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Incidence of Cholesterol in Periapical Biopsies among Adolescent and Elderly

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 Clinical Research

Incidence of Cholesterol in Periapical Biopsies

among Adolescent and Elderly Patients
Iris Slutzky-Goldberg, DMD,* Valery Baev, DMD,‡ Alexander Volkov, MD,§ Avi Zini, DMD,†
and Igor Tsesis, DMDjj

Abstract
Introduction: Cholesterol clefts are common histologic
findings in periapical biopsies; they have a reported inci-
dence in periapical periodontitis of up to 44%. Cholesterol
crystals are also recognized in advanced atherosclerotic
plaques in humans. Male sex, genetic abnormalities,
and age have been associated with advanced atheroscle-
rotic lesions. Among these nonmodifiable risk factors, age
is the most dominant. The aim of the study was to eval-
uate if age is also linked to cholesterol deposition in
periapical periodontitis. Methods: The database of
biopsy reports obtained between 2006 and 2009 was
searched for specimens diagnosed as radicular cysts or
periapical granulomas. Only data relating to biopsies ob-
tained from adolescent (13–21 years old) and elderly (over
60 years old) patients were selected. The biopsies were
examined by a pathologist under a light microscope (Zeiss,
Jena, Germany) at magnifications of 40–200. The
available material was scanned for the presence of choles-
terol clefts and foamy cells in radicular cysts and granu-
lomas. Results: A total of 41 specimens were collected
in the adolescent group and 48 specimens in the elderly
group over a 4-year period. A higher incidence of choles-
terol was found in the elderly group compared with that in
the adolescent group (odds ratio = 6.857). Conclusions:
The highly significant incidence of cholesterol deposits in
periapical biopsies among elderly patients may be
a possible cause for the lack of repair. The mechanism
for cholesterol accumulation is probably similar to the
process leading to atherosclerosis and coronary artery
disease. Statin administration may be advantageous for
the treatment of persistent lesions. A clinician should be
aware of the risk for persistent lesions after endodontic
treatment in elderly patients. (J Endod 2013;39:1477–
1480)
Key Words
Age related, biopsies, cholesterol, periapical
P eriapical radiolucency is a frequent finding in daily dental practice; granulomas and
cysts are the most common periapical lesions. Bhaskar (1) studied 2308 periapical
lesions and found that periapical granulomas (48%) were the most common type of
periapical lesion followed by periapical cysts (42%). Cholesteatomas were rare and
appeared in only 0.4%. More recent studies revealed a higher incidence of cholesterol
in such lesions. Cholesterol clefts are frequently shown in periapical biopsies (2–4).
Their reported incidence in periapical periodontitis is 18%–44% (5), and the inci-
dence of foamy cells is 28%.
Cholesterol crystals are believed to be released from cholesterol-disintegrating
erythrocytes of stagnant blood vessels within a lesion (6); dying lymphocytes, plasma
cells, and macrophages that disintegrate in chronic periapical lesions; and circulating
plasma lipids (7). Once the cholesterol crystals have been deposited, they act as irritants
and cause a foreign-body reaction (7, 8). Macrophages and giant cells attempt to engulf
the cholesterol crystals but are unable to degrade the crystalline cholesterol (8).
Furthermore, the cholesterol-exposed macrophages were shown to have bone-
resorbing activity because of the enhanced expression of interleukin 1a, and a chronic
inflammation in the periapical area is sustained (4, 8).
Cholesterol is also linked with another life-threatening disease. Cardiovascular
disease causes 38% of all deaths in North America and is the most common cause of
death in European men under 65 years of age and the second most common cause
in women (9). Atherosclerosis is a multifactorial disease that starts at a young age
and progresses with age. Nonmodifiable risk factors for atherosclerosis such as male
sex, genetic abnormalities, and age have been associated with advanced atherosclerotic
lesions. Among the nonmodifiable risk factors, age is dominant (10, 11), and the extent
of atherosclerotic lesions increases rapidly between 15 and 34 years (11, 12).
Atherosclerotic lesions are preceded by a fatty streak and an accumulation of lipid-
laden cells beneath the endothelium, most of which are macrophages. In the center of
the lesion, foam cells and extracellular lipid droplets form a core region surrounded by
smooth muscle cells and a collagen-rich matrix. Myocardial infarction occurs when the
atheromatous process prevents the blood flow through activation of the plaque (9). The
excessive cholesterol blood level is suspected of playing a role in atherosclerosis as
a result of its deposition in the vascular walls (10). Because the pathogenesis respon-
sible for cholesterol accumulation in both atherosclerosis and periapical lesions may be
similar, the aim of our study was to evaluate the possible link between age and choles-
terol deposition in periapical periodontitis.

