CLINICAL RESEARCH

“True” Versus “Bay” Apical Domenico Ricucci, MD, DDS,*

^ças, DDS, MSc,
Isabela N. Ro
PhD,†‡ Sandra Herna ndez, DDS,
Cysts: Clinical, Radiographic, MSc,†x and Jose F. Siqueira, Jr.,
DDS, MSc, PhD†‡
Histopathologic, and
Histobacteriologic Features

ABSTRACT
SIGNIFICANCE
Introduction: This study compared the main clinical, radiographic, and histologic features of
true and bay apical cysts. Methods: The study material comprised 95 biopsy specimens of This study found no
apical periodontitis lesions obtained attached to the root tip of both untreated and root canal– differences between true and
treated teeth. Clinical and radiographic data were recorded. Specimens were obtained by bay cysts concerning clinical
extraction or periradicular surgery and were meticulously processed for histopathologic and and histopathologic
histobacteriologic methods. All cases diagnosed as apical cysts (n 5 23) were divided into the manifestations. Both types
true and bay types, which were then compared for tooth location, patient’s sex, lesion size, always exhibited intraradicular
severity of clinical symptoms, presence of a sinus tract, previous abscess episodes, and and sometimes extraradicular
prevalence of bacteria in the main root canal lumen and ramifications, on the outer root infection. Findings do not
surface, and within the cyst cavity. Results: Eleven specimens were classified as true (48%) support the assumption that
and 12 (52%) as bay cysts. Bacteria were found in all specimens, regardless of the true cysts are self-sustainable
histopathologic diagnosis. Planktonic bacteria were observed in the main root canal in all true entities not associated with
cysts and in 11 of 12 (92%) bay cyst cases. Biofilms were detected in the main canal in 10 infection.
cases from each diagnostic group and were frequently observed in ramifications.
Extraradicular biofilms occurred in a few specimens only. Bacteria were visualized within the
cavity of both true (4/11, 36%) and bay (6/12, 50%) cyst specimens. The severity of histologic
inflammation was always high. There were no significant differences between true and bay
cysts for all the clinical, radiographic, histopathologic, and histobacteriologic parameters
assessed. Conclusions: Except for the morphologic relationship of the cyst cavity with the
root canal space, true and bay cysts exhibited no other significant differences in the various
parameters evaluated. The 2 cyst types were always associated with an intraradicular
infection and sometimes with an extraradicular infection. Findings question the need to
differentiate true and bay cysts and do not support the assumption that true cysts are self-
sustainable entities not maintained by infection. (J Endod 2020;46:1217–1227.)

KEY WORDS
Apical periodontitis; bay apical cyst; biofilm; endodontic infection; true apical cyst
From the *Private Practice, Cetraro, Italy;
†
Department of Endodontics, Faculty of
In response to root canal infection, the periradicular tissues mount an immune reaction that may give rise Dentistry, Grande Rio University, Rio de
to bone resorption and granuloma formation1. With the passage of time, the lesion may become Janeiro; ‡Department of Endodontics and
Dental Research, Iguaçu University, Nova
epithelialized as the epithelial cell rests of Malassez start to proliferate in the granuloma, and, ultimately, a
Iguaçu, Rio de Janeiro, Brazil; and
cavity lined by an epithelium is formed, which characterizes the apical cyst. The lumen of the apical cyst x
Department of Endodontics, Francisco
cavity is usually lined by a stratified squamous epithelium, although in about 8% of the apical cysts the Marroquín University, Guatemala City,
cavity may be partially or predominantly lined by ciliated columnar cells of respiratory origin2,3. Four Guatemala
theories have tried to explain the genesis of the apical cyst cavity, including the breakdown theory4, the Address requests for reprints to Dr
abscess theory5,6, the immunologic theory7, and the trapped connective tissue theory8, but none of them Domenico Ricucci, Piazza Calvario, 7,
has been clearly demonstrated to be true. 87022, Cetraro (CS), Italy.
E-mail address: dricucci@libero.it
Numerous studies have evaluated the prevalence of apical cysts among periradicular lesions. 0099-2399/$ - see front matter
Apical granuloma is the most common histopathologic form of apical periodontitis in the large majority of
Copyright © 2020 American Association
studies, and the prevalence of cysts ranges from 6%–55%9–16. Cysts and granulomas cannot be of Endodontists.
distinguished by radiographic examination alone9,13,14, although large lesions are more likely to be https://doi.org/10.1016/
cysts17,18. Although some studies have suggested that cysts can be differentiated from granulomas by j.joen.2020.05.025

