Journal of Conservative Dentistry

REVIEW ARTICLE
Year
: 2022  |  Volume : 25  |  Issue : 3  |  Page : 214--225

Nonmalignant nonendodontic lesions mimicking periapical lesions of endodontic origin: A systematic review


Kajal Modi, Ramanujam Padmapriya, Subashini Elango, Buvaneshwari Arul, Velmurugan Natanasabapathy 
 Department of Conservative Dentistry and Endodontics, Faculty of Dentistry, Meenakshi Academy of Higher Education and Research, Chennai, Tamil Nadu, India

Correspondence Address:
Dr. Velmurugan Natanasabapathy
Department of Conservative Dentistry and Endodontics, Faculty of Dentistry, Meenakshi Academy of Higher Education and Research, Chennai, Tamil Nadu
India

Abstract

The objective of the study is to describe the clinical and radiographic features of nonmalignant nonendodontic periapical lesions (NMNPLs) mimicking lesions of endodontic cause. Five electronic databases, PubMed, Web of Science, Scopus, Embase, and ProQuest, were searched (till July 2021) for case reports, case series, and cross-sectional studies, in English language, reporting NMNPLs, which were clinically and/or radiographically simulating periapical pathosis of endodontic origin. Data extraction was done followed by quality assessment of the included articles using the Joanna Briggs Institute tool for case reports and case series. Seventy-three articles comprising 176 cases were included. Sixty-one articles were case reports, nine articles were case series, and three articles were retrospective studies. Male:female ratio was 1.5:1, with a higher prevalence of lesions occurring in the fourth and second decades of life. The majority of the lesions were located in the anterior maxilla. Radiographically, most of the lesions were well defined, radiolucent, and unilocular. Histologically, 29 different types of NMNPLs were reported, with the most common ones being odontogenic keratocyst (25.56%), dentigerous cyst (17.61%), ameloblastoma (11.36%), nasopalatine duct cyst (10.79%), and adenomatoid odontogenic tumor (5.68%). As all the included studies were observational, the quality of available evidence is considered low. Various features such as loss of tooth vitality, history of trauma, and presence of periapical radiolucency may lead to misdiagnosis of NMNPLs and must be considered during diagnosis of the lesion. Additional imaging modalities and histopathology can aid in right diagnosis.



How to cite this article:
Modi K, Padmapriya R, Elango S, Arul B, Natanasabapathy V. Nonmalignant nonendodontic lesions mimicking periapical lesions of endodontic origin: A systematic review.J Conserv Dent 2022;25:214-225


How to cite this URL:
Modi K, Padmapriya R, Elango S, Arul B, Natanasabapathy V. Nonmalignant nonendodontic lesions mimicking periapical lesions of endodontic origin: A systematic review. J Conserv Dent [serial online] 2022 [cited 2022 Jul 7 ];25:214-225
Available from: https://www.jcd.org.in/text.asp?2022/25/3/214/347333


Full Text

 Introduction



Periapical lesions caused due to infections in the root canal system are most often present as radiolucency at the apex of the teeth on radiographs.[1] Cysts, granuloma, and abscess account for about 90% of all such lesions that occur in the periapical region.[2] They are diagnosed through clinical examination, pulp sensibility testing, and radiographic examination. Periapical lesions of endodontic origin usually heal after nonsurgical root canal treatment, and the cases that do not heal require endodontic retreatment or surgical intervention.[3]

However, other lesions such as benign cysts and tumors of odontogenic and nonodontogenic origin, malignant lesions, and infectious diseases can also occur in the periapical region. Sirotheau Corrêa Pontes et al. reported that out of all the cases that were initially misdiagnosed as periapical lesions of endodontic origin, 66% of them were benign lesions while 29% were malignant.[4] In a recent systematic review on malignant nonendodontic periapical lesions (MNPLs), it was reported that metastatic jaw lesions of primary tumors occurring elsewhere in the body (lungs and breast) and salivary gland malignancies represent 26.6% and 25% of all the malignant lesions. They emphasized the importance of correct diagnosis at the initial stages of the lesion, which will allow for early treatment and prevention of complications.[5]

In a recent multicenter study, 4.22% of the periapical lesions were of nonendodontic origin, among which 34.9% of the lesions were odontogenic keratocyst (OKC), 15.6% were dentigerous cyst (DC), and 9.15% were nasopalatine duct cyst (NPDC).[6] Previous studies in the literature have reported that 0.65%–6.7% of lesions with a histopathological diagnosis of nonendodontic cause were clinically diagnosed as endodontic lesions.[7],[8]

Differentiating between an endodontic and nonendodontic periapical lesion is of paramount importance. A wrong diagnosis may result in an unwanted endodontic treatment, nonhealing of the lesion, and persistence of signs and symptoms. Tsesis et al. in 2020 determined the accuracy of clinical diagnosis of periapical cystic lesions in comparison with histologic findings and found that nonendodontic cysts were clinically diagnosed correctly only in 41.7% of the cases.[9] Thus, it becomes pertinent for the clinicians to be familiar with periapical lesions that might be arising due to nonendodontic causes to enable correct diagnosis and hence proper treatment. To date, no systematic review has been done on nonmalignant nonendodontic lesions mimicking endodontic lesions. Hence, this systematic review aims at describing clinical and radiographic features of nonmalignant nonendodontic periapical lesions (NMNPLs) that mimic lesions of endodontic pathosis.

 Materials and Methods



Eligibility criteria

Research question

What are the clinical and radiographic features of nonmalignant nonendodontic lesions that mimic lesions of endodontic origin?

The review was formulated based on PICOS format (P – Population, I – Intervention, C – Comparison, O – Outcome, S – Study design).

P – Human deciduous and/or permanent teeth/tooth with periapical lesionsI – Clinical and/or radiographic features mimicking endodontic causeC – Not applicableO – Histopathological diagnosis of NMNPLsS – Observational studies (case reports, case series, and cross-sectional studies).

Inclusion criteria

Clinical studies, in English language, reporting cases with NMNPLs that were clinically and/or radiographically mimicking periapical pathosis of endodontic origin or any incidental findings confirmed by the histological analysis were included in this review.

Exclusion criteria

Clinical studies that did not present radiographic features or histological diagnosis, anatomical landmarks or deformities that were misinterpreted as endodontic pathology, animal studies and laboratory-based studies, letters to editor, book chapters, narrative/literature reviews, and abstracts of conferences were all excluded.

