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0 0 9 9 - 2 3 9 9 / 1 6 / 1 6 0 4 - 0 1 8 2 / $ 0 2 . 0 0 / 0JOURNAL OF ENDODONTICSCopyr igh t 9 1990 by The Ameri can Assoc ia ti on o f Endodo nt i s ts

C A S E R E P O R TPr in ted in U .S .A .VoL. 16, No. 4, APRIL 1990

Conserva t i ve Trea tment o f P ers is ten t P er i rad icu la rLes ions Us ing As pi ra t ion and Ir rigationM i c h a e l M . H o e n , D D S , G a r y L . L a B o u n t y , D D S , M S , a n d E d w a r d J . S tr i tt m a t t e r, D D S

A s p i r a t i n g t h e u n k n o w n c o n t e n t s o f a b o n y c a v i t ya n d s a l i n e i r r i g a t i o n o f a b o d y w o u n d a r e b o t h b a s i cs u r g ic a l t e c h n i q u e s . T h e s e t w o t e c h n i q u e s h a v eb e e n c o m b i n e d in tr e a t in g p e r s i s t e n t p e r i r a d i c u l arp a t h o s i s in t w o c a s e s . T h e c a s e s d e m o n s t r a t e s i g -n i f i c a n t b o n y h e a l i n g o f e x t e n s i v e p e r i r a d i c u l a r d e -f e c t s a f t e r th e u s e o f t h e c o m b i n e d p r o c e d u r e . B o t hc a s e s w e r e n o n r e s p o n s i v e t o n o n s u r g ic a l r o o t c a n a lt r e a t m e n t . T h e u s e o f a s p i r a t i o n a n d i r ri g a t io n m a yi n i ti a t e h e a l i n g i n c a s e s o f u n i n f e c t e d a p i c a l c y s t sw h i c h h e r e t o f o r e w o u l d r e q u i r e s u r g i c a l i n t e r v e n -t i o n . T h e c o n s e r v a t i v e n a t u r e o f t h e s e p r o c e d u r e sh a s a d v a n t a g e s o f re d u c e d t r e a t m e n t t i m e , a v o i d -a n c e o f i a t r o g e n i c p r o b l e m s , a n d e l i m i n a t i o n o fs o m e c o n v e n t i o n a l a p i c a l s u r g e r y .

C u r r e n t p h i l o s o p h y i n t h e e n d o d o n t i c t r e a t m e n t o f n o n v i t a lt ee th wi th l a rge pe r i r adicula r l e s ions inc ludes the in i t i a l useo f n o n s u r g i ca l r o o t c a n a l t h e r a p y . W h e n t h is t r e a t m e n t is n o ts uc c e s s f u l i n r e s o l v i ng t he pe r i r a d i c u l a r pa t hos i s , a dd i t i ona lt r e a t m e n t o p t i o n s s h o u l d b e c o n s i d e re d . S u c h t r e a tm e n t m a yi n c l u d e n o n s u r g i c a l r e t r e a t m e n t t o r u l e o u t m o r p h o l o g i c a la bno r m a l i t i e s o r t r e a t m e n t i na de q ua c i e s . I f ne c es s a ry , a s ub -s e q u e n t t r e a t m e n t o p t i o n w o u l d i n c l u d e s o m e v a r i e t y o fs u r g ic a l p r oc e du r e . S u r g i c a l t r e a t m e n t o f pe r s is t e n t e x t e ns i vepe r i r a d i c u l a r l e s i ons m os t o f t e n i nvo l ve s c u r e t t a ge a nd a p i c a lr e s e c ti on . T h e ob j e c t i ve s o f s uc h s u r g i c a l p r oc e du r e s w o u l di nc l ude e s t a b l i s h i ng a c l i n i c a l d i a gnos i s a nd p r ognos i s w h i l epe r f o r m i ng w ha t e ve r c o r r e c t i ve t r e a t m e n t i s ne c e s s a r y . T hes u r g i c a l t r e a t m e n t w ou l d be e xpe c t e d t o e s t a b l i s h a n e nv i r on -m e n t c o n d u c i v e t o h e a li n g .

