Apical periodontitis is a chronic inflammatory disorder of periradicular tissues caused by aetiological agents of endodontic origin. Persistent apical periodontitis occurs when root canal treatment of apical periodontitis has not adequately eliminated intraradicular infection. Problems that lead to persistent apical periodontitis include: inadequate aseptic control, poor access cavity design, missed canals, inadequate instrumentation, debridement and leaking temporary or permanent restorations. Even when the most stringent procedures are followed, apical periodontitis may still persist as asymptomatic radiolucencies, because of the complexity of the root canal system formed by the main and accessory canals, their ramifications and anastomoses where residual infection can persist. Further, there are extraradicular factors -- located within the inflamed periapical tissue -- that can interfere with post-treatment healing of apical periodontitis. The causes of apical periodontitis persisting after root canal treatment have not been well characterized. During the 1990s, a series of investigations have shown that there are six biological factors that lead to asymptomatic radiolucencies persisting after root canal treatment. These are: (i) intraradicular infection persisting in the complex apical root canal system; (ii) extraradicular infection, generally in the form of periapical actinomycosis; (iii) extruded root canal filling or other exogenous materials that cause a foreign body reaction; (iv) accumulation of endogenous cholesterol crystals that irritate periapical tissues; (v) true cystic lesions, and (vi) scar tissue healing of the lesion. This article provides a comprehensive overview of the causative factors of non-resolving periapical lesions that are seen as asymptomatic radiolucencies post-treatment.

https://onlinelibrary.wiley.com/doi/epdf/10.1111/j.1365-2591.2006.01099.x

On the causes of persistent apical periodontitis: a review.

Apical periodontitis is a sequel to endodontic infection and manifests itself as the host defense response to microbial challenge emanating from the root canal system. It is viewed as a dynamic encounter between microbial factors and host defenses at the interface between infected radicular pulp and periodontal ligament that results in local inflammation, resorption of hard tissues, destruction of other periapical tissues, and eventual formation of various histopathological categories of apical periodontitis, commonly referred to as periapical lesions. The treatment of apical periodontitis, as a disease of root canal infection, consists of eradicating microbes or substantially reducing the microbial load from the root canal and preventing re-infection by orthograde root filling. The treatment has a remarkably high degree of success. Nevertheless, endodontic treatment can fail. Most failures occur when treatment procedures, mostly of a technical nature, have not reached a satisfactory standard for the control and elimination of infection. Even when the highest standards and the most careful procedures are followed, failures still occur. This is because there are root canal regions that cannot be cleaned and obturated with existing equipments, materials, and techniques, and thus, infection can persist. In very rare cases, there are also factors located within the inflamed periapical tissue that can interfere with post-treatment healing of the lesion. The data on the biological causes of endodontic failures are recent and scattered in various journals. This communication is meant to provide a comprehensive overview of the etio-pathogenesis of apical periodontitis and the causes of failed endodontic treatments that can be visualized in radiographs as asymptomatic post-treatment periapical radiolucencies.

Pathogenesis of Apical Periodontitis and the Causes of Endodontic Failures

Accuracy of cone beam computed tomography and panoramic and periapical radiography for detection of apical periodontitis.

A new periapical index based on cone beam computed tomography.

http://www.endoexperience.com/userfiles/file/sdarticle_3.pdf

Accuracy of periapical radiography and cone-beam computed tomography scans in diagnosing apical periodontitis using histopathological findings as a gold standard.

AIM: To assess the reliability of routine single radiographs in the diagnosis of inflammatory apical root resorption by correlating the radiographic and histological findings. METHODOLOGY: The material comprised serial and step serial sections of plastic-embedded root-apices with attached apical periodontitis lesions that were prepared for a previous study and the diagnostic radiographs. The histological sections of 114 specimens were analysed by light microscopy and categorized into three groups: (i) those without any resorption (0); (ii) those with moderate resorption (+); and (iii) those with severe resorption (+ +). The radiographs were examined by a separate examiner and graded with a similar categorization of no resorption (0); moderate (+); and severe (+ +) apical resorption. RESULTS: Radiographically, 19% of the teeth were diagnosed as having apical inflammatory root resorption, whereas histologically, 81% of the teeth revealed apical inflammatory root resorption. A correlative radiographic and histological assessment (n = 104) revealed a coincidence of diagnosis in 7% of the specimens and noncoincidence of diagnosis in 76% of the specimens. CONCLUSIONS: The results indicate that routine single radiographs are not sufficiently accurate or sensitive to consistently diagnose apical root resorptive defects developing as a consequence of apical periodontitis.

Apical inflammatory root resorption: a correlative radiographic and histological assessment

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Apical inflammatory root resorption: a correlative radiographic and histological assessment