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other approaches, including polyacrylamide the bay cyst may be more prone to become 2. mild, when the patient reported no
gel electrophoresis of the periapical fluid, infected by bacteria advancing directly from episodes of spontaneous pain and no self-
tomography, and ultrasound real-time the canal into the cyst cavity, which might medication with analgesics, but the tooth
imaging18–21, a definitive diagnostic impair healing even after proper intracanal was slightly tender to chewing and
differentiation can only be attained by antimicrobial treatment. Indeed, an infected pressure;
histopathology, especially using a serial bay cyst has been reported as the cause of 3. moderate, when the patient declared
sectioning approach to include the entire nonsurgical treatment failure27. episodes of spontaneous pain and self-
lesion. Most of the studies that evaluated the Accurate histopathologic diagnosis of medication with analgesics, which
cyst prevalence did not perform serial apical periodontitis lesions is reliant on serial succeeded in resolving pain, and exhibited
sectioning, and this may have compromised sectioning evaluation of a biopsy specimen tenderness to percussion/palpation; and
the results and help explain the wide range that represents the entire lesion. 4. severe, when there was excruciating pain,
reported. The few studies that used serial Histopathology of a limited number of sections not resolved with analgesics, associated
sectioning or serial step sectioning showed a may be confusing and may make the operator with a painful response to percussion/
cyst prevalence of 15%–32% of the apical erroneously classify an epithelialized palpation.
periodontitis lesions3,10,22. granuloma as a cyst or a bay cyst as a true
Information on the occurrence of acute
Depending on the relationship of the cyst. In addition, a proper differentiation
abscess episodes related to the affected tooth
cyst cavity with the root canal via the apical between true and bay cysts can only be made
any time before surgery/extraction was also
foramen, the apical cyst has been classified as if the lesion specimen remains attached to the
available. These cases had been diagnosed by
a “true” or “bay” (also known as a “pocket”) root apex obtained by periradicular surgery or
the clinician based on the development of
cyst22,23. The lumen of the bay cyst cavity extraction because the continuity of the cyst
swelling and redness of the skin associated
communicates directly with the root canal cavity with the root canal is essential
with pain that prompted the patient to seek
system through the apical foramen with the information. Comparisons of the
professional aid. Some patients with
root apex protruding into the cavity, whereas histopathologic features of the 2 conditions are
abscesses had been treated with antibiotics.
the true cyst has a completely independent limited in the literature, and no study has so far
The radiographic lesion size was
cavity with no continuity or connection to the evaluated the histobacteriology of true and bay
determined as the mean diameter of the
root canal. Simon22 used the serial sectioning cysts.
periapical radiolucency and categorized as
approach to evaluate apical periodontitis The present study used meticulous
small if they were 5 mm and large if they were
lesions in untreated teeth that remained serial sectioning and histopathologic/
.5 mm. Teeth with periodontal pockets
attached to the root apices after extraction and histobacteriologic evaluations to compare the
communicating with the periapical lesion or
reported that true and bay cysts occurred in main features of true and bay cysts that might
teeth with vertical fractures were excluded
similar prevalences (ie, 9% of the lesions). justify the alleged different biological behavior
from the study.
Therefore, true and bay cysts each between them after root canal treatment.
To be included in the study, the
corresponded to 50% of the apical cysts.
specimen obtained by extraction or surgery
Another study using serial sections or serial
should have consisted of the entire apical
step sections of lesions adhered to the apices MATERIALS AND METHODS
periodontitis lesion still adhered to the root
reported that 9% were true cysts and 6% were
Clinical Specimens apex. Periradicular surgery was performed as
bay cysts10. Of the apical cysts, 61.5% were
The study material was composed of 95 follows. After elevation of a full-thickness
true, and 38.5% were bay cysts. The study by
human biopsies of apical periodontitis lesions periosteal flap, the buccal bone covering the
Ricucci et al3 was another one that evaluated
obtained attached to the root tip of both lesion was carefully removed until the
serial sections from whole lesion specimens
untreated and root canal–treated teeth. The pathologic tissue and the root tip were
attached to the apices of untreated extracted
specimens were obtained by endodontic exposed. The root tip was first resected
teeth. Although 42% of the lesions showed an
specialists or oral surgeons through approximately 3 mm short of the apex with a
epithelium, the frequency of cysts was 32%.
periradicular surgery or extraction in private fissure bur. Subsequently the soft tissue was
True cysts occurred in 16% of the lesions,
dental practices and dental schools and sent carefully enucleated from the bone crypt with
whereas bay cysts corresponded to 18%. Of
consecutively over a period of 12 years to a smooth microelevators, in an attempt to obtain
the apical cysts, 50% were true, and 56% were
single histologic laboratory. At the time of the resected root tip and the surrounding
bay cysts (1 lesion contained the 2 types).
treatment, the patients were presented with pathologic soft tissue in one piece.
It was proposed in a study of untreated
risks, benefits, treatments, and options and The teeth were processed for light
teeth22 and was reinforced by only 1 case
had given consent for examination of their microscopy. From this pool, only specimens in
report24 that the true cyst, assumed to be a
teeth. The patients’ mean age was 37.3 years which a cyst cavity was detected in the
self-sustaining lesion, cannot heal after
(range, 15–82 years). The protocol for this histologic sections (23 cases) were selected
nonsurgical root canal treatment, whereas bay
retrospective study was approved by the for the present study.
cysts, especially the smaller lesions, can10,22.
institutional review board.
The rationale provided was that the bay cyst is
Clinical and radiographic data were
open to the root canal and then amenable to Histopathologic and
available for all teeth. Symptoms were
intracanal infection control, whereas the true Histobacteriologic Analyses
categorized as follows:
cyst represents a disease entity no more Specimens were fixed in 10% buffered
dependent on the root canal infection and then 1. absent (asymptomatic), when the patient formalin for at least 48 hours. Demineralization
not responsive to root canal treatment22,23. reported no pain episodes and the tooth was performed in a solution of 22.5% (vol/vol)
This theory has been strongly questioned was comfortable with normal response to formic acid and 10% (wt/vol) sodium citrate for
because it does not exhibit biological vertical/lateral percussion and periapical a period of 3–4 weeks. The end point was
plausibility8,25. Siqueira26 raised the point that palpation; determined radiographically. For the