M a r s up i a l i z a t i on i s a s u rg i c a l t r e a t m e n t o p t i on t ha t m a ya i d t he c l i n i c i a n i n r e d uc i ng t he s i ze o f a n a p i c a l le s ion . S m i t ha n d P a r t s ch ( 1 ) w e r e a m o n g t h e o r i g in a l a d v o c a t e s o f th i sp r oc e d u r e f o r u s e i n t he t r e a t m e n t o f l a rge c ys t i c l e si ons .P r e s e rv a t io n o f t h e s u r r o u n d i n g b o n e s t r u c tu r e w a s c e rt a in l yone o f t he i r t r e a t m e n t goa l s. F r e e d l a nd ( 2 ) ha s de m o ns t r a t e dt h a t p o l y v i n y l o r p o l y e t h y l e n e t u b i n g m a y b e u t i li z ed t o c a u s et h e d e c o m p r e s s i o n a n d s u b s e q u e n t h e a l in g o f e x t en s iv e p e r i -a p i c a l r a r e f a c ti ons . H e e nu m e r a t e d s e ve r a l a dva n t a ge s o f t he

18 2

c ons e r va t i ve r e duc t i on o f e x t ens i ve bon y l es i ons , i nc l ud i ngt h e a v o i d a n c e o f i at r o g e n i c s u r g ic a l c o m p r o m i s e o f a d j a ce n tt oo t h v i t a l i t y . N e a ve r t h a nd B ur g ( 3 ) s ugge s t e d t ha t p r i o r t oi n s e r t ing a r a d i opa qu e t ub i ng , t he c on t e n t s o f t he l e s i on m a ybe a s p i ra t e d a nd t he c a v i t y ge n t l y i r ri ga te d . T h e m i n i m uma m o u n t o f d e c o m p r e s s i o n t i m e t h e y r e l at e d w a s 5 w k . I t isl og i c a l t ha t he a l i ng a f t e r m a r s up i a l i z a t ion o r de c om pr e s s i oni s t he r e s u l t o f r e m ov a l o f t he c a us e o f t he p a t hos i s o rm o d i f i c a t i o n o f t h e l o c a l e n v i r o n m e n t t o t h e e x t e n t t h a t h o s tde f e ns e m e c ha n i s m s c a n e xe r t a pos i t i ve i n f l ue nc e .

D i a g n o s i n g t h e p r e s e n c e o f a c y s t b y r a d i o g r a p h i c a p p e a r -a nc e i s ge ne r a l ly c ons i de r e d t o be a n un r e l ia b l e t e c hn i qu e . I n1984 , N a t k i n e t al . ( 4 ) a na l yz e d t he da t a o f va r i ous s t ud i e sr e l a t i ng r a d i og r a ph i c l e s i on s i z e a nd h i s t o l ogy . T he y c on -c l ude d t ha t f o r t he s t ud i e s w he r e r e l e va n t d a t a w a s a va il a b l e,t he r e w a s a s t r ong c o r r e l a t i on be t w e e n c ys t i nc i de nc e a ndi nc r e a s e d l e s i on s i z e . T he y s t a t e d t ha t w i t h a r a d i og r a ph i cl e s i on s i z e o f 200 m m 2 o r l a r ge r , t he i nc i de nc e o f c ys t s isa l m o s t 100% . T o l l e r ( 5 ) ha s p r opo s e d t ha t t he g r ow t h o f t hec ys t m a y be due t o t he i nc r e a s e d h yd r os t a t i c p r e s s u r e o f t hec on f i n e d f l u i d a nd l a c k o f l ym ph a t i c a cc e s s. A n i nc r e a s e dos m ol a r i t y w ou l d f a vo r i nc r e a s e d f l u id f l ow i n t o t he c ys t i cc a v i t y ge ne r a t i ng a n i nc r e a s e d p r e s s u re on t he b on y c a v i t yw a ll s. T h i s h i ghe r p r e s s u r e w o u l d c a us e a dd i t i ona l o s t e oc l a s ti ca c t i v i ty a nd e n l a r ge m e n t o f t he de f e ct . A dd i t i ona l l y , t he c ys tm a y e x p a n d d u e t o t h e a c t io n s o f p r o s ta g l a n d i n s i n t h e c y s tc a ps u l e , c o ll a ge na se s , i nc r e a s e d c yc l i c A M P l e ve ls a nd l ym -pho k i ne s ( 6 ).