Information sources and search strategy

The following five electronic databases were searched, without any filters, till July 2021: PubMed, Web of Science, Scopus, Embase, and ProQuest. The search strategy was developed for each electronic database using the following keywords: periapical diseases, benign lesion, and diagnostic errors. The search strategy aimed at identifying all the published case reports/case series/retrospective studies pertaining to the subject of this review. Detailed search strategies were formulated and utilized for each database to identify the relevant studies by four reviewers (K.M., R.P., S.E., and P.K.), which was further validated by two senior reviewers (B.A. and N.V.). The subject search used a combination of MeSH words using the Boolean method [Supplemental Table 1]. A manual search was conducted by going through the references of all the relevant articles. In addition, three peer-reviewed Endodontic journals (Journal of Endodontics, International Endodontic Journal, and Australian Endodontic Journal) were also manually searched for relevant articles.[INLINE:1]

Study selection

The lists of articles from search results were transferred to Zotero reference management software (Zotero 5.0 for Windows, Centre for History and New Media, George Mason University, Fairfax, Virginia, USA). Duplicates were identified and eliminated. Titles and abstracts were independently screened by four reviewers (K.M., R.P., S.E., and P.K.). Full-text article evaluation was done and articles fulfilling the inclusion criteria were included for the final qualitative assessment. Any disagreements were resolved by discussion with two senior reviewers (B.A. and N.V.).

Data extraction

Data were extracted using custom-designed Excel spreadsheet (Microsoft Excel, Redmond, WA 2016) by four reviewers (K.M., R.P., S.E., and P.K.) which was further verified by the two senior reviewers (B.A. and N.V.). The data extraction sheet included the following:

Study characteristics: Author, year of publication, study designDemographic details: Country, patient age, and sexClinical features: Clinical signs and symptoms, tooth number, location, tooth mobilityDiagnostic tests: Pulp sensibility or vitality tests, other testsRadiographic features: Type of radiographic imaging, radiographic appearance, radiographic lesion borders, image pattern, root resorption, cortical bone resorption, radiographic extentDiagnosis: Provisional/differential diagnosis, histopathological diagnosisIntervention and follow-up.

Quality assessment of included articles

All the included articles were independently assessed by four reviewers (K.M., R.P., S.E., and P.K.) for quality using the Joanna Briggs Institute (JBI) tool for case series[10] and case reports.[11] Retrospective studies were also assessed using the JBI tool for case series as the questions in the checklist better suited the included retrospective studies in this review. The JBI tool for case reports and case series consists of 8 and 10 questions, respectively. Each question was answered with either “yes,” “no,” “unclear,” or “not applicable.” The tenth question (“Was statistical analysis appropriate?”) in the JBI tool for case series was not applicable for any of the included articles, and hence, the question was not considered for quality assessment. Any disagreements were discussed and resolved by the two senior reviewers (B.A. and N.V.).

Risk of bias (RoB) for individual articles was calculated based on the number of positive responses (yes), out of a maximum score of 8 for case reports and 9 for case series. The final score was categorized as high (score equal or lower than 49%), moderate (50%–69%), or low (higher than 70%).[12]

Quality of evidence

To rate the quality of evidence in this review, the JBI levels of evidence was used.

 Results



Study selection

The search flow diagram is presented in [Figure 1]. A total of 1087 articles were identified from the initial search of the databases. After the title and abstract screening and removal of duplicates, 880 articles were excluded. After full-text reading of the remaining 86 articles, 66 articles were selected for the review. Hand searching of the journals and references of included articles resulted in the inclusion of additional seven articles, accounting for a total of 73 articles. The 73 included articles comprised 61 case reports, 9 case series (24 cases), and 3 retrospective studies (95 cases), accounting for a total of 176 cases.{Figure 1}

Study characteristics

There were 14 case series in the included articles. Among these, in five case series, only one of the cases fulfilled the inclusion criteria. Hence, these five articles were considered as case reports. The reason for exclusion of other cases in the case series and articles excluded[4],[6],[8],[9],[13],[14],[15],[16],[17],[18],[19,[20],[21],[22],[23],[24],[25],[26],[27] during full-text reading is provided in [Supplemental Table 2].[INLINE:2]

The 176 included cases were reported from five continents with 66.47% (115/176) from Asia, 13.06% (23/176) in South America, 12.5% (22/176) in North America, 6.81% (12/176) in Europe, and the remaining 1.13% (2/176) from Australia. The age of the patients ranged from 8 to 81 years. Patients in the fourth (40–49 years) and second decades of life (10–19 years) were most commonly affected with the prevalence of 20.5% each (21/102) [Figure 2]. Among the included cases, 60.7% (62/102) were male and 39.2% (40/102) were female, with male-to-female ratio of 1.5:1 [Figure 2].{Figure 2}

Twenty-nine different types of NMNPLs were found in this review, with the majority being OKC (25.56%) followed by DC (17.61%), ameloblastoma (11.36%), NPDC (10.79%), and adenomatoid odontogenic tumor (AOT, 5.68%) [Figure 3]. They were most commonly located in the anterior region of the maxilla (28.43%) followed by the posterior region of the mandible (27.45%) [Figure 2]. In 78.43% (80/102) of the cases, the patients presented with symptoms, while in 21.56% (22/102) cases, the patients were asymptomatic. The number of cases with the involved teeth either responding normally or not responding to pulp sensibility tests was equal (38.18%; 21/55) each. Previously, root canal-initiated/treated teeth were 9.09% (5/55).

For radiographic evaluation, various types of modalities were used such as intraoral periapical radiograph, orthopantomogram, occlusal radiograph, or a combination of these. In addition to the two-dimensional radiographic imaging, in 13 cases, cone-beam computed tomography (CBCT) was used, computerized tomography scan (CT scan) was used in five articles, and one article used magnetic resonance imaging (MRI). Fine needle aspiration cytology was carried out in five cases. Radiographically, 94.88% (167/176) were radiolucent, 90.64% (126/139) were unilocular, and 96.32% (121/136) had well-defined borders. Furthermore, 52.5% (21/40) cases reported cortical bone perforation, 30% (12/40) showed expansion of cortical bone, and 50% (17/34) had pathological root resorption.{Figure 3}

The follow-up of cases ranged from 2 weeks to 8 years. The overall percentages of all the characteristics of all the included articles are given in [Table 1], and data extraction of all the individual cases is provided in [Supplemental Tables 3,4].{Table 1}[INLINE:3][INLINE:4]

Quality analysis

On quality assessment of the case reports using the JBI tool, 49 articles had a low RoB and 12 had moderate RoB. Of the included case series and retrospective studies, two had low RoB, six had moderate RoB, and four had high RoB [Figure 4] and [Figure 5]. The majority of the included articles were case series/reports, and hence, a quantitative analysis was not possible.{Figure 4}{Figure 5}

Quality of evidence

As all the articles included in this review were case series, case reports, and retrospective studies, the JBI level of evidence falls in 4a category. Performing clinical trials on this topic will be extremely difficult, and hence, the currently available evidence from the existing case reports/series and retrospective studies is highly relevant.

