Clinical Research
Nonendodontic Lesions Misdiagnosed as Apical Periodontitis
Lesions: Series of Case Reports and Review of Literature
Flavia Sirotheau Corr^ea Pontes, PhD,* Felipe Paiva Fonseca, MSc,† Adriana Souza de Jesus,*
Ana Carolina Garcia Alves,* Leila Marques Ara ujo, MSc,* Liliane Silva do Nascimento, PhD,*
and Helder Ant^
onio Rebelo Pontes, PhD*
Abstract
Introduction: This study aimed to analyze cases
referred from a reference service in oral pathology that
were initially misdiagnosed as periapical lesions of
endodontic origin and to perform a review of the litera-
ture regarding lesions located in the apical area of teeth
with a nonendodontic source. Methods: A survey was
made of clinical cases derived from the service of oral
pathology from 2002 to 2012. The pertinent literature
was also reviewed using ScienceDirect and PubMed
databases. The lesions were grouped into benign lesions
mimicking endodontic periapical lesions (BLMEPLs),
malignant lesions mimicking endodontic periapical
lesions (MLMEPLs), and Stafne bone cavities. The clin-
ical presentations were divided into lesions with
swelling without pain, lesions with swelling and pain,
and lesions without swelling but presenting with pain.
Results: The results showed that 66% (37/56) of cases
represented benign lesions, 29% (16/56) malignant
lesions, and 5% (3/56) Stafne bone cavities. The most
commonly reported BLMEPLs were ameloblastomas
(21%) followed by nasopalatine duct cysts (13.5%).
The most frequently cited MLMEPLs were metastatic
injuries (31.5%) followed by carcinomas (25%). The
main clinical presentation of BLMEPLs was pain,
whereas that of MLMEPLs was swelling associated
with pain; Stafne bone cavities displayed particular clin-
ical findings. Conclusions: Clinical and radiologic
aspects as well as the analysis of the patients’ medical
history, pulp vitality tests, and aspiration are essential
tools for developing a correct diagnosis of periapical
lesions of endodontic origin. However, if the instruments
mentioned earlier indicate a lesion of nonendodontic
origin, a biopsy and subsequent histopathological anal-
ysis are mandatory. (J Endod 2013;-:1–12)
Key Words
Apical periodontitis, endodontic lesions, misdiagnosis,
neoplasia mimicking apical periodontitis, periapical
lesion
From the *Jo~ao de Barros Barreto University Hospital, Belem, Para, Brazil; and †Piracicaba Dental School, State University of Campinas, Piracicaba, S~ao Paulo, Brazil.
Address requests for reprints to Dr Helder Ant^onio Rebelo Pontes, Jose Malcher Street, No 1913, Ap 801, 66060-230 S~ao Braz, Belem, PA, Brazil. E-mail address:
harp@ufpa.br
0099-2399/$ - see front matter
Copyright ª 2013 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2013.08.021
JOE — Volume -, Number -, - 2013
A pical periodontitis lesions generally have an etiology that is associated with necrosis
and infection of the root canal system that manifests itself as the host defense response
to microbial challenge (1, 2); they are usually identified as radiolucency located in the
apex of the teeth on radiographic examinations. These lesions could be chronic (eg,
radicular cysts, granulomas, and chronic abscesses) or acute (eg, periradicular
abscess or cellulitis) and represent approximately 90% of all periapical lesions (3).
However, there are lesions of neoplastic sources, cystic lesions of nonendodontic
origin, and anatomic variations such as a Stafne bone cavity (SBC) that when located in
the periapical area of the teeth might radiographically and clinically mimic lesions of
endodontic origin, especially when associated with teeth with pulp necrosis or that
were previously treated endodontically, leading to misdiagnosis and an ineffective ther-
apeutic protocol (4, 5).
For a proper diagnosis, a detailed review of the patient’s past medical and dental
histories and the clinical aspects and specific radiographic findings represent important
steps in the diagnostic process and may prevent a diagnostic dilemma. Considering
these aspects, it is possible to reduce the amount of diagnostic confusion (6, 7). The
aim of this study was to analyze cases referred from a reference service in oral
pathology that were initially misdiagnosed as periapical lesions of endodontic origin
and to perform a review of the literature regarding lesions located in the apical area
of teeth with a nonendodontic source.
Materials and Methods
After a survey of the clinical cases referred from the service of oral pathology of the
University Hospital Jo~ao de Barros Barreto, Belem, Para, Brazil, from 2002 to 2012, 11
cases, which were initially misdiagnosed as periapical lesions of endodontic origin,
were selected. After a review of the patients’ past medical and dental histories, aspira-
tion, pulp vitality tests, and clinical/radiographic evaluations, these lesions were bio-
psied and correctly diagnosed as lesions of nonendodontic origin.
Beyond the case reports from the service of oral pathology, the pertinent literature
was reviewed using predefined key words in the ScienceDirect and PubMed databases to
search for articles that reported cases about periapical lesions of nonendodontic origin,
which were previously diagnosed and, in some cases, treated like endodontic disease.
To perform the literature search, the following key words were used: neoplasia
mimicking periapical lesions, carcinoma mimicking periapical lesions, benign lesion
mimicking periapical lesion, lesion mimicking a dentoalveolar abscess, lesion
mimicking dental infection, lesion mimicking radicular cyst, lesion mimicking dental
granuloma, lesion mimicking endodontic lesion, lesion mimicking apical periodontitis,
neoplasia mimicking apical periodontitis, and tumor mimicking apical periodontitis.
Nonendodontic Lesions Mimicking Apical Periodontitis 1
Clinical Research
Using these keywords, 147 articles were identified. Despite the
large amount, 27 titles appeared more than once (3–4 times each)
in the search, decreasing the number to 44 articles. Excluding those
that were unrelated to the topic (did not report nonendodontic lesions
mimicking apical periodontitis), 45 clinical cases remained for anal-
ysis. Thus, a total of 56 cases were analyzed, 11 from the service and
45 from the literature review. From the case reports, the following
data were extracted: the type of the lesion and its location, the patients’
age and sex, the evolution time of the lesion, radiographic aspects, posi-
tive/negative pulp vitality of the involved teeth, local signs and symptoms,
the initial diagnosis impression, and the treatment of the lesions.
The lesions were separated into the following 3 groups: benign
lesions mimicking endodontic periapical lesions (BLMEPLs), malig-
nant lesions mimicking endodontic periapical lesions (MLMEPLs),