From the Departments of *Endodontics and †Community Dentistry, Hebrew University Hadassah School of Dental Medicine, Jerusalem, Israel; ‡Medical Corps, Israeli
Defence Forces, Sheba Medical Centre, Ramat Gan, Israel; §Department of Pathology, Sheba Medical Center, Ramat- Gan, Israel; and jjDepartment of Endodontology,
The Maurice and Gabriella Goldschlegger School of Dental Medicine, Tel Aviv University, Tel Aviv, Israel.
Address requests for reprints to Dr Iris Slutzky-Goldberg, Director of Post Graduate Program, Department of Endodontics, Hebrew University Hadassah School of
Dental Medicine, POB 12272 Jerusalem, 91120, Israel. E-mail address: dr.iris1@gmail.com
0099-2399/$ - see front matter
Copyright ª 2013 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2013.08.008

JOE — Volume 39, Number 12, December 2013 Incidence of Cholesterol in Periapical Biopsies 1477
Clinical Research
Materials and Methods
This retrospective study was performed at the Department of Clinical
Pathology, Sheba Medical Center, Ramat Gan, Israel. The biopsy report
database from 2006–2009 categorized as radicular cysts and periapical
granulomas were searched. The biopsies were obtained during surgical
retreatment of teeth with an apical pathology, which were performed at
the Department of Oral and Maxillofacial Surgery, Sheba Medical Center.
Only data relating to the treatment of adolescent (13–21 years old) and
elderly (over 60 years old) (13) patients was selected. Biopsies from
patients in other age groups were excluded. The diagnosis of a radicular
cyst was confirmed when a true or imaginary lumen lined by epithelium
was found (Fig. 1). The formalin-fixed biopsies were stained with
hematoxylin-eosin and examined under a light microscope (Zeiss,
Jena, Germany) at magnifications varying from 40–200. One
researcher (AV) examined the available material for the presence of
cholesterol clefts and foamy cells in the radicular cysts and granulomas.
Only random sections were examined in this retrospective study. The
presence or absence of cholesterol clefts and foamy macrophages was Figure 2. Cholesterol clefts (100).
recorded for each specimen. Deposits of cholesterol appear as narrow
elongated clefts because the crystals dissolve in the fat solvents used for detected as cells with multiple, fine, clear granular spaces and centrally
tissue processing, leaving behind the spaces they occupied as clefts (4). located nuclei, often in close proximity to the cholesterol clefts. The
The study protocol was approved by the Ethics Committee of Sheba results are presented in Figures 3 and 4.
Medical Center.
Impact of Age and Gender
Statistical Analysis As can be seen in Figure 3, there was a highly significant incidence
The differences between groups were calculated using univariate of cholesterol clefts among the elderly compared with those in the
analysis of the Pearson chi-square test for categoric variables. Risk esti- adolescent group (P = .007, OR = 6.857). The difference in the inci-
mation was calculated by odds ratios (OR) and 95% confidence inter- dence of cholesterol clefts between male and female patients (P = .89,
vals. Statistical analyses were performed using SPSS software version OR = 1.008) and the incidence of foamy cells (P = .993, OR = 1.07)
19.0 (SPSS Inc, Chicago, IL). was insignificant.
A comparison of the impact of sex was also checked within each
Results age group. In the young group, cholesterol was found in females only
A total of 41 specimens were collected in the adolescent group and (2/2). However, because of the small number of patients, no statistical
48 specimens in the elderly group over a 4-year period (2006–2009). conclusion could be drawn for this group. In the elderly group, choles-
The majority of the cysts were lined by stratified squamous epithelium terol was found in 30.8% of the male biopsies and in 19% of the female
(Fig. 1). In some specimens, ciliated cell metaplasia was observed. biopsies (P = .36, OR = 0.529). The difference was insignificant.
The difference in the incidence of foamy cells among the elderly and
the adolescent groups was insignificant (P = .181, OR = 0.329). Like-
Determination of Cholesterol Clefts and Foamy
wise, when a comparison of the incidence of foamy cells was checked
Macrophages in Periapical Biopsies within each age group, the differences were also insignificant (elderly
The cholesterol clefts in the sections were recognized according group: P = .108, OR = 0.422; young group: P = .320, OR = 328).
to their distinctive needle shape (Fig. 2). Foamy macrophages were

