A dental granuloma is a common pathology in dental practice, manifesting as a sequela of dental pulp pathology in an untreated tooth.

How does a dental granuloma develop without proper treatment?

A dental granuloma, apical cyst or abscess can develop quite badly if not treated properly. The main complications can be:

• Damage to neighboring teeth, compromising their viability;

• Bacteria entering the bloodstream and developing an infection in another, distant organ;

• If the granuloma is located on the upper lateral teeth, it may be complicated by maxillary sinusitis;

• Tooth loss with dental granuloma;

Symptoms

What are the symptoms of a dental granuloma and how do we discover it?

Unfortunately, a dental granuloma evolves silently, often asymptomatically, and is often discovered by chance.

– Before it develops, when there is a pulpitis, the patient may feel pain in the tooth, which disappears over time precisely because the dental nerve is killed. Afterwards the symptomatic ‘silence’ sets in, but it can be observed how the tooth, now devitalized because it no longer has a nerve, blackens or turns yellow.

– This tooth affected by dental granuloma may also become more mobile than the other teeth, because the dental granuloma affects the tooth socket in which the root of the tooth rests.

There may also be a change in the level of the affected tooth, as it is pushed out (extruded) from the normal tooth line.

– On drilling, the tooth may be painful. If a dental abscess occurs, the tooth suddenly becomes painful, the gums swell, become sensitive to the touch and become more intensely colored than the rest of the oral mucosa. At this stage the symptoms are severe enough that the patient goes to the doctor.

Diagnosis

The diagnosis of dental granuloma is made following a dental X-ray, where the tissue changes at the root tip are observed, as well as the cause of the disease and the size of the granuloma or dental cyst.

Depending on the complications, blood tests may also be altered, so a routine blood count may reveal inflammation or infection in the body.

Treatment methods

There are several therapeutic approaches to a dental granuloma, depending on the affected tooth, the size of this dental granuloma, the condition of the tooth, the patient’s oral hygiene, etc.

The main methods of treatment of dental granuloma are:

• conservative root canal treatment;

• endodontic treatment using calcium hydroxide;

• aspiration-irrigation technique;

• lesion sterilization and apex procedure;

• non-surgical active decompression technique;

• apical resection of granuloma (represents surgery);

• tooth extraction.

The most commonly used techniques are endodontic treatment using calcium hydroxide, apical resection or tooth extraction.

Endodontic treatment with calcium hydroxide

This treatment consists of cleaning the dental canal and applying a calcium hydroxide treatment. This treatment will be changed weekly, and after a period of time the patient will again have a dental X-ray to see how effective the treatment is.

Studies show that more than 85% of dental granulomas respond to endodontic treatment with calcium hydroxide, so in small lesions this method of treatment should be the first one tried.

If no remission of the apical granuloma is seen on the control radiograph, then endodontic treatment is most likely not successful.

Apical resection of dental granuloma

Apical resection is surgery performed by the oro-maxillofacial surgeon under local anesthesia.

The procedure consists of pulling out the gum and soft tissues until the root of the tooth is reached, where the granuloma will be removed along with part of the tooth root. For the upper lateral teeth there is a risk of opening the maxillary sinuses, which requires an additional intervention to close them, to patch them.

The gum and soft tissues are then placed and a few sutures are placed to keep the wound closed until it heals. Bone will eventually deposit in the place where the granuloma was removed, but you will need to have a follow-up X-ray every half year or one year, depending on your doctor’s recommendations.

Tooth extraction

Dental extraction is the least desirable method of treatment and is recommended when the granulomas are too large and the tooth is compromised.

Once dental extraction has been performed, the remaining prosthetic solutions are dental implants or dental bridges.

Prevention

The development of dental granuloma can be avoided if you attend your routine dental check-up every half a year. In this way dental caries will be discovered at an early stage, when it is unlikely to have reached the dentine, so that the question of damage to the dental pulp does not even arise.

You should also be aware that a devital tooth, such as one affected by dental granuloma, has a higher risk of loss than a live tooth. Your doctor can often recommend a dental crown to “extend” the life of the tooth on the dental arch.

Conclusions

The dental pulp becomes infected either from tooth decay or accidental exposure leading to necrosis or death of the pulp. Persistent infection eventually causes inflammation, and our immune system prevents it from spreading by depositing granulation tissue consisting of leukocytes, lymphocytes, capillaries, plasma cells and fibroblasts.

This area is surrounded by a fibrous capsule and forms the so-called dental granuloma. This is the body’s natural way of preventing infection and its spreading to nearby areas.

However, because the granuloma contains a web of capillaries, it sometimes leads to the further spread of bacteria.

Dental granulomas are small in size and can form anywhere at the dental root of a devital tooth, but are most commonly seen at the root tip.

It does not normally cause problems and is often detected during routine dental examinations or X-rays. In some cases, the granuloma may remain inactive and the surrounding capsule may thicken, completely encasing dead bacteria and dental pulp.

But if it continues to evolve and increase in size, it will cause violent pain, inflammation of the gum tissue, sensitivity to thermal stimuli and discomfort when chewing on the affected tooth.

There are several factors that can lead to the sudden growth of a latent dental granuloma. Things like injuries, tooth fractures, tooth decay can lead to infections that can cause pulpitis, i.e. inflammation of the dental pulp. Another factor that leads to exacerbation of symptoms is periodontitis or inflammation that has spread to the tissues and bone around the tooth.

A granuloma can also become problematic after extraction of the infected tooth, where some infection remains if a cleaning of the remaining tooth socket is not carried out. Other triggers can be stress, pressure, colds, etc.

In addition to the severe pain that can occur in the development of this granuloma, other complications can include the spread of infection to the bone, leading to osteomyelitis. Also, in severe cases, this infection can pass beyond the oral cavity and reach the general circulation.

The treatment plan is based on the size of the granuloma, the degree of infection and the complications that may arise. In the initial stage of infection, endodontic treatments may be carried out, i.e. the removal of the root pulp, irrigation and sealing of the canals. The dentist may also prescribe antibiotic treatment to eliminate the infection entirely.

However, surgery may be necessary in some instances where conservative treatment is not effective. If the tooth is fractured or the caries process has destroyed a lot of hard tissue, it cannot be saved and must be extracted.

Nowadays, an apical resection is also an option, which is a conservative method and keeps the tooth on the arch. Apical resection involves removing the damaged part of the root of the related tooth together with the surrounding tissue.

If any abscess forms, it is incised and drained, and after its withdrawal one of the treatments described above may be used. If the granuloma has been completely excised and the treatment has been carried out correctly, it is unlikely to recur.