and Stafne bone cavities (SBCs).
Inclusion Criteria
All of the reviewed article were published in the English and pre-
sented case reports involving diagnosis through histopathological anal-
ysis, which included sufficient information about clinical and radiologic
aspects of the lesions.
Results
After a review of the archives derived from the service of oral
pathology from 2002 to 2012, 11 report cases were chosen, which are
detailed in Table 1. The cases described in the literature are detailed
in Table 2 (benign cases), Table 3 (malignant cases), and Table 4
(SBC cases).
Together, the results showed that 66% (37/56) of cases rep-
resented benign lesions, 29% (16/56) malignant lesions, and 5%
(3/56) SBCs. The most commonly reported BLMEPLs were amelo-
blastomas (21%) followed by nasopalatine duct cysts (13.5%). The
most frequently cited MLMEPLs were metastatic injuries (31.5%)
followed by carcinomas (25%). The main clinical presentation of
BLMEPLs was pain (29.7%), whereas that of MLMEPLs was swelling
associated with pain (46.6%); SBCs displayed particular clinical
findings (asymptomatic radiolucent lesions).
From the 56 cases, 48 cases reported pulp vitality; approximately
56.5% of teeth answered positively (27/48) and 43.5% negatively
(21/48). In 6 cases, the involved teeth had already been endodonti-
cally treated.
The predominant radiographic appearance of BLMEPLs in the
service of oral pathology was a radiolucent area associated with the
involved teeth (9/10 cases) as shown in Figure 1A–D. The intraoral
and radiographic aspects of the only malignant case are shown in
Figure 2A and B. The most observed radiographic profile of the lesions
collected from the literature review including benign, malignant, and
SBC cases was a radiolucent aspect, representing 93.3% of all cases.
There was no predominance between the mandible and maxilla in
MLMEPLs; however, the posterior region predominated (62.5%) when
compared with the anterior region (37.5%). The BLMEPL group
showed a mandibular predominance (22/37), with slight differences
between the anterior (43.25%) and posterior (56.75%) regions.
With regard to SBCs, the 3 cases reported in the literature occurred
in the anterior region of the mandible.
The majority of MLMEPLs were described from the third decade,
with only 2 cases occurring in previous decades. The mean age of meta-
static lesions in our study was 50 years (the youngest patient was 39
years and the oldest 62 years), with 80% located in the mandible.
The BLMEPL group comprised cysts, neoplasms, and fibro-
osseous lesions. Considering the neoplasms, the results show that the
2 Sirotheau Corr^ea Pontes et al.
mean age was 30.2 years. The cysts represent 35.2% of BLMEPLs
with a mean age of 29 years. The fibro-osseous lesions represent
10.8% of benign lesions with a mean age of 37.5 years.
Discussion
Reports about nonendodontic lesions mimicking apical periodon-
titis and their misdiagnosis can be frequently found in the literature.
This fact occurs because lesions, especially those of neoplastic origin,
can present an aspect of radiolucency in the jaws (8–11). In 2012,
Koivisto et al (12), analyzing the frequency and distribution of radiolu-
cent jaw lesions in 9,723 cases, found that 73% represented apical gran-
ulomas and cysts, 8.8% keratocystic odontogenic tumors, 1.3% central
giant cell lesions, 1.2% ameloblastomas, and less than 1% metastatic
lesions. Hence, the aim of this article was to analyze cases in the liter-
ature derived from a reference service in oral pathology that were
initially misdiagnosed as apical periodontitis lesions of endodontic
origin.
Periapical lesions of endodontic origin are associated with infec-
tion followed by necrosis of the dental pulp (1, 2). Once the dental pulp
is contaminated and infected, the periapical region starts to shelter
a series of host defense elements against toxic components contained
in the root canal system, including cytokines, antibodies, and host
defense cells. Therefore, the periapical area begins to undergo
osteolytic alterations (13). However, differential diagnoses of periapical
lesions should consider lesions of nonendodontic origin, including
cysts, anatomic variations, and neoplastic lesions, because of their
different treatments and prognoses (3).
Koivisto et al (12) showed that the majority of cysts (more than one
third) occur in the anterior maxilla. In this region, radicular cysts can
cause asymptomatic swelling because of the thin cortical bone of this
anatomic site (14). In our study, 25% and 10.8% of MLMEPLs and
BLMEPLs, respectively, presented asymptomatic swelling, and from these
cases, 75% (3/4) of BLMEPLs and 50% (2/4) of MLMEPLs with asymp-
tomatic swelling were found in the anterior maxilla. Thus, although
asymptomatic swelling in the anterior maxilla cannot be used as a crite-
rion to exclude benign and malignant lesions that could mimic
endodontic lesions, it is suggestive, in principle, of a radicular cyst, espe-
cially if there is a tooth without positive pulp vitality associated (15).
Swelling and pain were the most cited symptoms of MLMEPLs
(46.6%), whereas BLMEPLs presented these associated symptoms in
only 10.8% of all cases. Such clinical cases could simulate acute lesions
of endodontic origin. Therefore, pulp vitality tests may help to elucidate
the origin of the disorder (16). The teeth associated with apical periodon-
titis lesions will show negative responses to pulp sensitivity (4, 17). If the
teeth exhibit positive responses to the vitality test, despite having swelling
and associated pain, the dentist should consider lesions of
nonendodontic origin in the differential diagnosis. In the present study,
48 cases reported pulp vitality; approximately 56.5% of teeth answered
positively and 43.5% negatively. In 6 cases, the involved teeth had
already been endodontically treated. From this fact, it can be stated that
coincidental clinical findings may occur; the tooth can present pulp
necrosis or already have been endodontically treated, whereas the apex
lesion could be of a nonendodontic source.
Therefore, it is interesting to emphasize that lesions of nonendo-
dontic origin may lead to pulp necrosis when located close to root
apices (7, 18, 19). For this reason, the dentist cannot base diagnosis
only on the pulp vitality test but should also consider the clinical
history (20) and perform a judicious clinical examination (including
a review of the patient’s past medical and dental histories and physical
examination) to look for a local cause of the pulp infection, such as
caries, infiltrated restorations, or root canal treatment performed
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 TABLE 1. Data from Cases of the Oral Pathology Service
JOE — Volume -, Number -, - 2013