Discussion
To the best of our knowledge, this study is the first report that links
the incidence of cholesterol clefts in periapical periodontitis to a specific

Figure 3. The incidence of cholesterol clefts and foamy macrophages in the

elderly group. Note that in the male biopsies foamy cells were found only next to
Figure 1. Stratified squamous epithelium lining of the cystic lumen (200). cholesterol clefts. 1, cholesterol; 2, cholesterol and foamy cells; 3, foamy cells.

1478 Slutzky-Goldberg et al. JOE — Volume 39, Number 12, December 2013

Figure 4. The incidence of cholesterol clefts and foamy macrophages in the
adolescent group. Note that only foamy cells, but no cholesterol clefts, were found
in the male biopsies. 1, cholesterol; 2, cholesterol and foamy cells; 3, foamy cells.
age group. A higher incidence of cholesterol was found in the elderly
group compared with the adolescent group. The difference was highly
significant (P = .007, OR = 6.857, 95% confidence interval) and may be
attributed to the different cholesterol profiles of the groups. Under-
standing the pathogenesis may be a key factor in the resolution of the
problem. It may be assumed that the mechanism responsible for choles-
terol accumulation in periapical periodontitis has characteristics
similar to those of atherosclerosis. Consequently, the difference in
cholesterol content in periapical biopsies between the different age
groups can be explained by the same risk factors associated with athero-
sclerosis, such as age, sex, and genetics (11). Cholesterol crystals,
which are frequently seen in atherosclerotic plaques and foamy macro-
phages, were suggested to have an important role in the generation of
cholesterol crystals in atherosclerosis (14). The Lipid Research Clinics
Program reported plasma lipid and lipoprotein cholesterol distribu-
tions upon large-scale screening of 20- to 59-year-old men and women;
they found age-related trends for increasing levels of triglycerides and
cholesterol (15).
Serum triglycerides were suggested to be the source of
cholesterol in radicular cysts (7). Low-density lipoprotein–laden foamy
macrophages, which aggregate in the granulation tissue and ruptured
macrophages, release cholesterol that may be concentrated locally
(16). Macrophages are involved in the innate phagocytizing response
and the acquired response (17). When they phagocytize cholesterol
crystals, they are called foamy macrophages (8, 16). In accordance
with the findings of the present study, foamy cells were observed in
few cases, sometimes side by side with cholesterol crystals. The
authors attributed this to the fact that foamy macrophages
phagocytize small lipid accumulates before the formation of larger
crystals (3).
There are 6 possible causes for the persistence of periapical radio-
lucency after root canal treatment (4):
1. Persistent intraradicular infection
2. Extraradicular infection, especially periapical actinomycosis
3. Foreign body reaction
4. True cysts
5. Scar tissue
6. Accumulation of endogenous cholesterol crystals
A higher incidence of cholesterol in the elderly group may indicate
that the probability of healing periapical lesions in this age group would
be lower after root canal treatment compared with that in the treatment
of adolescents. In the Toronto study, the age factor was not found to be
significant although a distinction was made between patients under and
over 45 years (18). In an outcome study of endodontically treated
molars, there was a significantly positive correlation between age and
‘‘periodontal diagnosis’’ and ‘‘attachment loss’’; the latter 2 were signif-
icant preoperative factors for prognosis of the teeth (19). Based on our
JOE — Volume 39, Number 12, December 2013
Clinical Research
results, cholesterol accumulation may hamper the periapical healing
process; in the adolescent group, which has a lower incidence of
cholesterol, better healing is expected. It is not clear whether a nonheal-
ing apical lesion caused by cholesterol accumulation, which is more