 Discussion



With a wide range of benign odontogenic and nonodontogenic cysts and tumors in the periapical region simulating those of endodontic origin, it becomes imperative for clinicians to understand the prevalence, presentation, and diagnostic features of these lesions for making a correct diagnosis. To the best of our knowledge, this is the first systematic review to describe features of NMNPLs mimicking lesions of endodontic pathosis. Using strict inclusion and exclusion criteria, the present systematic review analyzed 73 articles (61 case reports, 9 case series, and 3 retrospective studies) of NMNPLs mimicking endodontic periapical lesion.

Quality assessment of the included articles was done using the JBI tool for case reports and case series.[10],[11] Majority of the case reports had low RoB while the case series had moderate RoB as the adverse events were not described in most of the cases.

The majority of the included cases were from Asia occurring most frequently in the second and fourth decades of life [Figure 2], with a higher male predilection. Clinically, NMNPLs were most commonly seen in the anterior region of the maxilla and posterior region of the mandible. However, the age, gender, and location of the lesion from one retrospective study[28] were not included in the results of this review due to an unclear distinction between the cases with and without the description of their radiographic features. In more than half the cases, the patients were symptomatic with the most common symptom being swelling, either with or without pain. In the previous systematic review on MNPLs, findings for the location of the lesion were different, with the posterior region of the mandible being the most commonly affected site.[5] The majority of the patients were symptomatic in their review although the description of the symptoms was not specified.[5]

Radiographically, a vast majority of NMNPLs had a unilocular radiolucency. This is similar to the previous review on MNPLs.[5] Only a small fraction of the included articles in this review exhibited multilocularity and/or mixed radiographic appearance. Besides this, 93% of NMNPLs had well-defined borders in radiographs, while only 21.8% of the MNPLs were well defined in the previous systematic review.[5]

The most commonly reported NMNPLs in this review were OKC, DC, NPDC, ameloblastoma, and AOT, in the descending order. OKC had the highest frequency accounting for 29.5% of all the NMNPLs. Previous studies reported frequencies of 14%, 32.2%, 34.6%, 34.9%, and 42.3%, respectively.[6],[8],[19],[20],[29]

OKCs are benign intraosseous lesions of odontogenic origin, accounting for about 10% of all jaw cysts.[30] They are characterized by an aggressive behavior with a relatively high recurrence rate.[31] In this review, there were a total of ten case reports,[32],[33],[34],[35],[36],[37],[38],[39],[40],[41] two case series,[42],[43] and two retrospective studies[28],[44] on OKC. It showed a high male predilection with a majority of the patients in the third decade of life 31–40 years. This is in accordance with the previous literature.[31],[45],[46],[47] The lesions were more commonly located in the anterior maxillary region.[32],[39],[40],[42] The most common clinical presentation was swelling with/without purulent discharge.[35],[37],[38],[39],[40],[42],[43] Two cases were incidental findings.[32],[43] Radiographically, OKC appears as a well-defined unilocular or multilocular radiolucency bounded by corticated margins.[45] While most of the cases in this review were unilocular,[34],[36],[37],[39],[43],[44] two articles reported cysts that were multilocular[40],[44] and another article reported a cyst appeared as two separate “sister lesions,” with one located apically and the other along the lateral aspect of the root.[44] When a small unilocular OKC occurs in the anterior region of the maxilla, it may simulate other odontogenic and nonodontogenic cysts, such as radicular cyst, lateral periodontal cyst, or NPDC.[15],[48] When a periapical lesion exhibits an aggressive nature or abnormally large size, clinicians must consider OKC in the differential diagnosis.[45] In this review, one of the cases exhibited root resorption[40] and one case series and two cases reported perforation of buccal/labial cortical plate.[34],[41],[43]

DCs were the second most common lesion in this review. DCs are developmental cysts that account for about 20% of all odontogenic cysts.[49] They are most commonly found enclosing the crown of an unerupted tooth at the level of the cementoenamel junction.[50] In this review, 17.61% of the cases had a histopathological diagnosis of DC,[22],[29],[51],[52],[53] and the affected teeth were permanent successors with the cyst seeming to involve the roots of the overlying primary teeth, thus mimicking periradicular pathosis of the primary teeth. In accordance with the literature evidence,[49] the age of all the affected individuals in this review was within the first two decades of life, and the majority of them were male. The posterior mandible was more affected, and all the reported lesions were unilocular and radiolucent. Three cases and one retrospective study (24 cases) described the borders of the lesion as well defined.[22],[29],[52],[53] Expansion of the buccal cortical plate was observed in one case.[22] Since DCs are found in relation to unerupted or impacted teeth, these are relatively easier to diagnose and differentiate from endodontic lesions. However, when associated with a permanent successor, like in the included cases, it can pose a diagnostic challenge. In such a scenario, DC can be distinguished by an intact lamina dura of the primary tooth and excessively widened follicular space of the erupting tooth on radiographs.[51]

Ameloblastoma is a locally aggressive odontogenic tumors, comprising 10% of all the tumors of the jaws. They clinically present as a painless swelling that may cause facial asymmetry.[54] In this review, three cases, one case series (two cases), and two retrospective studies (15 cases) were diagnosed with ameloblastoma.[1],[29],[55],[56],[57],[58] In the retrospective study by Gondak et al, two cases were asymptomatic while three cases presented with swelling and/or pain.[58] Additionally, two case reports and one case series also presented with similar symptoms.[1],[55],[57] One case had a history of trauma with nonvital tooth and pus discharge.[56] Similar to the previous literature,[59] all the cases of ameloblastoma had a well-defined radiolucency, and most of them occurred in the posterior mandible.[55],[58] Due to their aggressive nature, they may exhibit root resorption and bony expansion with “egg shell crackling” on palpation. “Soap bubble appearance” on radiograph is a classic feature of the multilocular variant.[60] These characteristics should lead to a suspicion of ameloblastoma in the periapical region. However, radiographic appearance of unicystic variant is difficult to distinguish from endodontic periapical lesion. Locularity of the lesion in this review was mentioned only in two cases wherein both were unilocular.[55],[56] Root resorption was present in one case report and the retrospective study (three cases),[55],[58] and bony expansion was mentioned in two cases.[1],[56]