Lesion Sex/age Evolution time Radiographic aspect Pulp vitality Local signs and symptoms Initial diagnosis impression Treatment
Odontogenic M/55 y Was not Well-circumscribed lesion Positive Pain and swelling Radicular cyst Curettage
keratocystic tumor mentioned from lower right lateral
incisor to right second
premolar
Fibro-osseous lesion F/37 y 1 mo Osteolytic lesion of mixed Positive Pain and swelling not Endodontic lesion Patient follow-up
radiographic next to reported
mandibular first and
second right premolars
Traumatic bone cyst M/14 y Was not Radiolucent unilocular Positive Pain absent Endodontic lesion Curettage
mentioned lesion from left lower
canine to left lower
second premolar
Nasopalatine F/49 y Was not Radiolucent lesion Positive Pain present Cyst Surgical removal
duct cyst mentioned associated with the
superior incisors
Cemento-osseous F/53 y 3y Radiolucent lesion Positive Pain not reported. Endodontic lesion Patient follow-up
dysplasia with radiopaque
well-defined margins
and central
radiopacities
Central giant F/16 y 1y Radiolucent area around Positive Pain absent Periapical granuloma Surgical removal
cell lesion the apex of mandibular
left second molar
Traumatic bone cyst F/15 y 2y Radiolucent area located First premolar Pain and swelling absent Endodontic lesion Curettage
between first and positive and
second right second negative
mandibular premolars
Traumatic bone cyst F/14 y — Radiolucent lesion Positive Pain and swelling absent Endodontic lesion Curettage
associated with the
apex of mandibular left
first premolar
Unicystic M/59 y 2y Radiolucent area Was not reported Pain present. Endodontic lesion Surgical removal
ameloblastoma associated with second
and third mandibular
Nonendodontic Lesions Mimicking Apical Periodontitis

