Presentation of a radicular cyst associated with a Primary Molar.
Background: A radicular cyst in a 9-year old girl is reported. Case Report: A 9-year-old child was referred from her General Dental Practitioner because of the need for obtaining expert care, assessment and treatment with regards to a radiolucency associated with her lower right second primary molar (85). Treatment: This included surgical intervention for the removal of the affected tooth, enucleation of the cyst and primary closure of the surgical area. Follow-up: This was satisfactory and 12 months post-operative the patient reported no further problems or symptoms. It could be seen that the area previously occupied by the cyst had undergone bony infill.
Key words: Radicular Cyst, Enucleation, Primary Molar, Pulp therapy
Radicular cysts are odontogenic cysts which are derived from the inflammatory activation of epithelial root sheath residues (cell rests of Malassez) [Main, 1985]. They are inflammatory in nature and usually arise within a periapical granuloma relating to stimulation resulting from a necrotic tooth [ten Cate 1972; Main 1985; Nair 1998].
They are the most common of all jaw cysts and comprise about 52.3% [Shear, 1992] to 68% [Killey et al., 1977] of all cysts affecting the mandible. Although this may be the case, the occurrence of radicular cysts in the primary dentition has been so poorly reported previously that they have been described as being a 'rare event' [Hill, 1978]. Lustmann and Shear  supported this low incidence of citing only 0.5% of all recorded radicular cysts arise from the primary dentition. Prior to their own presentation of 23 primary radicular cysts, there had only been 28 reported cases of primary radicular cysts since 1898. In a study conducted by Main , it was found that only 0.34% (1 out of 239 cysts) were radicular cysts associated with an infected primary tooth. However, it has since been suggested that the incidence is probably higher than this [Shear 1992; Mass et al, 1995]. Mass et al.  analysed 49 primary molar teeth with radiolucent lesions and found that 73.5% of all lesions were radicular cysts.
Despite the high prevalence of non-vital incisors as a result of trauma to the primary incisor region in the 'crawl-walk' stage [Smith and Cowpe, 2005], when radicular cysts are seen in the primary dentition, they are most frequently associated with non-vital/endodontically treated mandibular carious primary molars [Mass et al., 1995; Takiguchi et al., 2001; Ramakrishna and Verma, 2006]. This is in contrast to the permanent dentition where radicular cysts are most frequently associated with maxillary incisors due to trauma/caries/silicate restorations [Shear, 1992].
Whilst extraction or endodontic treatment may suffice for the treatment of a 'periapical radiolucency', the treatment options for a radicular cyst usually require more radical intervention including surgical removal of the tooth in question and enucleation or marsupialisation of the cyst [Nair, 1998]. Therefore the early diagnosis of these cases is imperative.
This report describes the treatment and management of a radicular cyst associated with a non-vital primary molar tooth. Furthermore the significance of radiographic monitoring for endodontically treated primary teeth and the consequences of failing to do so are discussed.
Presentation. A 9-year-old child was referred from her general dental practitioner (GDP) to the department of Child Dental Health, Bristol Dental Hospital for the assessment and treatment with regards to the patient's radiolucency associated with her mandibular right second primary molar (85). Although the patient was fit and well on presentation, in the past she had a history of tachycardia and a benign heart murmur.
History. On examination, the buccal mucosa and tongue were of normal appearance and the gingivae appeared healthy. She was in the mixed dentition phase. In the mandibular right quadrant it could be seen that there was a preformed metal crown present on 85 (Figure 1). From the GDP's records and dental history, this tooth had initially been restored with glass ionomer cement (33 months earlier) and later "pulp treated with Caustinerf Deciduous" and crowned (30 months earlier). Since then it had been asymptomatic and free from pain.
Intra-oral investigations suggested no sinus or swellings associated with the tooth 85, although it was slightly mobile. Furthermore, there was no buccal or lingual expansion associated with this tooth nor the region associated with it.
[FIGURE 1 OMITTED]
The dental panoramic tomograph and periapical radiographs (DPT and PA) provided by the GDP revealed a radiolucent area associated with the periradicular area of 85 (Figure 2a and Figure 2b). There was a well-defined unilocular lesion and when compared with the matching successor on the contra-lateral side, the permanent second premolar appeared to be displaced from its path of eruption. Based on the history, examination and clinical findings a provisional diagnosis of a periradicular cyst was made.
[FIGURE 2 OMITTED]
Treatment. The treatment plan included surgical exploration of the radiolucency as well as removal of tooth 85 under general anaesthesia. During the procedure, a full thickness mucoperiosteal flap was raised buccally from 83-46. The thin buccal cortical plate was removed during the procedure, and it could be seen that the cystic lesion was intimately associated with the roots of 85 (Figure 3a). It was also evident that whilst the cyst enveloped tooth 45 it did not adhere to it. As a result the cystic area was enucleated via blunt dissection, and was sent for histopathological examination (Figure 3b). The involved tooth, 85, which was also removed. Primary closure of the surgical area was achieved with the placement of 3/0 Vicryl resorbable sutures.