NPDCs are developmental, epithelial, and nonodontogenic cysts found on the palate behind the maxillary anterior teeth. It develops due to the proliferation of epithelial remnants of the nasopalatine ducts[61] stimulated by irritation, local trauma, or infections.[62],[63] NPDC prevalence ranges from 2.2% to 11.6%,[64],[65],[66] and in this review, it accounted for 10.79% of all the lesions.[67],[68],[69],[70],[71],[72],[73] It showed higher male predilection which is in accordance with previous literature.[62],[63],[74] The patient is usually asymptomatic, and it is an accidental radiographic finding.[61] In this review, two cases presented with swelling,[68],[72] three cases had a history of trauma,[69],[71],[73] and one case each complained of discomfort during palpation,[69] pain,[67] and ill-fitting denture.[70] Teeth involved in all the cases either responded normally to pulp sensibility tests or were previously endodontically treated. NPDC should be suspected when a radiolucency involving the anterior maxilla is associated with vital teeth. On CBCT examination, the lesion has shown to be involving the nasopalatine canal[69],[71],[73] or extending into the nasal cavity.[70] Hence, when a lesion at this site is associated with a nonvital or endodontically treated tooth, CBCT should be considered to aid in diagnosis. Radiographically, most of the cases were unilocular well-defined radiolucent lesions which are in agreement with the literature.[75] Cortical bone resorption, which is an uncommon finding, was found in two case series (two cases each) and one case report.[69],[70],[73]

AOT is a slow-growing, noninvasive, benign lesion with a prevalence of 2.2%–7.1% of all odontogenic tumors.[76] Of the ten cases of AOT in this review, eight were of extrafollicular variant[23],[77],[78],[79],[80],[81],[82],[83] and one case series (two cases) was of follicular type.[84] In agreement with the previous literature,[76] there were clear female predilection and higher prevalence in the second decade of life. AOTs were located mainly in the anterior region of the jaws. Radiographically, the lesions were unilocular with well-defined borders and most of them appeared radiolucent.[23],[78],[80],[81],[82],[84] Four cases exhibited root resorption[23],[79],[81],[83] and three cases had cortical bone perforation[80],[81],[83] which are uncommon in AOT.[76] In 70/% of the AOTs, small radiopacities are seen within the radiolucency.[85] This feature can be used to differentiate an AOT from a periapical lesion of endodontic origin, which usually does not have any opacities. AOTs are usually asymptomatic or may present as a painless, slow-growing swelling.[85] In this review, three cases were incidental findings,[78],[82],[83] four cases and one case series (two cases) had a painless swelling,[23],[79],[80],[81],[84] whereas one case presented with pain[77] and only three cases had flecks of radiopacities in the radiolucency.[79],[83],[84] Two cases had a history of trauma,[79],[82] out of which one case had a nonvital tooth in relation to the AOT, leading to misdiagnosis of radicular cyst.[79]

In addition to the above-mentioned lesions, five cases of cemento-osseous dysplasia,[27],[86],[87],[89] five cases of glandular odontogenic cyst,[25],[28],[90],[91],[92] one case series (3 cases) of surgical ciliated cyst,[93] one case and one retrospective study (2 cases) of traumatic bone cyst,[28],[94] two cases each of calcifying odontogenic tumor,[95],[96] central giant cell granuloma,[97],[98] central giant cell lesion,[99],[100] schwannoma,[101],[102] paradental cyst,[28],[103] lateral periodontal cyst,[28],[104] and osteomyelitis,[105],[106] and one case each of ossifying fibroma,[107] osseous dysplasia,[26] osteoblastoma,[108] lymphangioma,[109] cemental dysplasia,[24] eosinophilic granuloma,[110] central odontogenic fibroma,[111] cemento-osseous fibroma,[24] foreign body reaction,[28] squamous odontogenic tumor,[112] plasmacytoma,[113] tuberculosis,[24],[114] and actinomycosis[115] were also reported in the included articles [Supplemental Table 3].

Adverse or unanticipated events were not clearly described in most of the cases. One case reported an incomplete root fracture after the initial treatment.[35] Bone sequestration during extraction procedure,[106] inaccessibility and poor visibility to perform surgical root canal treatment after flap elevation,[111] and intraoperative hemorrhage with the sectioned root apex lost in the bleeding tissue[97] were some of the unanticipated events reported during surgical procedures. In addition, postoperatively, paresthesia with suppuration[55] and an emergency visit to the dental clinic due to pain[88] were also reported.

Other NMNPLs such as globulomaxillary cyst, median palatine/mandibular cyst, aneurysmal bone cyst, osteoclastoma, calcifying epithelial odontogenic tumor, squamous odontogenic tumor, and periapical scar have not been reported in any of the included articles in this review. Clinicians should also be aware that persistence of radiolucency after nonsurgical root canal treatment or periapical surgery can be a periapical scar.[2] These cases can be radiographically interpreted as failures. Histologically, this area consists of dense, fibrous connective tissue with no sign of inflammation.[116] Therefore, if the patient is asymptomatic or there is no increase in size of the lesion, periapical scar tissue formation should also be considered in differential diagnosis.

Presence of an undamaged crown, no history of trauma, tooth responding to pulp sensibility tests, intact lamina dura in radiographs, and abnormally large lesion are few indicators of the lesion being NMNPLs. Lesions such as NPDC, median palatine/mandibular cyst, and globulomaxillary cyst have a specific area of occurrence which makes it easier for the clinicians to diagnose. Previous history of periradicular surgery or trauma can hint to the possibility of surgical ciliated cyst or traumatic bone cyst. A cyst or tumor of nonendodontic origin expanding in the periapical region of a tooth may severe off the blood supply to the associated tooth, leading to loss of its vitality and misdiagnosis of the periapical lesion.

Anatomic landmarks such as maxillary sinus and mental foramen and the presence of thick cortical bone in the mandible may complicate radiographic interpretation. Currently, the use of limited field of view CBCT in endodontics for diagnosis of nonodontogenic pathoses or in patients with nonspecific signs and/or symptoms is recommended.[117],[118] In the included articles, additional imaging modalities such as CBCT, CT, and MRI were also used to aid in diagnosis of the lesion. Musu et al. used ultrasonography in the diagnosis of OKC, AOT, DC, and central giant cell granuloma.[119] Future studies should consider exploring the use of ultrasonography in the diagnosis of NMNPLs.

A guideline that would help arrive at the correct final diagnosis of all types of periapical lesions with respect to their origin is provided in [Figure 6].{Figure 6}

The strengths of this review are that a strict inclusion criterion was followed, and only articles with both radiographic examination and histopathological diagnosis were included. This review provides a comprehensive summary of cases that provided the presentation, diagnosis, and management of NMNPLs, mimicking lesions of endodontic origin which always pose a diagnostic challenge for the clinicians.

