Management of Teeth with Large Apical Periodontitis Lesions: A Series of Six Case Reports

Large apical periodontitis poses significant challenges for nonsurgical treatment due to the complexity of root canal infection and periradicular tissue destruction. This multicenter case series describes the management of six teeth with extensive apical periodontitis. Diagnosis, treatment planning, and follow-up were supported by cone-beam computed tomography (CBCT). All cases were initially managed with chemomechanical preparation with 2.5% sodium hypochlorite, supplemental irrigant agitation, and calcium hydroxide intracanal medication. Four cases healed following nonsurgical treatment, whereas two cases presented persistent clinical signs of infection, objectively defined by continuous purulent exudate and active sinus tracts, despite repeated nonsurgical management. These cases underwent periradicular surgery with retrograde apical sealing as a tooth-preserving approach. Clinical and CBCT follow-up demonstrated complete periapical healing in all cases. Given the heterogeneity of this case series, outcomes cannot be attributed to any specific protocol. However, these cases demonstrate the potential for successful management of extensive apical periodontitis through individualized treatment approaches.