H i s t o l og i c a l l y , t he r e ha s be e n s om e c on t r ove r s y r e ga r d i ngt he he a l i ng po t e n t i a l o f t he p e r i a p ic a l l e s i on . I f t he l e s ion i s ac ys t s e pa r a te f r om t he a p e x a nd w i t h a n i n t a c t e p i t he li a ll i n i ng , i t m a y ha ve de ve l ope d i n t o a s e l f - pe r pe t ua t i ng e n t i t yt h a t m a y n o t h e a l w h e n t r e a t e d w i t h o n l y n o n s u r g i c a l r o o tc a na l t he r a py ( 7 ) . O t he r t i m e s a n e no r m ous pe r i a p i c a l l e s i onm a y h a v e a d ir e c t c o m m u n i c a t i o n w i t h t h e r o o t c an a l s y s te ma n d r e s p o n d f a v o r a b l y to n o n s u r g i c al e n d o d o n t i c t r e a t m e n t .S t a ti s ti c a ll y , s om e c ys t - l ike l e si ons und e n i a b l y he a l du e o n l yt o n o n s u r g i c a l t r e a t m e n t . W h e t h e r o r n o t a n a c u t e i n f l a m -m a t o r y r e s pons e i s ne c e s s a r y f o r he a l i ng t o oc c u r i s de ba ta b l e .T o a t t e m p t t o h i s t o l og i c a ll y c la s s if y pe r ia p i c a l l e s i ons a s e i t he rc ys t i c o r g r a nu l om a t ou s s e e m s t o i gno r e the pos s i b i l i ty o f at r an s i ti o n a l p h a s e b e t w e e n t h e t w o . S u c h a p h a s e m a y a c c o u n tf o r s om e o f t he r a d i c u l a r c y s t he a li ng r e fe r r e d t o by B ha s ka r( 8 ) a nd L a l on de a nd L u bk e ( 9 ). R e ga r d l e s s o f t he h i s t o l og i c a l

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V o l . 1 6 , N o . 4 , A p r i l 1 9 9 0d i a gnos i s, f o r bo ny he a l i ng t o oc c u r , a l oc a l c ha n ge i n t heos t e ob l a s t i c : o s t e oc l a s l i c r a t i o m us t a l l ow f o r i nc r e a s e d bonede pos i t i on . I t i s s ugge s t e d t ha t t h i s l oc a l c ha nge m a y be t her e su l t o f s o m e t h i n g a s s i m p l e a s a s p i ra t io n a n d a t h o r o u g hsa l ine r inse .

A s p i r a ti o n o f a n u n k n o w n b o n y l e si o n i s a r e la t iv e l y in -n o c u o u s s u r g i c a l p r o c e d u r e w h i c h m a y p r o v i d e i n f o r m a t i o na s t o t he p r e s e nc e o f pu r u l e nc e , c y s t i c f l u id , o r he m o r r ha ge .S u b s e q u e n t l y t h e a s p i ra n t m a y b e u t i l iz e d t o p r o v i d e m i c r o -b i a l i de n t i f i c a t i on a nd i m m unoh i s t oc he m i c a l a na l y s i s . S a l i nei r r iga t i on i n t he de b r i de m e n t o f a w o un d i s l ike w i s e a m a i n -s t a y o f ba s i c su r g i c a l t r e a t m e n t . A t r e a t m e n t r e g i m e n i s de -s c r i b e d w h i c h c o m b i n e s t h e s e t w o p r o c e d u r e s i n a n a t t e m p tt o pr o m o t e he a l i ng o f pe r s i st e n t pe r i r a d i c u l a r l e s i ons.

T he p u r pos e o f t h i s a rt i c le w a s to p r e s e n t a no t he r c ons e r v -a t i ve t r e a t m e n t op t i on t o t he t r a d i t i ona l pe r i a p i c a l s u r g i c a lt r e a t m e n t s f o r e x t e ns i ve bo ny l e s i ons.