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specimens obtained by extraction, the apical presenting patterns of calcification Eleven specimens were identified as
4-to 5-mm segment of the root was separated (calculuslike structures) true cysts (48%) and 12 (52%) as bay cysts.
with a sharp razor blade. At the end of the 3. The presence of bacteria/bacterial The mean age for patients with true cysts
demineralization process, specimens were aggregations within the cyst lumen. If was 37 years (men 5 34 years and women 5
washed in running water for 24 hours and present, occasional bacterial cells or 43 years), and for bay cysts, it was 43 years
dehydrated in ascending grades of ethanol aggregations observed on the peripheral (men 5 39 years and women 5 46 years).
(50%–100%). After clearing in xylene, they collagenous surface of the periapical lesion Treated teeth with true cysts were followed
were infiltrated and embedded in paraffin. and not surrounded by an inflammatory up for 5–10 years. One treated tooth with a
Next, the biopsies were oriented parallel to the infiltrate were regarded as contaminants, bay cyst was followed up for 4 years,
long axis of the main root canal in the apical possibly resulting from the passage of the whereas another tooth with a bay cyst had
third in order to obtain sections with the main specimen through the socket during showed persistent exudation and symptoms
canal and periapical tissue in direct continuity. extraction; as such, they were excluded that could not be resolved after several
Serial sections were taken with the microtome from evaluation. sessions of nonsurgical treatment and
set at 4–5 mm. Every fifth slide was stained with 4. The intensity of histologic inflammation was required periradicular surgery.
hematoxylin-eosin for screening purposes in ranked as none; mild, when limited The frequency of true cysts according to
order to locate the areas with the most severe aggregations of exclusively chronic the tooth type was as follows: maxillary
reactions. Additional slides were stained as inflammatory cells were seen in the cyst premolars (5), maxillary molars (3), maxillary
needed. Selected slides were stained with lumen and/or a few chronic inflammatory incisors (1), mandibular premolars (1) and
Masson trichrome to identify collagen and with cells infiltrated the subepithelial connective mandibular molars (1). For bay cyst, frequency
the Taylor modification of the Brown-Brenn tissue; moderate, when discrete was as follows: maxillary molars (6), maxillary
stain for the presence of bacteria28. accumulations of chronic inflammatory incisors (3), mandibular premolars (2) and
Apical periodontitis lesions were cells occurred in the cyst lumen and maxillary premolars (1).
classified according to agreed epithelial walls with some occasional Bacteria were found in all cases
histomorphologic criteria into granulomas, polymorphonuclear leukocytes (PMNs); or examined, regardless of the histopathologic
abscesses, and cysts29,30. The diagnosis of a severe, when large accumulations of acute diagnosis (Figs. 1–5). Planktonic bacteria were
cyst was made when a distinct cavity lined by and chronic inflammatory cells with a observed in the main root canal in all true cyst
epithelium and filled with semisolid material prevalence of PMNs were evident in the cases and in 11 of 12 (92%) bay cyst cases.
was observed. Depending on the relationship cyst lumen intermixed with necrotic debris Biofilms were detected in the main canal in 10
between the epithelial lining of the cyst cavity or cholesterol crystals or in the cyst walls, cases from each of the diagnostic groups.
and the root and between the cyst cavity and heavily infiltrating the epithelium. These appeared to be very thick, often filling
