E, Area of
resorption (lower arrow in A): resorption of the dentine wall of the canal: multinucleated resorbing cell in lacuna of the dentin wall
(hematoxylin and eosin, original magnification 31000).
Fig. 4. A, Section taken through the bucco-palatal plane of a maxillary second premolar: 2 distinct cystic cavities lined by
epithelium. There is no evidence of communication with the foramen in this section (hematoxylin and eosin, original magnification
325). B, Cyst cavity on the left side in A. Accumulation of foam cells and scattered PMNs in the upper area (inset) (hematoxylin
and eosin, original magnification 350, inset 31000). C, Lower part of cavity in B, dense infiltration of PMNs adjacent to empty
spaces (hematoxylin and eosin, original magnification 31000). D, Cystic cavity on the right side in A. Large quantity of debris in
the lumen; surrounding epithelial strands accompanied by granulomatous tissue (hematoxylin and eosin, original magnification
350). E, Cystic wall (yellow arrow) in D. Disintegrated PMNs and epithelial cells adjacent to the lumen (LU) (hematoxylin and
eosin, original magnification 31000). F, Section taken approximately 0.75 mm away from the section in A and deeper into the
cystic lumen; cystic cavity at the right side. Three apical ramifications are present, one of them containing an apical foramen
(arrow). Foam cells, PMNs, and necrotic debris inside the cyst (inset), but no bacteria (Taylor’s modified Brown and Brenn, original
magnification 325, inset 31000). G, Area arrowed in F. From bottom to top: bacterial colonization (blue); area of necrosis; PMNs
(Taylor’s modified Brown and Brenn, original magnification 31000).
246 Ricucci et al. February 2006

cases, necrotic debris filled the canal to the constriction excised biopsies.20 The concept that bacteria are present
sometimes entering the apical region that contained in asymptomatic lesions more frequently than previ-
a concentration of neutrophilic leukocytes (Fig. 4). ously believed is based on recent techniques for
molecular identification of bacteria.21-22
DISCUSSION Besides the contamination caused by the presence of
The cases examined in this study came from a single saliva in the surgical field, one must also consider that
dental practice. For inclusion the lesions had to remain during root-end resection there may be displacement of
attached to the roots, and any that did not were excluded. the bacteria from the canal into the periapical tissues
These strict criteria were not used in some previous during handling. In addition, evaluation of the periapical
studies14,15 and explain the smaller number of cases. tissue separated from the apical foramen can lead to
The method adopted in this study was serial sectioning false results. Using adequate histological techniques,
from one side to another of a periapical lesion that was only the morphological study of the apical radicular
attached to a root in order to study the relationship of the third with the foramen and the periapical lesion in their
lesion to the foramina. This relationship was important original spatial relationship will demonstrate the local-
for diagnosis of cysts and their division into true or ization of bacteria in the canal and in the lesion.
pocket types.18 Some previous studies14,15 had not The frequency of cysts found in this study was 32%
examined serial sections all through a lesion or had not and is higher than the 15% reported by Nair et al.18 but
examined lesions attached to roots. Thus, there is the lower than the 42% and 44% reported by Bhaskar14 and
likelihood that the prevalence of cysts may have been Lalonde and Luebke,15 respectively. It is important to
overstated. A lesion identified as a granuloma in one emphasize that the prevalence of lesions reported by
section, was 0.5 mm away, an abscess containing a large Nair et al.18 and in this study may not reflect their real
area of disintegrated tissue; the diagnosis was decided incidence in the population, as these only reflect lesions
by the most severely inflamed part. It is known clinically attached to a sample of extracted teeth and not a ran-
that not all periapical lesions remain attached to teeth domized study of patients. Sections containing epithe-
during extraction. This happens only when there is a lial strands might be erroneously diagnosed as cysts. In
strong fibrous connective tissue adherence to the root at a recent study of 256 lesions, 52% showed epithelial
the periphery of the lesion. strands but only 15% could effectively be diagnosed as
Histological bacterial staining methods, including the periapical cysts.18 In the present study, 21 of 50 lesions
Brown and Brenn technique used in this study, are showed epithelium but only 16 could be diagnosed as
modifications of the Gram staining technique and are cysts. The presence of epithelium is slightly higher than
technique-sensitive. However, where root remnants the 31% reported by Summers,23 but of a similar order to
were enclosed in the section, bacteria were stained in that reported by Simon.17 In this study all of the teeth
the necrotic tissue. Therefore, the demonstration of were untreated endodontically and the duration of the
bacteria in the necrotic part of the canal, in adjacent apical periodontitis was not assessable. As the teeth
dentinal tubules and in gingival bacterial plaque where were largely unrestorable, the sample would be biased
present, shows the effectiveness of the staining method. toward advanced lesions.
As a result, the presence or absence of bacteria in the In this study, it was demonstrated that 18 roots
periapical tissues of the same sections should not be showed the presence of varying amounts of remaining
unreliable (Fig. 2 and Fig. 3). The reported frequency of tissue in the apical root canal with different degrees of
bacterial cells in the periapical lesions does not exclude inflammation. The coronal aspect presented an accu-
the presence of bacterial components such as cell walls mulation of PMNs in direct contact with the bacterial
or metabolic products that are not identified by the invasion (Fig. 1), adjacent to a transition zone contain-
staining technique. ing nerves and vessels (Fig. 2) and infiltrated by chronic
Where the periapical lesion was free of bacteria inflammatory cells (Fig. 3). In some cases, this tissue
internally, the presence of scattered bacterial cells on the only showed areas of slight inflammation (Fig. 2 and
external surface of 6 lesions is considered to have been Fig. 3). The interrelationship between bacteria and the
caused by oral contamination during the procedure to adjacent tissue is important. Since bacteria only colo-
obtain the specimens. Despite care taken during the nize in necrotic tissue and because there was a large
procedure, it was impossible to avoid surface contam- concentration of PMNs near these areas of necrosis
ination by oral bacteria. The histological method (Fig. 1, Fig. 3, and Fig. 4), these cells must have been
enabled this contamination to be recognized as it was actively phagocytosing. Observing the canal further in
not related to inflammation. Demonstration of bacterial the apical direction, away from the bacterial contami-
contamination questions the results of those studies that nation, the number of PMNs decreased and the number
have used bacterial culture techniques on surgically of chronic inflammatory cells increased (Fig. 2 and
Volume 101, Number 2 Ricucci et al. 247