[FIGURE 3 OMITTED]
HistoPathological Findings. The histopathological examination reported findings consistent with a radicular cyst--an inflamed cyst lined wholly by non-keratinized stratified squamous epithelium.
On review, the surgical defect healed uneventfully postoperatively (Figure 4). It could be seen that the area previously occupied by the cyst had undergone bony infill. Furthermore, it could be seen that the lower right premolar was showing signs of root development, appearing to move into its correct position (Figure 5a and Figure 5b).
[FIGURE 4 OMITTED]
[FIGURE 5 OMITTED]
Previous literature has suggested that radicular cysts arising from primary teeth are rare. There have been many reasons as to why this may be the case. It has been cited that cysts related to primary molars are in fact frequent [Mass, et al., 1995], but they may be overlooked due to resolution after removal/exfoliation of the offending tooth [Shear, 1992; Lustig, et al., 1999]. Furthermore, it has been suggested that whilst it may be difficult to obtain natural drainage for pulpal and periapical infections in permanent teeth, this does not seem to be the case for the primary dentition [Shear, 1992].
It has also been proposed that radicular radiolucencies relating to primary teeth are often neglected [Shear 1992]. This often leads to the absence of any histopathological examinations as well as sometimes having a misdiagnosed dentigerous cyst in the form of a radicular cyst [Lustmann and Shear, 1985]. Even with the aid of clinical and radiographic findings it may be difficult to differentiate between a radicular and a dentigerous cyst. In this case, the diagnosis was confirmed surgically and histologically.
The importance of the co-operation required between the paediatric dentist, radiologist and pathologist can be highlighted by the armamentarium used to support the diagnosis of a radicular cyst:
1) Evidence of a non-vital tooth [Shear, 1992];
2) Mandibular buccal cortical expansion [Ramakrishna and Verma 2006];
3) Painless lesion associated with a primary tooth [Takiguchi et al., 2001].
1) Well defined unilocular radiolucency associated with a primary tooth [Ramakrishna and Verma, 2006],
2) No involvement with a successive permanent tooth [Takiguchi et al., 2001];
3) Displacement of permanent successor [Ramakrishna and Verma, 2006];
No association with the successive permanent tooth [Takiguchi et al., 2001].
Confirmation of a cystic epithelial lining [Takiguchi, et al., 2001].
Radicular cysts are thought to increase in size no more than 4 mm per year and usually remain asymptomatic providing there are no acute inflammatory exacerbations [Smith and Cowpe, 2005]. As a result, lesions are often detected only after a thorough clinical and radiographic examination.
Although many pulp therapies continue with an uneventful outcome, it must be remembered that radicular cysts may develop in some of these endodontically treated teeth. This is what was suspected in this case, however this cannot be confirmed due to the lack of pre-restorative and preendodontic radiographs. As discussed, the phenol containing 'Caustinerf Deciduous' was the medicament used for pulp treating the tooth in this report. This medicament contains parachlorophenol (8%), camphor (13%), lidocaine (36%), and paraformaldahyde (18%). It has been suggested by the manufacturers, Septodont Limited (UK), that failure to carefully seal Caustinerf Deciduous within the cavity can 'cause local destruction of the periodontium and necrosis of bone. It may also cause transitory but painful mucosal ulcers' (www.septodont.co.uk).
In addition, the need for monitoring endodontically treated primary molars can be supported with the suggestion that there is a link between root canal medicament, in particular the phenol groups and radicular cysts [Savage, et al, 1986]. More recently it has been reported that pulp therapy in the form of calcium hydroxide/iodoform (non-phenol) may also be responsible for the stimulation of radicular cysts in primary molars [Takiguchi et al., 2001].
The sequelae of an untreated or undiagnosed radicular cyst could be harmful to the patient's future dental development. A patient with an untreated radicular cyst may present with the following: swelling, tenderness, tooth mobility and a bluish tinge caused by buccal expansion of the cortical plates [Takiguchi et al., 2001; Smith and Cowpe, 2005]. Furthermore, displacement of the successor tooth or even more unforgiving, the loss of its vitality may result [Wood et al., 1988; Lustig et al., 1999] . However, if early diagnosis via regular radiographic monitoring of these teeth can be conducted, then it may prove productive in preventing the above problems, as well as the need for invasive surgical treatment [Rodd et al., 2006].
Pulp treated primary molar teeth should be regularly monitored both clinically and radiographically.
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S. Gandhi, D.L. Franklin,
Dept. Paediatric Dentistry, Bristol Dental Hospital, Bristol, England.
Postal address: Dr S. Gandhi, Dept. Child Dental Health, University of Bristol, Lower Maudlin Street, Bristol, England, BS1 2LY. Gandhishan@hotmail.com
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|Title Annotation:||CASE REPORT:|
|Author:||Gandhi, S.; Franklin, D.L.|
|Publication:||European Archives of Paediatric Dentistry|
|Article Type:||Case study|
|Date:||Mar 1, 2008|
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