the root canal space, cystic lesions were the entire canal lumen in the apical portion
differentiated into “true” or “bay” cysts22. The (Figs. 1A, C, and D and 2A, C, and D) and
lesions classified as true cysts were faced with a severe concentration of PMNs
Statistical Analysis
characterized by the presence of a cavity (Fig. 1C and D). Biofilms were frequently
Statistical analysis was performed to evaluate if
bordered by an epithelial wall that was not observed in ramifications from both treated
there were differences between true and bay
continuous with the canal lumen in any of the and untreated teeth (Figs. 1B, 4B and D).
cysts regarding tooth location (maxillary or
serial histologic sections. The lesions classified Ramifications were sometimes clogged by
mandibular); patient’s sex; lesion size (small or
as bay cysts showed a cystic space dense biofilms exhibiting different bacterial
large); severity of clinical symptoms (severe or
surrounded by an epithelial wall that joined the morphotypes, with the bacterial cells prevailing
not); presence of a sinus tract; history of a
external root surface forming a “sac,” isolating over the extracellular matrix component
previous acute abscess; and prevalence of
the foramen from the rest of the lesion. The bay (Fig. 4D).
planktonic bacteria or bacterial biofilms in the
cyst cavity had a direct opening into the canal Extraradicular biofilms formed on the
main canal lumen, biofilms in ramifications,
lumen. external apical surface were detected only in a
extraradicular biofilm, and bacteria in the cyst
In the 23 cases diagnosed as apical few specimens from both types of cysts. None
lumen. The Fisher exact test was used for all
cysts (true or bay), the following aspects were of them showed signs of calcification. These
analyses with the level of significance set at 5%
specifically looked for in the histopathologic biofilms exhibited varying proportions of cells
(P , .05).
and histobacteriologic analyses (Table 1): and extracellular substance, and in 1 instance
the biofilm was observed between the layers of
1. The presence, location, and arrangement
cementum that were detached from the
of bacteria (planktonic or biofilm structures) RESULTS radicular surface (Fig. 4E).
in the apical portion of the root canal
Twenty-three cystic lesions were obtained Bacterial cells occurred in the lumen of
system, including the main canal lumen and
from 21 patients (11 men and 10 women) true cysts in 4 of 11 (36%) specimens (Figs. 2A
walls and apical ramifications (intraradicular
without contributory medical conditions. These and B and 3A and B) and in 6 of 12 (50%) bay
infection). The parameter used for biofilm
patients ranged in age from 20–70 years cyst specimens (Figs. 4B, C, and F and 5B and
classification was as defined elsewhere as
(mean age 5 40 years). Cyst specimens were C). These bacteria were arranged in
follows: “populations of microorganisms
collected from maxillary and mandibular aggregations of varying sizes intermixed with
that are concentrated at an interface and
treated and untreated teeth. Of the 23 necrotic debris and inflammatory cells,
typically surrounded by an extracellular
specimens, 2 true cysts from different teeth apparently free in the cyst lumen (Figs. 3A and
polymeric substance matrix”31.
belonged to the same patient, and 2 bay cysts B; 4B, C, and F; and 5B and C). In 2 cases (1
2. The presence of bacterial aggregations
from different teeth were from another patient. bay and 1 true cyst), they were present in the
adhering to the outer apical root surface
Twenty specimens were obtained from tooth cyst lumen in the form of typical actinomycotic
(extraradicular biofilm) eventually
extraction and 3 from apical surgery. colonies, with intertwining branching