C A S E 1A 4 5 - y r - o ld C a u c a s i a n m a l e w i t h a n o n c o n t r i b u t o r y m e d -

i ca l h is t o r y p re s e n t ed f o r t r e a t m e n t o f a n a s y m p t o m a t i c p e r t -a p i c a l le s i on a r ou nd t he a p e x o f h i s r igh t m a x i l l a r y l a t e ra li nc i s o r . T he l e s i on ha d be e n d i s c ove r e d du r i ng r ou t i ne pa n -o r e x s c r e e n i n g a n d a f o r m o c r e s o l p u l p o t o m y h a d b e e n p e r -f o r m e d p r i o r t o t he r e f er r a l. T h e a d j a c e n t t e e t h r e s pon de dw i t h i n no r m a l l i m i t s t o t he r m a l a nd e l e c t r i c a l pu l p t e s t i ng . A

T r e a t m e n t o f P e r s i s te n t L e s i o n s 1 8 3t h r o u g h a n d t h r o u g h b o n y l e s io n o f th e m a x i l l a c o u l d b epa l pa t e d . T he pa t i e n t ' s c l i n i c a l c ond i t i on w a s c l a s s i f i e d a sne c r os i s w i t h pe r ] a p ic a l r a d i o l uc e nc y o f t oo t h 7 ( F ig . 1 ).

T h e t o o t h w a s i s o l a t e d w i t h a r u b b e r d a m , t h e t e m p o r a r yr e s t o ra t i o n w a s re m o v e d , a n d b e c a u s e o f th e a m o u n t o fe x u d a t e a c u l t u r e s a m p l e w a s o b t ai n e d . T h e t o o t h w a sc l e a ns e d a nd s ha pe d u t i l i z i ng bo t h ha nd a nd u l t r a s on i c i n -s t r u m e n t a t i o n w i t h 2 . 6% s o d i u m h y p o c h l o r i t e i rr ig a ti o n . B e -c a us e o f pe r s is t e n t d r a i na ge i n t o t he c a na l , a n i n t e r a ppo i n t -m e n t i n t r a c a n a l m e d i c a t io n o f c a lc i u m h y d r o x i d e w a s p l a c e dp r i o r t o t e m p o r a r y c l o su r e w i th C a v i l. T h e p a t i e n t w a s g i v e na p r e s c r i p t i on f o r P e n i c i l l i n V a nd t o l d t o r e t u r n i n I 0 da ys .C u l t u r e r e s u l t s s h o w e d n o a e r o b i c o r a n a e r o b i c m i c r o b eg r o w t h . D u r i n g t h e s u b s e q u e n t a p p o i n t m e n t , t h e t o o t h w a sr e i n s t r u m e n t e d a n d o b t u r a t e d w i t h w a r m l a te r al ly c o n d e n s e dgu t t a - pe r c ha a n d S e a l a pe x s e al e r ( F i g . 2 ).

A 6 - m o n t h r ec a ll e x a m i n a t i o n r e v e al e d n o b o n y h e a l in ga nd pos s i b l e e n l a r ge m e n t o f t he pe r i a p i c a l l e s i on (F i g . 3 ).F o l l o w i n g l o c a l a n e s t h e s i a a n d a p o v i d o n e - i o d i n e s w a b b i n go f t he i nv o l ve d t i s sue s , a n 18 - ga uge ne ed l e a t t a c he d t o a 20 -m l s y r i nge w a s u s e d t o pe ne t r a t e t he buc c a l m uc os a a n da s p ir a te a p p r o x i m a t e l y 4 m l o f b l o o d - t in g e d f l u id f r o m t h el e s i on . A s e c ond s y r i nge f i l l e d w i t h s a l i ne w a s t he n u s e d t or i n s e t he bony l e s i on . T he ne w ne e d l e w a s i n s e r t e d t h r ought h e f ir st e n t r y w o u n d a n d t h e n p a s s ed o u t t h r o u g h t h e pa l a t a lt i ss ue ( F i g . 4) . T he s y r i nge w a s t he n r e t r a c te d i n t o t he b on yde f e c t a nd t he s a l i ne ge n t l y i n j e c t e d . T h i s r i n s i ng p r oc e du r ew a s r e pe a t e d un t i l t he f l u i d e x i t i ng t he pa l a t a l w ound a p -pe a r e d t o be c l e ar . A ppr o x i m a t e l y 50 m l o f s a l ine w e r e

FIG 1. Pr e o p e r a ti v e r a d io g r a p h d e m o n s t r a t in g p e r i ra d ic u la r l e s i on ont o o t h 7 . F IG 2 . R a d io g r a p h o f t o o t h 7 o n t h e d a y o f g u t t a - p e r c h a o b t u ra t io n .