Inconsistent and incomplete reporting in some included articles is one of the limitations of this review. Besides this, seven retrospective studies were excluded due to lack of radiographic details [Supplemental Table 2]. In addition, there is a difficulty in addressing various other potential NMNPLs due to their rarity in occurrence. The results of prevalence of the lesions in this review [Figure 3] must be viewed with caution because these data are pertaining only to cases of NMNPLs that have been reported. The actual prevalence could differ. Lack of long-term follow-up and missing details on adverse/unanticipated events are the other limitations of this review.

In future cases, complete details of the patient's history and treatment with follow-up should be provided following the Case Report Guidelines.[120] Retrospective studies should provide more data on the clinical and radiographic findings. Thorough clinical examination along with interpretations of different diagnostic tests (CBCT, CT, ultrasound, or MRI) should be correlated for provisional diagnosis and confirmed using histopathological examination.

 Conclusion



This systematic review has highlighted the various clinical and radiographic features of several NMNPLs that mimic endodontic pathosis. They should be considered as a part of differential diagnosis of periapical lesions. Detailed medical and dental history-taking, thorough extraoral and intraoral clinical examination, appropriate diagnostic tests, and a sound knowledge of various NMNPLs will help clinicians in correct diagnosis and ultimately improve prognosis and treatment outcomes of such lesions. In cases of nonhealing periapical lesions of endodontically treated teeth, definitive diagnosis should be based on histopathological evaluation.