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TABLE 1 - Clinical, Radiographic, Histopathologic, and Histobacteriologic Findings Associated with True and Bay Apical Cysts

True cyst Bay cyst

Total, N (%) Untreated, n (%) Treated, n (%) Total, n (%) Untreated, n (%) Treated, n (%) P value*
Specimens 11 7 4 12 10 2
Sex† .2
Male 7 (70) 4 (67) 3 (75) 4 (36) 3 (33) 1 (50)
Female 3 (30) 2 (33) 1 (25) 7 (64) 6 (67) 1 (50)
Tooth location 1.0
Maxillary 9 (82) 5 (71) 4 (100) 10 (83) 8 (80) 2 (100)
Mandibular 2 (18) 2 (29) 0 (0) 2 (17) 2 (20) 0 (0)
Lesion size .68
Small (5 mm) 5 (45) 4 (57) 1 (25) 7 (58) 7 (70) 0 (0)
Large (.5 mm) 6 (55) 3 (43) 3 (75) 5 (42) 3 (30) 2 (100)
Clinical symptoms .4
None 2 (18) 1 (14) 1 (25) 2 (17) 2 (20) 0 (0)
Mild 0 (0) 0 (0) 0 (0) 3 (25) 2 (20) 1 (50)
Moderate 6 (55) 4 (57) 2 (50) 1 (8) 1 (10) 0 (0)
Severe 3 (27) 2 (29) 1 (25) 6 (50) 5 (50) 1 (50)
Previous acute abscess .4
Yes 6 (55) 4 (57) 2 (50) 9 (75) 8 (80) 1 (50)
No 5 (45) 3 (43) 2 (50) 3 (25) 2 (20) 1 (50)
Sinus tract .6
Yes 1 (9) 1 (14) 0 (0) 3 (25) 2 (20) 1 (50)
No 10 (91) 6 (86) 4 (100) 9 (75) 8 (80) 1 (50)
Planktonic bacteria 1.0
Main canal 11 (100) 7 (100) 4 (100) 11 (92) 10 (100) 1 (50)
Bacterial biofilm
Main canal 10 (91) 6 (86) 4 (100) 10 (83) 10 (100) 0 (0) 1.0
Ramifications 10 (91) 7 (100) 3 (75) 9 (75) 7 (70) 2 (100) .59
Extraradicular 1 (9) 1 (14) 0 (0) 3 (25) 2 (20) 1 (50) .59
Bacteria in the cyst cavity 4 (36) 3 (43) 1 (25) 6 (50) 5 (50) 1 (50) .68

*Fisher’s exact test.

†
One patient contributed 2 true cysts and another patient contributed 2 bay cysts.

filamentous bacteria surrounded by a severe histobacteriologic parameters evaluated (P . between the cyst cavity and the root canal
accumulation of PMNs (Fig. 2A and B). .05). Data are shown in Table 1. space, there were no other significant
The severity of inflammation was high in differences between true and bay cysts in
all specimens, so it was not subjected to terms of clinical, radiographic, histopathologic,
statistical analysis. All kinds of inflammatory DISCUSSION and histobacteriologic features. These findings
cells were observed in the cyst lumen question the need to subdivide the
This study compared the prevalence and
together with varying amounts of amorphous several features of true and bay cysts classification of apical cysts.
necrotic debris. The epithelial lining of all but 4 diagnosed histopathologically using a The frequency of cysts observed in this
radicular cysts was constituted by a typical study was 24% (23/95) of the apical
meticulous research protocol. All apical
stratified squamous epithelium. One true cyst periodontitis lesions included in this study were periodontitis lesions examined. When
and 3 bay cysts in 4 maxillary (one third, one obtained attached to the teeth and therefore compared with other studies that also
second, and two first) molars showed the maintaining their natural morphologic evaluated serial or serial step sections of
characteristics of a respiratory epithelium, with lesions attached to the apex, this figure is
relationship with the root apex. This strict
ciliated epithelial cells and goblet cells in criterion was not used in the large majority of higher than the 15% and 17% reported by Nair
limited portions of the cyst walls. The epithelial studies evaluating the prevalence of the et al10 and Simon22, respectively, but is lower
lining was in general thick and irregular, with than the 32% reported by Ricucci et al3
different types of apical periodontitis lesions
extensive proliferation and the tendency to because it is more difficult to meet. This (Table 2). As for the prevalence of the 2 types
form arcading structures (Figs. 1A; 2A; 3A; justifies the smaller number of cases evaluated of apical cysts, this study is in agreement with
4A; and 5A, B, and D) with entrapped islands two others that shown that each type occurs in
herein. Serial sectioning from 1 side to the
of highly vascularized connective tissue other of the apical periodontitis lesion was also approximately half of the cases with a cyst
(Fig. 5D and E). The strands of epithelium and performed in this study to report on the diagnosis3,22. The true cyst corresponded to
the connective tissue islands were heavily 12% of all lesions, which is within the range
relationship of the lesion to the apical foramina.
infiltrated by acute and chronic inflammatory These 2 approaches are essential for an previously reported of 9% to 16% of all lesions.
cells (Fig. 5E and F). accurate histopathologic diagnosis of cysts Corresponding figures for the bay cyst were
There were no significant differences and their classification as true or bay types. 13% in this study, in a previously reported
between true and bay cysts for all the clinical, range of 6% to 18% of all lesions3,10,22
Findings from the present study showed that,
radiographic, histopathologic, and apart from the morphologic relationship (Table 2).