right molars
Myxoma F/34 y 1 mo Radiolucent Treatment Pain absent Endodontic lesion Surgical removal
multilocular lesion with endodontic
well-defined borders
associated with first
and second mandibular
right molars
Mucoepidermoid F/49 y 6 mo Diffuse multilocular Negative Pain present. Expanding Endodontic lesion Surgical removal

Clinical Research
carcinoma radiolucent lesion and punching the
associated with upper cortical bone
left lateral incisor and
canine
F, female; M, male.
3
 TABLE 2. Data from the Benign Cases of the Literature Review
4

Clinical Research
Local signs and Initial diagnosis
Article Lesion Sex/age Evolution time Radiographic aspect Pulp vitality symptoms impression Treatment/follow-up
Sirotheau Corr^ea Pontes et al.

Suter et al Nasopalatine duct M/42 y 3 mo Extensive round Negative Painless, palatal Radicular/residual cyst Surgical removal
(8), 2011 cyst radiolucency was swelling
present in the midline
of the anterior maxilla
Suter et al Nasopalatine duct M/17 y 3.5 y Large radiolucency Negative Swelling and pain Radicular cyst Endodontic
(8), 2011 cyst extending from the treatment and
upper left to the upper Surgical removal
right canine region
andincluding the nasal
cavity
Drazic and Minic Focal cemento- M/19 y Not Mentioned Unilocular periapical Negative Asymptomatic Periapical granuloma Surgical removal
(34), 1999 osseous dysplasia radiolucency, with
well-definedmargins
associated with the
upper right first
premolar
Curran et al Adenomatoid F/21 y Several months Well-circumscribed Was not reported Pain present Periapical lesion of Surgical removal
(39), 1997 odontogenic (not specifically radiolucency endodontic origin
tumor reported) apicalbetween the
upper canine and
lateral incisor
Islam et al Cemento-osseous F/41 y 3y Fairly well-defined The tooth had Painless swelling Periapical lesion of Surgical removal
(18), 2008 dysplasia radiolucent area at the already been endodontic origin
apex of the maxillary endodontic
central incisor. The treated.
lesion was unilocular
Huey et al Central M/42 y 3y Multilocular radiolucent Positive Presence of a painless Central ossifying Nonsurgical root canal
(40), 1995 odontogenic lesion of the right ‘‘sinus tract-like’’ fibroma, radicular therapy on the upper
fibroma anterior maxilla cyst, or right central incisor to
odontogenic myxoma right canine because
these teeth would
be devitalized during
the surgical procedure
and then surgical
removal
Kashyap et al Ameloblastoma M/18 y 6 mo Radiolucency extending Negative Pain on palpation Periapical cyst Surgical removal
(41), 2012 from the mandibular
left canine to the
right first molar
Nary Filho et al Central giant cell F/16 y Lesion detected Oval, regular, and Negative Painless swelling Periapical lesion of Surgical curettage
(42), 2004 lesion upon routine well-delineated endodontic origin
orthodontic radiolucent area
follow-up located between the
radiography mandibular left central
JOE — Volume -, Number -, - 2013

incisor to left
lateral incisor
de Moraes Ossifying fibroma F/40 y 5 mo A well-circumscribed, Mandibular left Pain present Persistent apical Surgical removal
Ramos-Perez unilocular, radiolucent canine: negative; periodontitis and an
et al (4), 2010 lesion located in the mandibular right odontogenic cyst
periapical region of central incisor,
the mandibular right, lateral incisor, and
there was disruption of first premolar:
the lamina dura and the positive
root canalof the tooth
had been
endodontically treated
(Continued )
 TABLE 2. (Continued )
JOE — Volume -, Number -, - 2013

Local signs and Initial diagnosis

Article Lesion Sex/age Evolution time Radiographic aspect Pulp vitality symptoms impression Treatment/follow-up
Philipsen et al Adenomatoid F/15 y Not mentioned A well-defined, round to Positive Asymptomatic Lesion of endodontic Surgical removal
(10), 2002 odontogenic oval radiolucent lesion origin
tumor with radiopaque margin
associated with the
upper right central and
lateral incisor
Ribera Osteoblastoma M/69 y 6y Area of rarefying osteitis Positive Pain Lesion of endodontic Surgical removal
(43), 1996 superior to the apices of origin
both teeth upper right
central and lateral
incisors
Rodrigues Traumatic bone M/12 y 3y Small circumscribed Positive Asymptomatic Inflammatory periradicular Surgical removal
and Estrela cyst radiolucentimage cyst, traumatic bone
(5), 2008 below cyst,odontogenic
the periradicular area of keratinizing cystic
teeth mandibular right tumor, giant cell
central and lateral central granuloma, and
incisors unicysticameloblastoma
Faitaroni et al Ameloblastoma M/54 y Not mentioned Well-defined radiolucent Upper left lateral Pain present Symptomatic apical Surgical removal
(3), 2008 area in the periapical incisor:positive; periodontitis
areaof the upper left upper left canine
lateral incisor to left first and first premolar:
premolar negative
Philipsen et al Adenomatoid F/17 y 2 mo Well-circumscribedcystic Positive but Asymptomatic Radicular cyst Surgical removal
(44), 1992 odontogenic radiolucency extending diminished
tumor from theupper left
central
incisor to the left second
premolar region with
root
resorptionof the upper
left lateral incisor,
canine,
and first premolar
Faitaroni et al Nasopalatine M/49 y 2y Radiographs showed root The patient had Occasional discomfort Apical periodontitis Surgical removal
(7), 2011 duct cyst canal filling extending already treated during palpation of
Nonendodontic Lesions Mimicking Apical Periodontitis