Fig. 5. A, Apical part of a mandibular second premolar and its periapical lesion. A cyst cavity is present and is partly filled. The
inset shows fuchsin stained filamentous material surrounded by PMNs (Taylor’s modified Brown and Brenn, original magnification
325, inset 31000). B, Area indicated by upper arrow in A: bacterial colonies and filaments in an area of necrosis (Taylor’s
modified Brown and Brenn, original magnification 31000). C, Area indicated by lower arrow in A: bacterial colony with a ray
fungus appearance completely surrounded by PMNs (Taylor’s modified Brown and Brenn, original magnification 3400). D,
Higher power view of the colony in C showing pallisading of PMNs (Taylor’s modified Brown and Brenn, original magnification
248 Ricucci et al. February 2006

Table I. The types of lesion that were diagnosed enzymes capable of liquefying tissues. The process was
Type of lesion Number Percentage also observed in this investigation. As a result of cell
death, micro-cavities appeared inside the tissue, and
Epithelialized abscess 1
Non-epithelialized abscess 13 near epithelium a fluid-filled space could develop.
Total periapical abscess 14 28 It is currently assumed that among the cystic lesions,
Epithelialized granuloma 4 only the pocket cyst can heal after conventional root
Non-epithelialized granuloma 16 canal treatment. The true cyst, which has its own
Total granuloma 20 40 dynamics independent of the canal and is auto-sufficient,
True cyst 8*
Pocket cyst 9* is assumed not to be influenced by root canal treat-
Total cyst 16 32 ment.16 This assumption cannot be verified by clinical,
radiological, or histological findings. Since clinicians
*One lesion contained 2 distinct cysts (1 pocket and 1 true).
are unable to establish beforehand whether or not there
is a cyst (true or pocket), the effect of treatment cannot
Fig. 3). This study has demonstrated the presence of be established in retrospect regardless of the methods
vital tissue in the apical third of the canal coexisting used. Although the use of serial sections demonstrated
with a large periapical lesion in one third of cases. a true cyst with no apparent communication with the
Although such a possibility has been a matter of clinical root canal in 8 cases, these lesions cannot be regarded
controversy, it is readily explainable: periapical inflam- as a separate disease entity.
matory response is the product of tissue reaction to and
effects of bacteria, their cell walls, and toxins. Since CONCLUSIONS
these products may be transported from their original Bacterial colonization was observed in the root
site in the canal to the periapical tissue through canals of all teeth, but in only 18 periapical lesions
functioning vessels, the reason for the presence of that were classified as abscesses or cysts. Out of 50
healthy pulp tissue between the 2 areas of severe lesions, 21 lesions were epithelialized; there were
inflammation becomes clear.3 Clinicians are convinced 20 granulomas, 14 abscesses, and 16 cysts with a
that in cases with periapical lesions, the entire pulp is similar number of true and pocket cysts. All types of
necrotic, however this study demonstrated that this was inflammatory cells were found in all lesions, but their
so in only about two thirds of cases. proportions differed. In 18 specimens there was
We found that 18 out of 50 lesions had bacterial remaining pulp tissue in the apical root canal despite
colonization in the periapical tissue; these were lesions the presence of a periapical lesion. The root canal ended
classified as abscesses or cysts. Previously, Block et al.3 in 1 foramen in 13 cases. Ramifications in the apical
had reported this in only 1 out of 230 biopsy cases. third were common (37 cases).
Using both light and electron microscopy Nair6 dem-
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