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 A B

C D

FIGURE 1 – A bay cyst. (A ) A section cut through the main canal and foramen. The cyst lumen is continuous with the root canal space (Taylor modified Brown and Brenn, original
magnification !16). (B ) An area of the canal located approximately 5 mm coronal to the foramen (not shown in A ). Biofilms with low bacterial density in the main canal and
ramifications (original magnification !50). (C ) Detail of the area of the apical canal indicated by the arrow in A. A thick bacterial biofilm fills the entire lumen and is faced with an
accumulation of inflammatory cells. Note the “floc” displaced apically in the inflammatory tissue (arrow ) (original magnification !100). (D ) A high-power view of the biofilm showing a
dense aggregation of filamentous forms (original magnification !400).

No previous study had compared the assumption that true cysts can be an cavity and 1 as a biofilm adhered to the outer
histobacteriology of true and bay cysts. No independent entity in the absence of root surface. Of these 5 cases, 4 had a history
distinct pattern of infection was observed concomitant bacterial infection because of previous acute abscess, and 1 had a sinus
between the 2 types. Intraradicular bacteria infection occurred in all cases. tract. These may have been the most possible
were found in all cases, regardless of the Extraradicular bacteria were found in explanations for the bacteria detected in the
associated cyst type and the root canal status many cases, either inside the cyst lumen or in extraradicular space, particularly in the cyst
(untreated or treated). Planktonic bacteria were fewer cases as a biofilm adhered to the outer lumen. After resolution of the abscess,
observed in the main canal in all teeth, except root surface near the exits of apical foramina. bacteria may have persisted in the
for 1 bay cyst specimen, in which bacteria The histobacteriologic method permits better periradicular tissues and maintained a chronic
occurred as a biofilm in ramifications and in the distinction of bacterial contaminants when infectious process. Even though the case with
extraradicular space. Bacteria organized in compared with other methods of bacterial a sinus tract had not had a previous report of
biofilm structures were observed in the main detection, such as culture and molecular acute abscess, this might have occurred with
apical canal in the large majority of specimens, methods, because it provides information on subclinical symptoms to justify the fistula.
except for 1 true cyst and 2 bay cyst cases. In bacterial spatial location in the lesion and the Cases with a sinus tract have been shown to
response to bacteria present in the root canal association with inflammation. Specimens harbor an extraradicular infection in about
and sometimes inside the lesion, severe with contaminants were excluded from the 83% of the teeth32. Bacteria present within
inflammation was observed in both cyst types. study. Extraradicular bacteria were found in 5 the cyst cavity are beyond the reach of
The present findings do not give support to the specimens of true cysts, 4 within the cyst nonsurgical root canal procedures and are

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 A B

C D

FIGURE 2 – A true cyst. (A ) A section cut through 2 ramifications filled with bacterial biofilms. The cyst lumen is separated from the root canal space (this anatomic feature is
maintained in all sections of the series) (Taylor modified Brown and Brenn, original magnification !16). (B ) Detail of the cyst cavity whose lumen is filled with cells and debris. A high-
power view of the blue spot at the center of the cyst lumen reveals an actinomycoticlike colony surrounded by a severe concentration of PMNs (original magnification !50, inset !
630). (C ) A section cut approximately 150 sections from that in A disclosing another large ramification clogged with a thick bacterial biofilm (original magnification !16). (D ) Middle
magnification from C (original magnification !100).

