title: Extraradicular infection as the cause of persistent symptoms: a case series.
abstract: BACKGROUND
  This article describes 3 cases that presented persistent symptoms after appropriate endodontic treatment. Histopathologic and histobacteriologic investigation were conducted for determination of the cause.
  
  
  METHODS
  Three cases are reported that presented with persistent symptoms after endodontic retreatment (cases 1 and 2) or treatment (case 3). Periapical surgery was indicated and performed in these cases. The biopsy specimens, consisting of root apices and the apical periodontitis lesions, were subjected to histopathologic and histobacteriologic analyses.
  
  
  RESULTS
  Case 1 was an apical cyst with necrotic debris, heavily colonized by ramifying bacteria, in the lumen. No bacteria were found in the apical root canal system. Case 2 was a granuloma displaying numerous bacterial aggregations through the inflammatory tissue. Infection was also present in the dentinal tubules at the apical root canal. Case 3 was a cyst with bacterial colonies floating in its lumen; bacterial biofilms were also seen on the external apical root surface, filling a large lateral canal and other apical ramifications, and between layers of cementum detached from the root surface. No bacteria were detected in the main root canal.
  
  
  CONCLUSIONS
  Different forms of extraradicular infection were associated with symptoms in these cases, leading to short-term endodontic failure only solved by periapical surgery.
authors.affiliation: Private Practice, Cetraro, Italy. Electronic address: dricucci@libero.it.
authors.forename: Domenico
authors.initials: D
authors.lastname: Ricucci
authors.affiliation: Faculty of Dentistry, Department of Endodontics, Estácio de Sá University, Rio de Janeiro, Rio de Janeiro, Brazil.
authors.forename: José F
authors.initials: JF
authors.lastname: Siqueira
authors.affiliation: Specialization Course, Brazilian Association of Dentistry, Juiz de Fora, Minas Gerais, Brazil.
authors.forename: Weber S P
authors.initials: WS
authors.lastname: Lopes
authors.affiliation: Specialization Course, Brazilian Association of Dentistry, Juiz de Fora, Minas Gerais, Brazil.
authors.forename: Adalberto R
authors.initials: AR
authors.lastname: Vieira
authors.affiliation: Faculty of Dentistry, Department of Endodontics, Estácio de Sá University, Rio de Janeiro, Rio de Janeiro, Brazil.
authors.forename: Isabela N
authors.initials: IN
authors.lastname: Rôças
mesh_terms: D000328:Adult; D001047:Apicoectomy; D006801:Humans; D008297:Male; D010485:Periapical Periodontitis / Q000382:microbiology / Q000473:pathology* / Q000601:surgery; D011842:Radicular Cyst / Q000382:microbiology / Q000473:pathology / Q000601:surgery; D019233:Retreatment / Q000009:adverse effects; D018915:Root Canal Preparation / Q000009:adverse effects*; D019227:Tooth Apex / Q000382:microbiology / Q000473:pathology* / Q000601:surgery; D019553:Tooth, Nonvital / Q000382:microbiology / Q000473:pathology* / Q000601:surgery
keywords: Endodontic retreatment; extraradicular infection; post-treatment apical periodontitis; treatment outcome