Other information

Protocol and registration

This systematic review was reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analysis checklist.[121] The protocol was registered in International Prospective Register of Systematic Reviews (CRD42021237990).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Faitaroni LA, Bueno MR, De Carvalhosa AA, Bruehmueller Ale KA, Estrela C. Ameloblastoma suggesting large apical periodontitis. J Endod 2008;34:216-9.
2Bhaskar SN. Periapical lesion: Types, incidence, and clinical features. Oral Surg Oral Med Oral Pathol 1966;21:657-671.
3Sullivan M, Gallagher G, Noonan V. The root of the problem: Occurrence of typical and atypical periapical pathoses. J Am Dent Assoc 2016;147:646-9.
4Sirotheau Corrêa Pontes F, Paiva Fonseca F, Souza de Jesus A, Garcia Alves AC, Marques Araújo L, Silva do Nascimento L, et al. Nonendodontic lesions misdiagnosed as apical periodontitis lesions: Series of case reports and review of literature. J Endod 2014;40:16-27.
5Schuch LF, Vieira CC, Uchoa Vasconcelos AC. Malignant lesions mimicking endodontic pathoses lesion: A systematic review. J Endod 2021;47:178-88.
6Vieira CC, Pappen FG, Kirschnick LB, Cademartori MG, Nóbrega KH, do Couto AM, et al. A retrospective Brazilian multicenter study of biopsies at the periapical area: Identification of cases of nonendodontic periapical lesions. J Endod 2020;46:490-5.
7Nobuhara WK, del Rio CE. Incidence of periradicular pathoses in endodontic treatment failures. J Endod 1993;19:315-8.
8Ortega A, Fariña V, Gallardo A, Espinoza I, Acosta S. Nonendodontic periapical lesions: A retrospective study in Chile. Int Endod J 2007;40:386-90.
9Tsesis I, Krepel G, Koren T, Rosen E, Kfir A. Accuracy for diagnosis of periapical cystic lesions. Sci Rep 2020;10:14155.
10Moola S, Munn Z, Tufanaru C, Aromataris E, Sears K, Sfetcu R, et al. Chapter 7: Systematic reviews of etiology and risk. In: Aromataris E, Munn Z (Editors). JBI Manual for Evidence Synthesis. JBI, 2020; 263-6.
11Moola S, Munn Z, Tufanaru C, Aromataris E, Sears K, Sfetcu R, et al. Chapter 7: Systematic reviews of etiology and risk. In: Aromataris E, Munn Z (Editors). JBI Manual for Evidence Synthesis. JBI, 2020; 267-8.
12Saletta JM, Garcia JJ, Caramês JM, Schliephake H, da Silva Marques DN. Quality assessment of systematic reviews on vertical bone regeneration. Int J Oral Maxillofac Surg 2019;48:364-72.
13Neville B, Damm D, Brock T. Odontogenic keratocysts of the midline maxillary region. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;82:206.
14Kuc I, Peters E, Pan J. Comparison of clinical and histologic diagnoses in periapical lesions. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:333-7.
15Ali M, Baughman RA. Maxillary odontogenic keratocyst: A common and serious clinical misdiagnosis. J Am Dent Assoc 2003;134:877-83.
16Islam MN, Cohen DM, Kanter KG, Stewart CM, Katz J, Bhattacharyya I. Florid cemento-osseous dysplasia mimicking multiple periapical pathology – An endodontic dilemma. Gen Dent 2008;56:559-62.
17Kamal M, Kaur P. An unusual case of unicystic ameloblastoma involving the anterior of maxilla. J Clin Diagn Res 2010;4:3659-663.
18Morais AL, Mendonça EF, de Alencar AH, Estrela C. Intraosseous lipoma in the periapical region of a maxillary third molar. J Endod 2011;37:554-7.
19Kontogiannis TG, Tosios KI, Kerezoudis NP, Krithinakis S, Christopoulos P, Sklavounou A. Periapical lesions are not always a sequelae of pulpal necrosis: A retrospective study of 1521 biopsies. Int Endod J 2015;48:68-73.
20Huang HY, Chen YK, Ko EC, Chuang FH, Chen PH, Chen CY, et al. Retrospective analysis of nonendodontic periapical lesions misdiagnosed as endodontic apical periodontitis lesions in a population of Taiwanese patients. Clin Oral Investig 2017;21:2077-82.
21Bains R, Verma P, Chandra A, Tikku AP, Singh N. Nasopalatine duct cyst mimicking an endodontic periapical lesion: A case report. Gen Dent 2016;64:63-6.
22Patil AS, Jathar PN, Panse AM, Bahutule SR, Patil RU, Patil M. Infected dentigerous cyst and its conservative management: A report of two cases. Int J Clin Pediatr Dent 2019;12:68-72.
23Philipsen HP, Samman N, Ormiston IW, Wu PC, Reichart PA. Variants of the adenomatoid odontogenic tumor with a note on tumor origin. J Oral Pathol Med 1992;21:348-52.
24Xia WW, Zhu YQ, Wang XY. Six cases report of differential diagnosis of periapical diseases. Int J Oral Sci 2011;3:153-9.
25Natarajan S, Khalid I. Glandular odontogenic cyst mimicking a radicular cyst: A case series. Int J Med Dent Case Rep 2016;3:1-4.
26Daviet-Noual V, Ejeil AL, Gossiome C, Moreau N, Salmon B. Differentiating early stage florid osseous dysplasia from periapical endodontic lesions: A radiological-based diagnostic algorithm. BMC Oral Health 2017;17:161.
27Brody A, Zalatnai A, Csomo K, Belik A, Dobo-Nagy C. Difficulties in the diagnosis of periapical translucencies and in the classification of cemento-osseous dysplasia. BMC Oral Health 2019;19:139.
28Kosanwat T, Poomsawat S, Kitisubkanchana J. Non-endodontic periapical lesions clinically diagnosed as endodontic periapical lesions: A retrospective study over 15 years. J Clin Exp Dent 2021;13:e586-93.
29Guimarães GG, Perez DE, Netto JD, Costa AC, Leonel AC, Castro JF, et al. Nonendodontic periapical lesions: A retrospective descriptive study in a Brazilian population. Med Oral Patol Oral Cir Bucal 2021;26:e502-9.
30Eryilmaz T, Ozmen S, Findikcioglu K, Kandal S, Aral M. Odontogenic keratocyst: An unusual location and review of the literature. Ann Plast Surg 2009;62:210-2.
31Chirapathomsakul D, Sastravaha P, Jansisyanont P. A review of odontogenic keratocysts and the behavior of recurrences. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:5-9.
32Hancock MA, Brown CE Jr., Hartman KS. Orthokeratinized odontogenic cyst presenting as a periapical lesion. J Endod 1986;12:539-41.
33Tan BT. A unilocular odontogenic keratocyst associated with the periradicular area of an upper right maxillary canine – A case report. Aust Endod J 2001;27:25-8.
34Pace R, Cairo F, Giuliani V, Prato LP, Pagavino G. A diagnostic dilemma: Endodontic lesion or odontogenic keratocyst? A case presentation. Int Endod J 2008;41:800-6.
35Onuki M, Saito A, Hosokawa S, Ohnuki T, Hayakawa H, Seta S, et al. A case of orthokeratinized odontogenic cyst suspected to be a radicular cyst. Bull Tokyo Dent Coll 2009;50:31-5.
36Mamatha R, Bela M, Musarrat K, Rajiv SD, Duggal Arun G. An interdental radiolucent lesion of mandible: A case report and differential diagnosis. Int J Clin Dent Sci 2011;2:13-7.
37Rajalakshmi R, Sreeja C, Vijayalakshmi D, Leelarani V. Orthokeratinised odontogenic cyst mimicking periapical cyst. BMJ Case Rep 2013;2013:bcr2013200883.
38Santos JN, Carneiro Júnior B, Alves Malaquias PD, Henriques AC, Cury PR, Rebello IM. Keratocystic odontogenic tumour arising as a periapical lesion. Int Endod J 2014;47:802-9.
39Silva Servato JP, Cardoso SV, Parreira da Silva MC, Cordeiro MS, Rogério de Faria P, Loyola AM. Orthokeratinized odontogenic cysts presenting as a periapical lesion: Report of a case and literature review. J Endod 2014;40:455-8.