to the root apex and the tooth the upper left

a large radiolucency endodontically central incisor
in the area of the upper
left central and lateral
incisors
Faitaroni et al Nasopalatine M/28 y Not mentioned Radiographsshowed a root The patient had Tooth mobility Apical periodontitis Surgical removal
(7), 2011 duct cyst canal filling with already treated
intracanal dressing and the tooth
a periapical endodontically

Clinical Research
radiolucency
in the area of the upper
right central and lateral
incisors
Faitorani et al Nasopalatine duct M/32 y Not reported Well-defined radiolucency Not reported Asymptomatic Apical periodontitis injury Enucleation
(7), 2011 cyst of
about 2-cm diameter in
the periapical region
(Continued )
5
 TABLE 2. (Continued )
6

Clinical Research
Local signs and Initial diagnosis
Article Lesion Sex/age Evolution time Radiographic aspect Pulp vitality symptoms impression Treatment/follow-up
Sirotheau Corr^ea Pontes et al.

Faitorani et al Nasopalatine duct M/53 y >5 y Large radiolucency The tooth had Discomfort during Apical periodontitis lesion Cyst enucleation
(7), 2011 cyst measuring about 1 cm in already been palpation of tooth
diameter endodontically 12 and presence of
treated a buccal sinus tract
Silva et al Paradental cyst M/14 y Not mentioned Radiolucency situated on Initially interpreted Pain sensation Radicular cyst Surgical removal
(45), 2003 the as negative
buccal aspect and
extendingapically on
the
mandibular right first
molar
Rodrigues et al Lymphangioma F/81 y 8y A radiolucent multilocular The teeth had Asymptomatic Periapical inflammation The patient was
(19), 2011 image inthe left already been and after endodontic not treated
mandibular molar endodontic treatment neoplasia because of health
region treated issues and died 2
years after of
cardiac
complications
Martins et al Intraosseous F/34 y Not mentioned In the alveolar bone, a Positive Asymptomatic Keratocyst or Surgical removal
(46), 2007 schwannoma radiolucent, unilocular, ameloblastoma, a
well-circumscribed central giant cell
lesion granuloma or idiopathic
with a dense sclerotic bone cavity
border situated
between
the second premolar
and
first molar in the right
mandibular area was
noted
Morais et al Intraosseous F/39 y Not mentioned In a follow-up Positive Asymptomatic Periapical lesion of Surgical removal
(47), 2011 lipoma appointment endodontic origin
10 months after surgery,
periapical radiographic
analysis showed
complete
bone formation in the
region of the upper left
second molar
Gondak et al Unicystic Not Two patients Well-defined radiolucent Was not reported 1 patient presented Apical periodontitis Surgical
(23), 2013 ameloblastoma mentioned reported the images with variable withdiscreet facial removal
time since dimensions of asymmetry and 2
onset of the themandible patients presented
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lesionsvarying with intraoral

from 12–72 swellings; 2 of these
mo (mean of patients complained
45.6 mo), of slight discomfort
and 3 patients associatedwith their
reported lesions
anunknown
time of onset

