Infection in a Complex Network of Apical Ramifications as the Cause of Persistent Apical Periodontitis: A Case Report

Introduction: This article reports a case of persistent apical periodontitis lesion in a mesiobuccal root of a maxillary molar subjected to single-visit endodontic treatment. Methods: The treatment protocol followed endodontic standards including using nickel-titanium instruments with working length ending 0.5-mm short of the apex, establishment and maintenance of apical foramen patency, irrigation with 5% NaOCl, smear layer removal, a final rinse with and ultrasonic agitation of chlorhexidine, and filling by the vertical compaction technique. Even so, the lesion in the mesiobuccal root became larger in size after follow-up examination at 1 year 6 months, and periradicular surgery was performed. Radiographic control after 11 months showed that periradicular healing was almost complete. The root apex and the lesion were analyzed histologically and histo-bacteriologically. Results: The lesion was diagnosed as a "pocket cyst," and no bacteria were noted extraradicularly. The cause of continued disease was a heavy bacterial biofilm infection located in an intricate network of apical ramifications. Bacteria were also observed on the walls of one of the, mesiobuccal canals packed between the obturation material and the root canal wall. Conclusions: This case report reinforces the need for treating the infected root canal as a complex system that possesses anatomic intricacies in which bacteria can spread and remain unaffected by treatment procedures.