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1 8 4 H o e n e t a l . J o u r n a l o f E n d o d o n t i c su t i l iz e d . T h e p a t i e n t w a s g i v e n a n o t h e r p e n i c i l l i n p r e s c r i p t i o na n d d i s m i s s e d .

T w o d a y s l a t e r t h e p a t i e n t w a s r e e x a m i n e d . A 5 - m m c i r -c u l a r h e m a t o m a w a s p r e s e n t a t t h e e n t ry w o u n d s i te a n d m i l de d e m a w a s p r e s e n t in t h e d e p t h o f t h e m u c o b u c c a l f o l d . T h ep a t i e n t ' s m i l d p a i n w a s r e l i e v e d b y a s p i r i n d u r i n g t h e f i rs t 2 4 -h p o s t o p e r a t i v e p e r i o d . A n a n a l y s i s o f th e a s p i r a n t r e v e a l e dn o a e r o b i c o r a n a e r o b i c m i c r o b e g r o w t h . A G r a m s t a i n re -v e a le d n o m i c r o o r g a n i s m s a n d o n l y o c c a s i o n al p o l y m o r p h o -n u c l e a r l e u k o c y t e s.

F i g u r e 5 is a r a d i o g r a p h t a k e n 1 3 m o n t h s a f t e r t h e a s p i r a -t i o n a n d i r r i g a ti o n p r o c e d u r e . S i g n i f i c a n t b o n y h e a l i n g h a so c c u r r e d . T h e p a t i e n t i s c u r r e n t l y a s y m p t o m a t i c a n d t h e t o o t hf u l ly f u n c t io n a l . H e h a s b e e n a d v i s e d t o h a v e a c r o w n p l a c e dd u e t o t h e e x t e n s i v e si z e o f t h e c o m p o s i t e r e s t o r a t i o n .

C A S E 2A 3 7 - y r -o l d C a u c a s i a n m a l e w i th a n o n c o n t r i b u t o r y m e d -

i c a l h i s t o r y p r e s e n t e d 1 7 m o n t h s a f t e r n o n s u r g i c a l e n d o d o n t i ct r e a t m e n t o f h i s m a x i l l a r y l e f t c e n t r a l i n c i s o r , l a t e r a l i n c is o r .a n d c u s p i d . A l l t h r e e t e e t h w e r e s e n s it i v e to p a l p a t i o n a n dp e r c u s s i o n . A d r a i n i n g s i n u s t r a c t w a s p r e s e n t b e t w e e n t h ei n c i s o r s o n t h e b u c c a l m u c o s a a n d a l a r g e p c r i r a d i c u l a r l es i o nw a s n o t e d r a d i o g r a p h i c a l l y (F i g . 6) . S i n c e th e p a t i e n t ' s r e c o r di n d i c a t e d t h a t n o s e a l e r h a d b e e n u s e d i n t h e p r e v i o u s o b t u -r a t i o n , n o n s u r g i c a l e n d o d o n t i c r e t r e a t m e n t w a s p e r f o r m e d .A l l t h r e e te e t h w e r e t r e a t e d i n a m a n n e r s i m i l a r t o t h a t i n

FIG 3 . Six-month fol low-up radiograph of tooth 7 demonstratingenlargement of bon y defect.

F~G 4. Photograph of 18-gauge needle passing completely through F~G 5. Radiograph taken 13 mon ths after aspirat ion and irrigationmaxil lary bon y defect associated with too th 7. demo nstrating signif icant bon y healing.