located in an area that makes it difficult for the However, the fate of bacteria eventually There are no reports demonstrating that
host defenses to eliminate, given the type and persisting in a cyst cavity after elimination of bacterial colonies located inside the cyst
consistency of the cyst lumen content. the intraradicular component is not known. cavity may cause root canal treatment failure

A B

FIGURE 3 – A true cyst. (A ) A large cyst cavity containing some debris (Taylor modified Brown and Brenn, original magnification !16). (B ) Magnification of the rectangular area in A.
Large numbers of bacteria colonize the necrotic debris in the lumen (original magnification ! 100, inset ! 400).

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 A B C

D E F

FIGURE 4 – A bay cyst. (A ) A section encompassing the root canal, foramen, and cyst cavity. Overview (hematoxylin-eosin, original magnification !8). (B ) A section taken 80
sections away passing through the canal but not including the main foramen. Several ramifications can be seen in the thickness of the left canal wall (Taylor modified Brown and Brenn,
original magnification !16). (C ) Magnification of the area demarcated by the rectangle in B (original magnification !100). (D ) A high-power view of the exit of the lateral canal
indicated by the arrow in B. Its lumen is occupied by a dense biofilm showing varying bacterial morphotypes (original magnification !400). (E ) A high-power view of the area indicated
by the arrow in C. Filaments prevail in a biofilm structure adhering to the radicular surface and showing varying bacterial concentrations (original magnification !400). (F ) A high-
power view of the elongated free colony in C (original magnification !400).

in the absence of a concomitant intraradicular cutting approach is used in that stained including the lesions examined in the present
infection. sections are examined under the light investigation.
The only case report that suggested microscope to locate sites for further The assumption that the true cyst
that true cysts could be a self-sustaining entity sectioning and evaluation in a transmission becomes a pathologic entity independent of
independent from canal infection found no electron microscope. Miniature pyramids are the root canal system and is not affected by
bacteria in the canal by culture and a prepared at the selected sites that show nonsurgical root canal treatment is only
correlative light and electron microscopic bacteria in light microscopy or that are likely to speculative and has neither scientific evidence
approach24. However, bacteria may have harbor bacteria34. The low sensitivity for support nor biological plausibility8,25. Although
passed unnoticed when using methods with bacterial detection is recognized by the this cyst type has no apparent communication
low sensitivity for bacterial detection. A authors themselves—“the extremely limited with the root canal, this by no means can be
negative culture does not guarantee that the area that still can be covered by this means of interpreted as being a separate disease entity.
root canal is free of bacteria, especially investigation makes it rather easy for bacteria The etiology is the same as the bay cyst (ie,
because of the limitations of the culture to go undetected”34. This is because of the infection of the root canal system that causes
technologies in detecting difficult-to-grow and loss of biopsy material due to preparation for periradicular inflammation), and some locally
as-yet-uncultivated bacteria and the inability transmission electron microscopy and the released inflammatory mediators serve as
to detect bacteria at low levels33. In addition, very small area that can be examined under a growth factors for epithelium proliferation and
the correlative light and electron microscopic transmission electron microscope. In turn, the cyst formation. There is no reason to believe
approach used in the previous study can histobacteriology approach used in this study that the epithelium lining of the true cyst can
provide highly detailed information from some has been very successful in revealing bacteria become self-sustainable, like neoplastic
selected areas but has a very low sensitivity to in the vast majority of cases with lesions8,25. The present study lends
detect bacteria. In that method, a serial step- posttreatment apical periodontitis27,35,36, substantial additional information to debunk

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 A B C

D E

FIGURE 5 – A bay cyst. (A ) A section cut through the apical canal and foramen (Taylor modified Brown and Brenn, original magnification !25). (B ) A section taken approximately 80
sections away from that in A, not encompassing the apical foramen (original magnification !25). (C ) A high-power view of the area of the cyst lumen indicated by the arrow in B.
Bacterial aggregation intermixed with amorphous fuchsin-stained material and inflammatory cells (original magnification !630). (D ) Another section of the series taken 40 sections
after that in B. The cyst lumen is lined by a thick wall of arcading epithelium (Masson trichrome, original magnification !25). (E ) A high-power view of epithelial strands indicated by the
arrow in D. The epithelium surrounds cores of connective tissue infiltrated with inflammatory cells (original magnification !400). (F ) The strands appear infiltrated by polymor-
phonuclear neutrophils (original magnification !1000).