F, female; M, male.
JOE — Volume -, Number -, - 2013

TABLE 3. Data from the Malignant Cases of the Literature Review

Local signs and Initial diagnosis
Article Lesion Sex/age Evolution time Radiographic aspect Pulp vitality symptoms impression Treatment/follow-up
Lee et al Squamous cell F/46 y 3 months No radiographic Negative Pain absent Dentoalveolar abscess Surgical treatment
(48), 2007 carcinoma changes noteworthy erythematous with partial
papule on the labial maxillectomy
attached gingiva
Saund et al Lymphoma F/38 y 6 mo Radiolucency and The teeth had already Pain present; Lesion of endodontic Radiotherapy and
(49), 2010 dense radiopaque been endodontically nonhealing socket origin chemotherapy
lesion treated where the left upper
lateral incisor was
removed4 months
previously
Davido et al Ewing sarcoma M/25 y Not mentioned Unilocular Was not reported Pain and swelling Apical infectious lesion Chemotherapy
(11), 2011 radiolucency present of endodontic origin followed by a partial
maxillectomy
Copeland Breast metastasis F/52 y Several weeks Diffuse periapical Negative Swelling, teeth Lesion of endodontic Hemimaxillectomy
(50), 1980 radiolucencies mobility, and pain origin followed by
chemotherapy
Choi et al Intraosseous M/52 y 10 d Well-defined periapical Positive Pain present Pericoronitis Surgical treatment
(51), 2012 squamous cell rarefaction
carcinoma
Yamada et al ATLL M/44 y 1 mo Diffuse radiolucent Was not reported Paresthesia diffuse Dental infection Chemotherapy and
(52), 2010 lesion swelling pain was radiotherapy
not reported
Shah and Sarkar Plasmacytoma M/21 y 8y Large radiolucent Positive to upper left Presence of swelling Periapical cyst Apical surgery
(53), 1991 lesion central incisor and and pain absent comprising
Negative to lateral complete
incisor enucleation of the
cystic lesion and
extraction of the
involved tooth was
performed
Fujihara et al Liver metastasis M/62 y 1 mo A radiolucent Negative Painless slight swelling Radicular cyst with Chemotherapy
(9), 2010 well-defined lesion little possibility of
malignant tumor or
otherpathology
unrelated to the
Nonendodontic Lesions Mimicking Apical Periodontitis

tooth
Bueno et al Chondrosarcoma F/28 y Not mentioned Large radiolucency Was not reported Swelling and pain Apical periodontitis Hemimandibulectomy
(54), 2008 presented
Ardekian et al Burkitt lymphoma M/16 y 2 wk Radiolucent lesion Positive Swelling and pain Lesion of endodontic Was not reported
(55), 1996 with poorly defined present origin
and diffused and
widening of the PDL
space
Block et al Breast carcinoma F/59 y Not mentioned Large radiolucent area Was not reported Pain present Lesion of endodontic The patient died before

Clinical Research
(56), 1977 metastasis origin receive any
treatment three
months later
Khalili et al Breast carcinoma F/40 y 2 mo Unilocular Negative Paresthesia and pain Pulpal/periapical Chemotherapy
(24), 2010 metastasis well-circumscribed present inflammatory
radiolucency with process
ill-defined border
Nevins et al Metastatic F/39 y Not mentioned Radiolucency with Negative Swelling present, pain Periapical lesion of Was not reported
(57), 1988 carcinoma ill-defined borders absent endodontic origin
(Continued )
7
 8

Clinical Research
TABLE 3. (Continued )
Sirotheau Corr^ea Pontes et al.

Local signs and Initial diagnosis

Article Lesion Sex/age Evolution time Radiographic aspect Pulp vitality symptoms impression Treatment/follow-up
Bornstein et al Ewing sarcoma F/19 y Not mentioned The right sinus showed Negative Pain and swelling Acute perio-endo Initial chemotherapy,
(58), 2008 a diffuse cloudy present lesion hemimaxillectomy,
radiopacity, and the and postsurgical
lower border of the chemoradiotherapy
sinus was not as
clearlydemarcated
as on the left side
Grimm et al (59), Adenoid cystic F/45 y 2y Multiple osteolytic Negative Pain and paresthesia Apical periodontitis Surgical treatment
2012 carcinoma lesions present

ATLL, adult T-cell leukemia/lymphoma; F, female; M, male; PDL, periodontal ligament.

TABLE 4. Data from the Cases of the SBC Group

Local signs and Initial diagnosis
Article Lesion Sex/age Evolution time Radiographic aspect Pulp vitality symptoms impression Treatment/follow-up
Bornstein et al Stafne bone cyst M/62 y Not mentioned Radiolucent area Positive Probing depths, Odontogenic cyst Unnecessary
(35), 2009 around the pain absent
mandibular left
canine and first
premolar
Anneroth et al Intraosseous M/57 y The lesion was Radiolucency between Mandibular left Asymptomatic Lesion of endodontic Surgical removal
(60), 1990 salivary gland detected in an the apices of the lateral incisor: origin
annual check-up canine and lateral negative;
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incisor mandibular left

canine: positive
Bornstein et al Stafne bone M/47 y 2 wk Roundradiolucency Positive Asymptomatic Odontogenic cyst Unnecessary
(35), 2009 cyst with a well-defined
peripheral border in
the apical area of
teeth the
mandibular right
canine, first
premolar and second
premolar
F, female; M, male.
 Clinical Research

Figure 1. Panoramic radiographies from cases of (A) myxoma, (B) central giant cell lesion, (C) unicystic ameloblastoma, and (D) keratocyst that were initially
misdiagnosed as lesions of endodontic origin. A and D clinically showed no swelling, whereas B and C presented cortical expansion.