40Satappa BS, Vasant DU, Kanitkar S, Kamat M. Keratocystic odontogenic tumor of the maxillary anterior region masquerading as a radicular cyst. Asian J Pharm Clin Res 2017;10:3-4.
41Prashanth BR, Vidhya MS, Karale R, Kumar GV. Is odontogenic keratocyst an endodontic enigma? A rare case report of management of odontogenic keratocyst in anterior mandible. J Oral Maxillofac Pathol 2020;24:S7-10.
42Wright BA, Wysocki GP, Larder TC. Odontogenic keratocysts presenting as periapical disease. Oral Surg Oral Med Oral Pathol 1983;56:425-9.
43Nohl FS, Gulabivala K. Odontogenic keratocyst as periradicular radiolucency in the anterior mandible: Two case reports. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;81:103-9.
44Garlock JA, Pringle GA, Hicks ML. The odontogenic keratocyst: A potential endodontic misdiagnosis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;85:452-6.
45Avril L, Lombardi T, Ailianou A, Burkhardt K, Varoquaux A, Scolozzi P, et al. Radiolucent lesions of the mandible: A pattern-based approach to diagnosis. Insights Imaging 2014;5:85-101.
46Johnson NR, Gannon OM, Savage NW, Batstone MD. Frequency of odontogenic cysts and tumors: A systematic review. J Investig Clin Dent 2014;5:9-14.
47Bilodeau EA, Collins BM. Odontogenic cysts and neoplasms. Surg Pathol Clin 2017;10:177-222.
48Neville BW, Damm DD, Brock T. Odontogenic keratocysts of the midline maxillary region. J Oral Maxillofac Surg 1997;55:340-4.
49Thompson LD. Dentigerous cyst. Ear Nose Throat J 2018;97:57.
50Vasiapphan H, Christopher PJ, Kengasubbiah S, Shenoy V, Kumar S, Paranthaman A. Bilateral dentigerous cyst in impacted mandibular third molars: A case report. Cureus 2018;10:e3691.
51Narang RS, Manchanda AS, Arora P, Randhawa K. Dentigerous cyst of inflammatory origin-a diagnostic dilemma. Ann Diagn Pathol 2012;16:119-23.
52Maitin SN, Mukherjee CG, Verma A. Conservative management of a misdiagnosed infected dentigerous cyst in transition dentition. Int J Appl Dent Sci 2015;1:12-4.
53Gupta P, Jawanda M, Narula R, Singh J. Inflammatory dentigerous cyst mimicking a periapical cyst. J Int Clin Dent Res Organ 2016;8:63-6.
54Becelli R, Carboni A, Cerulli G, Perugini M, Iannetti G. Mandibular ameloblastoma: Analysis of surgical treatment carried out in 60 patients between 1977 and 1998. J Craniofac Surg 2002;13:395-400.
55Cunha EM, Fernandes AV, Versiani MA, Loyola AM. Unicystic ameloblastoma: A possible pitfall in periapical diagnosis. Int Endod J 2005;38:334-40.
56Kashyap B, Reddy PS, Desai RS. Plexiform ameloblastoma mimicking a periapical lesion: A diagnostic dilemma. J Conserv Dent 2012;15:84-6.
57Satyabhusan NV, Routray S, Bendi L, Suresh BV, Majumdar S, Mohanty N. Unicystic ameloblastoma masquerading as huge periapical lesion, both clinically and histopathologically: Two case reports with review of literature. J Clin Imaging Sci 2013;3:9.
58Gondak RO, Rocha AC, Neves Campos JG, Vargas PA, de Almeida OP, Lopes MA, et al. Unicystic ameloblastoma mimicking apical periodontitis: A case series. J Endod 2013;39:145-8.
59Nakamura N, Mitsuyasu T, Higuchi Y, Sandra F, Ohishi M. Growth characteristics of ameloblastoma involving the inferior alveolar nerve: A clinical and histopathologic study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;91:557-62.
60Masthan KM, Anitha N, Krupaa J, Manikkam S. Ameloblastoma. J Pharm Bioallied Sci 2015;7:S167-70.
61Tsuneki M, Maruyama S, Yamazaki M, Abé T, Adeola HA, Cheng J, et al. Inflammatory histopathogenesis of nasopalatine duct cyst: A clinicopathological study of 41 cases. Oral Dis 2013;19:415-24.
62Shylaja S, Balaji K, Krishna A. Nasopalatine duct cyst: Report of a case with review of literature. Indian J Otolaryngol Head Neck Surg 2013;65:385-8.
63Mesquita JA, Luna AH, Nonaka CF, Godoy GP, Alves PM. Clinical, tomographic and histopathological aspects of the nasopalatine duct cyst. Braz J Otorhinolaryngol 2014;80:448-50.
64Daley TD, Wysocki GP, Pringle GA. Relative incidence of odontogenic tumors and oral and jaw cysts in a Canadian population. Oral Surg Oral Med Oral Pathol 1994;77:276-80.
65Grossmann SM, Machado VC, Xavier GM, Moura MD, Gomez RS, Aguiar MC, et al. Demographic profile of odontogenic and selected nonodontogenic cysts in a Brazilian population. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;104:e35-41.
66Shear M, Speight PM. Cysts of the Oral and Maxillofacial Regions. 4th ed., Ch. 9. UK: Blackwell Publishing Ltd; 2007.
67Gulabivala K, Briggs PF. Diagnostic dilemma: An unusual presentation of an infected nasopalatine duct cyst. Int Endod J 1992;25:107-11.
68Gnanasekhar JD, Walvekar SV, al-Kandari AM, al-Duwairi Y. Misdiagnosis and mismanagement of a nasopalatine duct cyst and its corrective therapy. A case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995;80:465-70.
69Faitaroni LA, Bueno MR, Carvalhosa AA, Mendonça EF, Estrela C. Differential diagnosis of apical periodontitis and nasopalatine duct cyst. J Endod 2011;37:403-10.
70Suter VG, Büttner M, Altermatt HJ, Reichart PA, Bornstein MM. Expansive nasopalatine duct cysts with nasal involvement mimicking apical lesions of endodontic origin: A report of two cases. J Endod 2011;37:1320-6.
71Hilfer PB, Bergeron BE, Ozgul ES, Wong DK. Misdiagnosis of a nasopalatine duct cyst: A case report. J Endod 2013;39:1185-8.
72Aparna M, Chakravarthy A, Acharya SR, Radhakrishnan R. A clinical report demonstrating the significance of distinguishing a nasopalatine duct cyst from a radicular cyst. BMJ Case Rep 2014;2014:bcr2013200329.
73Levy DH, Dinur N, Becker T, Azizi H, Ben Itzhak J, Solomonov M. Use of cone-beam computed tomography as a critical component in the diagnosis of an infected nasopalatine duct cyst mimicking chronic apical abscess: A case report. J Endod 2021;47:1177-81.
74Nonaka CF, Henriques AC, de Matos FR, de Souza LB, Pinto LP. Nonodontogenic cysts of the oral and maxillofacial region: Demographic profile in a Brazilian population over a 40-year period. Eur Arch Otorhinolaryngol 2011;268:917-22.
75Escoda Francolí J, Almendros Marqués N, Berini Aytés L, Gay Escoda C. Nasopalatine duct cyst: Report of 22 cases and review of the literature. Med Oral Patol Oral Cir Bucal 2008;13:E438-43.
76Philipsen HP, Reichart PA. Adenomatoid odontogenic tumour: Facts and figures. Oral Oncol 1999;35:125-31.
77Curran AE, Miller EJ, Murrah VA. Adenomatoid odontogenic tumor presenting as periapical disease. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;84:557-60.
78Philipsen HP, Srisuwan T, Reichart PA. Adenomatoid odontogenic tumor mimicking a periapical (radicular) cyst: A case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;94:246-8.
79Kumar CA, Reddy J, Gupta S, Raghav N, Bagga M. An unusual site of adenomatoid odontogenic tumor presenting as periapical radicular cyst: A Rare Case Report. J Indian Acad Oral Med Radiol 2010;22:39-41.