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TABLE 2 - The Prevalence of Apical Cysts and Their 2 Types in Studies That Used Histopathologic Serial or Serial Step Sectioning to Evaluate Lesions Attached to the Root Apices

Cyst among True cyst among Bay cyst among True cyst among Bay cyst among
Study all lesions, n (%) all lesions, n (%) all lesions, n (%) all cysts, n (%) all cysts, n (%)
Simon, 198022 6/35 (17) 3/35 (9) 3/35 (9) 3/6 (50) 3/6 (50)
Nair et al, 199610 39/256 (15) 24/256 (9) 15/256 (6) 24/39 (61.5) 15/39 (38.5)
Ricucci et al, 20063 16/50 (32) 8/50 (16) 9/50 (18) 8/16 (50) 9/16 (56)
This study 23/95 (24) 11/95 (12) 12/95 (13) 11/23 (48) 12/23 (52)

this theory because true and bay cysts complete healing in 74% and incomplete true and bay cysts as to their prevalence,
showed no significant differences for all healing in 9.5% of cases40. Therefore, it seems clinical, radiographic, histopathologic, and
variables evaluated. In addition, the cysts that reasonable to assume that apical cysts, histobacteriologic manifestations. The 2 types
represented posttreatment apical periodontitis regardless of their types, can heal provided the of cysts were always associated with an
were of both types, and concurrent bacterial source of epithelial proliferation (ie, the root intraradicular infection and sometimes with an
infection was always present inside the canal canal infection) is eliminated by treatment. If extraradicular infection as well. The fact that
and sometimes outside. Therefore, it seems this is true, differentiation between granulomas the 2 types of cysts only apparently differ from
evident that failure of the endodontic and cysts or true and bay cysts would be of no the morphologic relationship of the cavity to
treatment, including cases of true cysts, is clinical relevance. the root canal puts into question the real need
primarily caused by persistent or secondary A curious finding from this study was to differentiate them and subdivide the apical
intraradicular bacterial infection with, in some that from the 2 patients who contributed 2 cyst into categories. Finally, the fact that all
cases, concurrent extraradicular bacterial specimens each, 1 had 2 true cysts associated cases of true cysts from both untreated and
infection. with 2 different teeth and the other had 2 bay treated teeth had an infectious component
A definitive answer as to whether cysts cysts from different teeth as well. This might does not support the assumption that true
(all or only the “true” ones) can heal or not after suggest an individual predisposition to develop cysts are self-sustainable entities not
nonsurgical root canal treatment would only be a true or a bay cyst, but the limited number of associated with infection.
provided if cysts and other lesions could be patients providing more than 1 specimen was
distinguished without biopsy. A differentiation too small to draw such a conclusion.
CREDIT AUTHORSHIP
cannot be achieved by radiographs alone, and As typically found in apical cysts, a
the effectiveness of the other methods has not stratified squamous epithelium was found
CONTRIBUTION STATEMENT
been confirmed; only an old study using composing the lining of the cyst cavity in the Domenico Ricucci: Investigation,
polyacrylamide gel electrophoresis of the root large majority of specimens. However, 4 of 23 Methodology, Writing - review & editing,
canal aspirates to differentiate granulomas and cysts (17%), all in the maxillary region, showed Visualization. Isabela N. Ro^ ças: Data
cysts suggested that many cysts healed after a ciliated columnar epithelium partially or curation, Formal analysis, Validation. Sandra
root canal treatment37. Indirect evidence that completely lining the cyst wall. All involved Herna  ndez: Data curation, Formal analysis.
cysts heal can be inferred from the fact that the teeth were maxillary molars, and the Jose F. Siqueira: Conceptualization, Formal
success rate of endodontic treatment is higher occurrence of a ciliated columnar epithelium in analysis, Writing - review & editing.
than the cyst prevalence9,15,38,39. Moreover, the lesions may be related to the proximity of
suggestive evidence is given by a study in the root apexes and lesions to the maxillary
which the nonsurgical root canal treatment of sinus floor2.
ACKNOWLEDGMENTS
large cysticlike lesions with a fluid content In conclusion, the present findings The authors deny any conflicts of interest
containing cholesterol crystals resulted in revealed no significant differences between related to this study.

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