incorrectly, to construct a correct diagnosis (21). It is also essential to history is essential because 4 of the 5 patients with metastatic lesions had
consider that antibiotic therapy, including root canal treatment, when previous knowledge of the existence of the primary malignant lesion. In
correctly performed is capable of initiating the improvement of swelling addition, a careful evaluation of the radiographic and clinical aspects
of an endodontic lesion after a few days (22). Therefore, it is relevant to mentioned previously should be performed to help build a correct diag-
follow up with patients after treatment to confirm that the symptoms nosis of these metastatic lesions (30). Finally, the mean age of metastatic
have dissipated (23). Moreover, symptomatology of paresthesia is lesions in our study was 50 years old with 80% located in the mandible.
not expected when the source of the lesion is endodontic (24). Koivisto et al (12) reported that the mean age for the cases of metastatic
Another important tool to aid in the correct diagnosis is a radio- lesions in jaws was 63 years and that 80% were located in the mandible,
graphic examination. Our data show that the predominant radiographic which corroborates our findings.
appearance of BLMEPLs in the service of oral pathology was a well- The results of the analyses of the BLMEPL group showed a mandib-
circumscribed radiolucent area associated with the involved teeth (9/ ular predominance, with discrete differences between the anterior
10 cases), whereas the only MLMEPL had a diffuse multilocular radio- (43.25%) and posterior (56.75%) regions. The BLMEPL group
lucent appearance associated with the involved teeth. Among the lesions comprised cysts, neoplasm, and fibro-osseous lesions. Considering
collected from the literature review, including benign and malignant the group of benign neoplastic lesions that could mimic apical
cases, a huge variety of radiolucent images were observed such as large
or small, well defined or diffuse, radiolucent areas with radiopaque
borders, and multilocular or unilocular aspects. Hence, the most
observed radiographic profile was a radiolucent aspect, representing
93.3% of all cases. Endodontic lesions invariably show disruption of
the lamina dura and are represented by radiotransparent images with
well-defined borders in chronic cases and with diffuse borders in acute
lesions (25). Mixed and multilocular images are not expected. In addi-
tion, malignant lesions usually present a diffuse radiolucent image with
widening of the periodontal ligament space of 1 or 2 teeth. The widened
space results from tumor invasion of the periodontal ligament and
resorption of the surrounding alveolar bone (26). Advanced tumors
can be visualized as moth-eaten radiolucencies or irregular poorly
defined radiopacities. Furthermore, MLMEPLs can produce deposition
in layers of non-neoplastic bone when the periosteum is elevated by the
perforating tumor (Codman triangle). Sometimes these lesions cause
disruptions of the cortical tissue and infiltration of soft tissue, indicating
aggressive lesions and discarding the lesion of endodontic origin (27).
Another important fact is the presence of a characteristic sunray appear-
ance caused by a periosteal reaction, which may be seen in occlusal
radiographs, indicating aggressive lesions and discarding the lesion
of endodontic origin (28). Finally, irregular resorptions of the roots
of the teeth (‘‘floating teeth’’) in which the affected teeth are unsup-
ported by surrounding bone also suggest more aggressive lesions (29).
There was no predominance between the mandible and maxilla
from MLMEPLs when the cases were examined; however, the posterior
region predominated when compared with the anterior region. The Figure 2. (A) A case of mucoepidermoid carcinoma with the radiographic
majority of MLMEPLs were described in the third decade, with only 2 aspect showing a multilocular radiolucency associated with the maxillary left
cases occurring in previous decades. The most frequently cited malig- lateral incisor and canine, expanding cortical bone. (B) Clinically, a bluish
nant lesions in the review literature were metastatic, representing increase of volume in the lateral posterior region of the hard palate is
31.25% of all malignancies. Thus, the obtainment of a complete medical observed.

JOE — Volume -, Number -, - 2013 Nonendodontic Lesions Mimicking Apical Periodontitis 9