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V o l . 1 6 , N o . 4 , A p r i l 1 9 9 0 T r e a t m e n t o f P e r s i s t e n t L e s i o n s 1 8 5

FIG 6. Rad iograph of teeth 9 to 11 de mon strat ing large per i rad icu larlesion 17 m onths af ter in i tia l endodo nt ic t reatmen t .

c a s e 1 u s i n g c a l c i u m h y d r o x i d e , h a n d a n d u l t r a s o n i c i n s t r u -m e n t a t i o n w i t h 2 . 6 % s o d i u m h y p o c h l o r i t e i r ri g a t i o n , a n do b t u r a t i o n w i t h l a t e r a ll y c o n d e n s e d g u t t a - p e r c h a a n d R o t h8 0 1 s e a l e r . F o u r w e e k s l a t e r t h e t e e t h w e r e s t i l l s e n s i t i v e t op e r c u s s i o n a n d t h e s i n u s t r a c t p e r s i s t e d . F i g u r e s 7 a n d 8d e m o n s t r a t e t h e i n c r e a s e d s i z e o f t h e p e r i r a d i c u l a r le s i o ni m m e d i a t e l y b e f o r e th e a s p i r a t i o n a n d i r r i g a t i o n . T h e a s p i r a -t i o n a n d i r r i g a t i o n t e c h n i q u e w a s t h e s a m e a s t h a t u s e d i nc a s e 1 . A p p r o x i m a t e l y 8 m l o f b l o o d - t i n g e d f l u i d w e r e r e -m o v e d a n d s e n t t o t h e l a b o r a t o r y . A g a i n , n o m i c r o b i a l g ro w t hw a s n o t e d i n e i t h e r c u l t u r e a n d t h e G r a m s t a i n r e v e a l e d o n l yp o l y m o r p h o n u c l e a r l e u k o cy t e s . A n 1 8 - m o n t h f o l lo w - u p ra -d i o g r a p h d e m o n s t r a t e s s i g n i f i c a n t b o n y h e a l i n g o f t h e d e f e c t( F i g. 9) . A l l th r e e t e e t h a r e c u r r e n t l y a s y m p t o m a t i c a n d f u n c -t i o n a l .

D I S C U S S I O N

I f u p o n a t t e m p t i n g a s p i r a t i o n , t h e c l i n i c i a n is u n a b l e t or e m o v e f l u i d f r o m t h e b o n y c a v i t y , t h i s w o u l d i n d i c a t e t h ep r e s e n c e o f g r a n u l a t i o n t i s s u e o r s o m e o t h e r t y p e o f s o f t t is s u em a s s . T h e r e f o r e , n o s a l i n e i r r ig a t i o n s h o u l d b e a t t e m p t e d .S u c h a c a s e w o u l d r e q u i r e a c o n v e n t i o n a l s u r g i c a l e x p l o r a t i o na n d t r e a t m e n t . C a s e s e l e c t i o n i s o b v i o u s l y i m p o r t a n t . T h ea s p i r a t i o n a n d i r r i g a t i o n t e c h n i q u e i s n o t i n t e n d e d t o b e ap a n a c e a f o r a ll p e r s i s t e n t b o n y l e s io n s . T h e c l i n i c i a n m u s t n o tl i m i t t h e d i f f e r e n t i a l d i a g n o s i s o f s u c h l e s i o n s t o o n l y t h a t o f

FIG 7. R adiogra ph of teeth 9 and 10 at the t ime of aspira t iondem onstra t ing increase in s ize of bony lesion.

a p e r i a p i c a l c y s t . R a t h e r , a l l t y p e s o f c y s t s , a b s c e s s e s , f r a c t u r e s ,a n d s o f t t i s s u e r a d i o l u c e n t m a s s e s m u s t b e i n c l u d e d i n a ni n t e l l i g e n t d i f f e r e n t i a l d i a g n o s i s .

A n i m p o r t a n t a s p e c t o f t h e i r r i g a t i o n p r o c e d u r e i s t o e n s u r et h a t t h e r e i s a n e s c a p e w o u n d o r v e n t f r o m w h i c h t h e s a l i n ec a n d r a i n . T h e s e c o n d p u n c t u r e o p e n i n g s h o u l d a ll o w ac o n t r o l l e d e x i t o f th e s a l i n e f r o m t h e b o n y c a v i t y . T h e g e n t l ei r r i g a t i o n w o u l d t h e n t e n d t o c l e a n s e o n l y t h e b o n y d e f e c ta n d n o t b e f o r c e d i n t o s u r r o u n d i n g t i s s u e s o r c a v i t i e s . I ts h o u l d b e n o t e d t h a t n o a t t e m p t w a s m a d e t o r e m o v e a l l o ft h e s a l i n e f r o m t h e o s s e o u s d e f e c t s . I n a l l i n s t a n c e s t h e i r r i -g a t i o n d i d s e e m t o i n i t i a t e b l e e d i n g i n t o t h e d e f e c t. I t i s f e ltt h a t t h i s b l e e d i n g a n d s u b s e q u e n t c l o t f o r m a t i o n a r e th e s t a r to f a h e a l i n g m e c h a n i s m s i m i l a r t o t h a t d e s c r i b e d b y S e l t z e r( 6 ) .