80Avinash Tejasvi ML, Prashanth Shenai K, Chatra L. Atypical case of periapical adenomatoid odontogenic tumour. J Maxillofac Oral Surg 2010;9:99-101.
81Bhandari N, Kothari M. Adenomatoid odontogenic tumour mimicking a periapical cyst in pregnant woman. Singapore Dent J 2010;31:26-9.
82Jawanda MK, Anand KR, Mathur N, Gupta P, Jain S. Extrafollicular adenomatoid odontogenic tumour presenting as a periapical lesion: Report of a rare entity. Int J Pediatr Otorhinolaryngol Extra 2014;9:47-51.
83Mosavat F, Rashtchian R, Zeini N, Goodarzi Pour D, Mohammed Charlie S, Mahdavi N. An extrafollicular adenomatoid odontogenic tumor mimicking a periapical cyst. Case Rep Radiol 2018;6987050:1-5.
84Chugh A, Srivastava I, Khatana S, Nalwa A, Bharti JN. Case series of adenomatoid odontogenic tumour of jaws with variations in presentation. BMJ Case Rep 2020;13:e229358.
85Becker T, Buchner A, Kaffe I. Critical evaluation of the radiological and clinical features of adenomatoid odontogenic tumour. Dentomaxillofac Radiol 2012;41:533-40.
86Drazić R, Minić AJ. Focal cemento-osseous dysplasia in the maxilla mimicking periapical granuloma. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;88:87-9.
87Galgano C, Samson J, Küffer R, Lombardi T. Focal cemento-osseous dysplasia involving a mandibular lateral incisor. Int Endod J 2003;36:907-11.
88Huh JK, Shin SJ. Misdiagnosis of florid cemento-osseous dysplasia leading to unnecessary root canal treatment: A case report. Restor Dent Endod 2013;38:160-6.
89Rekabi AR, Ashouri R, Torabi M, Parirokh M, Abbott PV. Florid cemento-osseous dysplasia mimicking apical periodontitis: A case report. Aust Endod J 2013;39:176-9.
90Surej Kumar LK, Manuel S, Nair BJ, Nair S V. An ambiguous asymptomatic swelling in the maxillary anterior region – A case report. Int J Surg Case Rep 2016;23:65-9.
91Kurien NM, Kumar LK, Uma PB, Vivek V, Joseph AP. An extensive swelling in the anterior mandible – A case report. Ann Med Surg (Lond) 2017;21:30-3.
92de Freitas Silva BS, Yamamoto-Silva FP, Sena-Filho M, Silva Sant'Ana SS, Mariano-Júnior WJ, de Almeida OP, et al. 20-year follow-up of recurrent glandular odontogenic cyst mimicking a periapical lesion. J Endod 2017;43:1915-20.
93Leung YY, Wong WY, Cheung LK. Surgical ciliated cysts may mimic radicular cysts or residual cysts of maxilla: Report of 3 cases. J Oral Maxillofac Surg 2012;70:e264-9.
94Kahler B. Traumatic bone cyst suggestive of a chronic periapical abscess: A case report. Aust Endod J 2011;37:73-5.
95Estrela C, Decurcio DA, Silva JA, Mendonça EF, Estrela CR. Persistent apical periodontitis associated with a calcifying odontogenic cyst. Int Endod J 2009;42:539-45.
96de Carvalhosa AA, de Araújo Estrela CR, Borges AH, Guedes OA, Estrela C. 10-year follow-up of calcifying odontogenic cyst in the periapical region of vital maxillary central incisor. J Endod 2014;40:1695-7.
97Selden HS. Central giant cell granuloma: A troublesome lesion. J Endod 2000;26:371-3.
98Candeiro GT, de Souza CV, Chaves RS, Ley AM, Feijão CP, Costa FW, et al. Central giant cell granuloma mimicking a periapical lesion of endodontic origin: A case report. Aust Endod J 2020;46:381-6.
99Nary Filho H, Matsumoto MA, Fraga SC, Gonçales ES, Sérvulo F. Periapical radiolucency mimicking an odontogenic cyst. Int Endod J 2004;37:337-44.
100de Carvalhosa AA, Zandonade RM, de Souza Castro, de Araújo Estrela CR, Borges AH, Estrela C. 8-year follow-up of central giant cell lesion mimicking apical periodontitis. J Endod 2014;40:1708-12.
101Martins MD, Taghloubi SA, Bussadori SK, Fernandes KP, Palo RM, Martins MA. Intraosseous schwannoma mimicking a periapical lesion on the adjacent tooth: Case report. Int Endod J 2007;40:72-8.
102Buric N, Jovanovic G, Pesic Z, Krasic D, Radovanovic Z, Mihailovic D, et al. Mandible schwannoma (neurilemmoma) presenting as periapical lesion. Dentomaxillofac Radiol 2009;38:178-81.
103Silva TA, Batista AC, Camarini ET, Lara VS, Consolaro A. Paradental cyst mimicking a radicular cyst on the adjacent tooth: Case report and review of terminology. J Endod 2003;29:73-6.
104Maciel-Santos ME, De Farias PV, Pettely PT, Deigo MS, Daniel LB, Uoston HS. Lateral periodontal cyst with extremely rare clinical-radiographic presentation. Rev Odonto Cienc 2011;26:176-81.
105Wannfors K, Hammarström L. Periapical lesions of mandibular bone: Difficulties in early diagnostics. Oral Surg Oral Med Oral Pathol 1990;70:483-9.
106Araújo JP, Cadavid AM, Lemos CA, Trierveiler M, Alves FA. Bilateral mandibular osteomyelitis mimicking periapical cysts in a patient with sickle cell anemia. Autops Case Rep 2015;5:55-60.
107de Moraes Ramos-Perez FM, Soares UN, Silva-Sousa YT, da Cruz Perez DE. Ossifying fibroma misdiagnosed as chronic apical periodontitis. J Endod 2010;36:546-8.
108Ribera MJ. Osteoblastoma in the anterior maxilla mimicking periapical pathosis of odontogenic origin. J Endod 1996;22:142-6.
109Rodrigues CD, Villar-Neto MJ, Sobral AP, Da Silveira MM, Silva LB, Estrela C. Lymphangioma mimicking apical periodontitis. J Endod 2011;37:91-6.
110Lee BD, Lee W, Lee J, Son HJ. Eosinophilic granuloma in the anterior mandible mimicking radicular cyst. Imaging Sci Dent 2013;43:117-22.
111Huey MW, Bramwell JD, Hutter JW, Kratochvil FJ. Central odontogenic fibroma mimicking a lesion of endodontic origin. J Endod 1995;21:625-7.
112Koshy SJ, Senthilnathan, Madhulaxmi M. Squamous odontogenic tumour – A paradoxical pathology. Biosc Biotech Res Comm 2020;13:150-5.
113Shah N, Sarkar C. Plasmacytoma of anterior maxilla mimicking periapical cyst. Endod Dent Traumatol 1992;8:39-41.
114Garg AK, Chaudhary A, Tewari RK, Bariar LM, Agrawal N. Coincidental diagnosis of tuberculous lymphadenitis: A case report. Aust Dent J 2014;59:258-63.
115Shah KM, Karagir A, Kanitkar S, Koppikar R. An atypical form of cervicofacial actinomycosis treated with short but intensive antibiotic regimen. BMJ Case Rep 2013;2013:bcr2013008733.
116Nair PN, Sjögren U, Figdor D, Sundqvist G. Persistent periapical radiolucencies of root-filled human teeth, failed endodontic treatments, and periapical scars. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;87:617-27.
117Patel S, Brown J, Semper M, Abella F, Mannocci F. European society of endodontology position statement: Use of cone beam computed tomography in Endodontics: European Society of Endodontology (ESE) developed by. Int Endod J 2019;52:1675-8.
118Special Committee to Revise the Joint AAE/AAOMR Position Statement on use of CBCT in Endodontics. AAE and AAOMR joint position statement: Use of cone beam computed tomography in endodontics 2015 update. Oral Surg Oral Med Oral Pathol Oral Radiol 2015;120:508-12.
119Musu D, Rossi-Fedele G, Campisi G, Cotti E. Ultrasonography in the diagnosis of bone lesions of the jaws: A systematic review. Oral Surg Oral Med Oral Pathol Oral Radiol 2016;122:e19-29.
120Gagnier JJ, Kienle G, Altman DG, Moher D, Sox H, Riley D, et al. The CARE guidelines: Consensus-based clinical case report guideline development. J Clin Epidemiol 2014;67:46-51.
121Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ 2021;372:n71.