Clinical Research
Figure 3. (A) Aspiration of a radicular cyst; straw-colored fluid can be observed inside the lesion. (B) Blood aspiration in a case of aneurysmal bone cyst.
(C) Pasty content within the syringe and radiographic aspect from a case of a keratocyst.
periodontitis, the results show that the mean age was 30.2 years. Ame-
loblastoma was the commonest lesion, which is a benign neoplasm of
odontogenic epithelial origin characterized by frequent locally aggres-
sive behavior and accounting for approximately 10% of all odontogenic
tumors (31). This neoplasm is frequently asymptomatic; however, it can
cause painless cortical bone expansion and is usually represented by
a radiolucent ill-defined area that can be unilocular in unicystic amelo-
blastomas, affecting patients starting from age 20, and multilocular in
conventional solid or multicystic ameloblastomas, affecting patients
starting from age 30 (32). Hence, in lesions associated with the apex
of posterior teeth showing swelling without a history of pain and with
a positive response to pulp vitality testing, ameloblastoma should be
included in the differential diagnosis.
The cystic group represents 35.2% of BLMEPLs with a mean age of
29 years. Furthermore, the cystic lesions were predominantly located in
the anterior area (69.3%). In this group, the most frequent lesion was
the nasopalatine duct cyst, which is the more common nonodontogenic
cyst that occurs in the oral cavity and originates from remnants of the
nasopalatine duct. This lesion is usually asymptomatic, but patients
can present swelling in the anterior region of the palate and even
pain if there is infection associated with the lesion. The radiographic
aspect is an ill-defined radiolucency next to or in the middle line of
the anterior maxilla between the incisors apex, which may be round,
ovoid, or heart shaped (33). Therefore, it can be deduced that in cases
of swelling in the region of the palate, without pain, with the upper inci-
sors responding positively to vitality testing, in patients between the
fourth and sixth decade of life that present the radiographic
aspects described, this lesion should be thought of as a differential diag-
nosis.
10 Sirotheau Corr^ea Pontes et al.
The fibro-osseous lesions group represents 10.8% of benign
lesions. The mean age of this kind of lesion was about 37.5 years,
and the posterior region was the most affected (3/4 cases). The most
commonly reported lesion of this group was cemento-osseous
dysplasia, which is the commonest fibro-osseous lesion found in clin-
ical practice; it is asymptomatic and is usually found in routine radio-
graphs (34). The group is composed of periapical osseous dysplasia,
focal osseous dysplasia, and florid osseous dysplasia. In the early stages
of development, the lesion is radiolucent and may mimic a radicular cyst
or a periapical granuloma because in the lucent phase of development
the periapical lamina dura is usually lost (18). Under conditions in
which the lesion develops away from the apex, the preservation of
the lamina dura is maintained, discarding the lesion of endodontic
origin. In its areas of development, this lesion shows radiopacity on
radiographs, which discards lesions of endodontic origin because
they do not have mixed aspects in radiography. It is important to high-
light that endodontic origin can be ruled out if the pulp vitality test is
positive.
The SBC is an asymptomatic lesion occasionally found on the
lingual surface of the mandible, which usually contains salivary glands,
fat, or connective tissue. Almost all cases appear in adults or seniors,
particularly in men (35). The radiologic features are pathognomonic
when it is located just anterior to the mandibular angle, between the
angle and the molars, and usually below the mandibular canal. Similar
lingual cortical defects have also been reported previously at the
mandible in the region of incisors, canines, and premolars. When
SBC occurs in the more anterior part of the mandible and is in close
contact with tooth roots, it can cause a diagnostic dilemma, mimicking
periapical lesions of endodontic origin. The 3 cases reported in the
JOE — Volume -, Number -, - 2013

literature, which mimicked lesions of endodontic origin, occurred in
the anterior region of the mandible. After intraoral examination, if
pulp vitality testing is normal, a lesion of endodontic origin can be
excluded.
Although it is widely accepted that SBCs in their posterior and ante-
rior variants do not need further treatment, surgical explorations, inci-
sional biopsies, and enucleations are frequently reported, mostly for
diagnostic reasons. To avoid invasive surgery, computed tomographic
imaging, magnetic resonance imaging, or sialography is recommended.
Sialography has been used to confirm the diagnosis by showing salivary
ducts within the bony defect. Computed tomographic imaging has
proven to be very helpful in identifying the relationship of the lesion
to the lingual bone plate of the mandible. Magnetic resonance imaging
is advocated as the imaging method of choice to confirm a diagnosis
once the signal can clearly visualize characteristics of salivary tissue
on T2- and T1-weighted multiplanar imaging (36).
Finally, in cases of radiotransparent lesions associated with tooth
roots presenting a moderate to large diameter, aspiration should be
performed (Fig. 3A–C). If the lesion corresponds to a cystic lesion,
straw-colored fluid should be expected. However, a more pasty content,
corresponding with keratin in the cyst lumen, suggest the keratocyst or
orthokeratinized variants. Blood aspiration suggests a vascular lesion,
and a negative aspiration suggests a solid lesion (37). Hence, it is inter-
esting to mention an unusual case report of a lymphoma associated with
a cyst in the periapical region of a premolar in the maxilla. In this case, if
the lesion presented positive aspiration, it would possibly mask the
presence of the associated malignant lesion, leading to misdiagnosis.
However, to the best of our knowledge, this is the only case cited in
the literature in which a periapical lesion was associated with a malig-
nant lesion (38).
In conclusion, clinical and radiologic aspects as well as analysis of
the patients’ medical history, pulp vitality tests, and aspiration are essen-
tials tools to develop a correct diagnosis of endodontic lesions. Further-
more, it should be emphasized that a well-performed endodontic
treatment can eliminate symptoms and promote bone repair a few
months after the end of treatment. However, if the previously mentioned
instruments indicate a lesion of nonendodontic origin, a biopsy and
sequential histopathological analysis are mandatory.
Acknowledgments
The authors deny any conflicts of interest related to this study.
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