E x p e r i e n c e t o d a t e i s l im i t e d t o l e s i o n s t h a t a p p a r e n t l y w e r eu n i n f e c t e d p e r i a p i c a l c y s t s . T h i s c o n c l u s i o n i s b a s e d o n t h et y p e o f f l u id r e m o v e d a n d t h e l a c k o f m i c r o b i a l p r e s e n c e i nb o t h c u l t u r e a n d G r a m s t ai n s p e c im e n s .

T o d a t e o n l y a n t e r i o r m a x i l l a r y l e si o n s h a v e b e e n t r e a t e d .H o w e v e r , i t i s b e l i e v e d t h a t t h i s p r o c e d u r e w o u l d b e a p p r o -p r i a t e i n o t h e r a r e a s o f t h e o r a l c a v i t y w h e r e a d j a c e n t t i s s u es p a c e s o r s i n u s c a v i t i e s a r e n o t i n v o l v e d . F i v e a d d i t i o n a lp a t i e n t s h a v e r e c e i v e d s i m i l a r t r e a t m e n t a n d a r e c u r r e n t l yb e i n g f o l lo w e d . T h i s t e c h n i q u e s h o w s o b v i o u s a d v a n t a g e s w i t hr e g a r d t o t r e a t m e n t t i m e , p a t i e n t c o m f o r t , p a t i e n t a c c e p t a n c e ,a n d r e d u c t i o n o f p o s s i b l e i a t r o g e n i c c o m p l i c a t i o n s .

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1 8 6 H o e n e t a l . J o u r n a l o f E n d o d o n t i c s

F IG 8 . R a d i o g r a p h o f t e e t h 1 0 a n d :1 1 a t t h e t i m e o f a s p i r a t io nd e m o n s t r a t i n g i n c r e a s e i n s i z e o f b o n y l e s i o n .

The opinions and assert ions herein are the pr ivate views of the authors andare not to be co nstrued as of f ic ial or as reflect ing the view s of the Departmentof the Army o r the Depar tment o f D efense.

Dr. Hoen is a staf f endodont ist, US Army D ENTAC, Ft . Knox, KY. Dr.LaBounty is an endodont ist and the Commander 768th Medical DetachmentDS, Kafertal, Wes t Germany. Dr. Str i t tmat ter is a staf f endodont ist , US ArmyDENTAC, Walter Reed Arm y Medical Center, Washington, D C.

R e f e r e n c e s1. Arche r WH. Oral and maxil lofacial surgery. Phi ladelphia: WB Saunders,1975:540-59.2. Freedland JB. Conservative reduction of large periapical lesions. OralSurg 1970;29:455-64.

F IG 9 . R a d i o g r a p h t a k e n 1 8 m o n t h s a f t e r a s p i ra t i o n a n d i r ri g a t io nd e m o n s t r a t i n g s i g n i f ic a n t b o n y h e a l in g .

3. Neaverth EJ, Burg HA . Decompression of large per iapical cyst ic lesions.J Endodon 1982;8:175-82.4. Natkin E, Oswald RJ, Carnes LI. The relationship of lesion size todiagnosis, incidence, and t reatment of per iapical cysts and granulomas. OralSurg 198 4;57:82-94.5. Toi ler PA. Newer concepts of odontogenic cysts. Int J Oral Surg1972;1:3-16.6. Seltzer S. Endodontology. 2nd ed. Phi ladelphia: Lea & Febiger,1988:2391-428.7. Simon JHS. Incidence of per iapical cysts in relat ion to the roo t canal. JEndodon 1980;6:845-8.8. Bhaskar SN. Nonsurgical resolut ion of radicular cysts. Oral Surg1972;34:458-68.9. Lalonde ER, Lubke RG. The f requency and dist r ibut ion of per iapicalcysts and granulomas. Oral Surg 1968;25:861-8.