frequent in elderly patients, has an impact on tooth prognosis.
Observational studies have shown a positive and continuous rela-
tionship between the risk of coronary heart disease and blood choles-
terol levels (20). It was recently found that atherosclerosis is a chronic
immune-inflammatory disease in which the interaction of monocytes
with activated luminal endothelium leads to atherosclerosis (21) and
coronary artery disease (9). More recent published data revealed an
association between oral disease and coronary heart disease (22).
Furthermore, in studies testing the influence of simvastatin, a reductase
inhibitor on induced periapical lesions in rats, simvastatin lowered the
progression of the periapical lesions (23, 24), possibly through
attenuating Cyr61 expression in osteoblasts (25) and by regulating
the autophagy/apoptosis of osteoblastic cells (26). It was suggested
that statins, which are extensively used for the treatment of cardiovas-
cular disease, may have an effect on the reduction of inflammatory
cell activity in atherosclerosis (27, 28). Another in vivo study in rats
showed the effect of statins by the enhancement of osteoprotegerin
expression in induced periapical lesions (29). Further study is required
to test the possible efficacy of statins on the resolution of persistent peri-
apical lesions, especially among elderly patients.
Only random sections were examined in this retrospective study,
and, in addition, the foamy cells may have been damaged during the
preparation of the sections. If serial sections had been performed,
the incidence of cholesterol and foamy cells might have been higher
in both groups (6). In addition, biopsies were obtained during surgical
treatment. However, because most of the periapical lesions are mostly
treated by a nonsurgical orthograde approach, information is lacking as
to their exact nature with regard to cholesterol content. The expected
outcome of tooth retreatment is 80% (28). In view of the results of
the present study, after retreatment of teeth with periapical periodontitis
caused by cholesterol accumulation, these lesions are less likely to heal.
This may explain the negative prognostic effect of a periapical lesion on
treatment outcome (28, 29).
Conclusions
Within the limitations of this retrospective study, it may be
concluded that the incidence of cholesterol deposits in periapical biop-
sies among elderly patients is higher than in that of periapical biopsies
of adolescent patients. A higher incidence of cholesterol among the
elderly may be a possible cause for the lack of repair, and a low choles-
terol level could perhaps explain the fast healing rate of periapical
lesions among adolescents.
Acknowledgments
The results of this study are based on a thesis submitted by Dr
Valery Baev in partial fulfillment of the requirements for the degree
of specialist in endodontics.
The authors deny any conflicts of interest related to this study.
References
1. Bhaskar SN. Oral surgery—oral pathology conference No. 17, Walter Reed Army
Medical Center. Periapical lesions-types, incidence, and clinical features. Oral
Surg Oral Med Oral Pathol 1996;21:657–71.
2. Sanchis JM, Pe~narrocha M, Bagan JV, et al. Incidence of radicular cysts in a series of
125 chronic periapical lesions. Histopathologic study. Rev Stomatol Chir Maxillofac
1998;98:354–8.
3. Santos LC, Vilas B^oas DS, Oliveira GQ, et al. Histopathological study of radicular
cysts diagnosed in a Brazilian population. Braz Dent J 2011;22:449–54.
Incidence of Cholesterol in Periapical Biopsies 1479
Clinical Research
4. Nair PNR. On the causes of persistent apical periodontitis: a review. Int Endod J
2006;39:249–81.
5. Nair PNR, Sjogren U, Sundqvist G. Cholesterol crystals as an etiological factor in non-
resolving chronic inflammation: an experimental study in guinea pigs. Eur J Oral Sci
1998;106:644–50.
6. Browne RM. The origin of cholesterol in odontogenic cysts in man. Arch Oral Biol
1971;16:107–13.
7. Shear M. Cholesterol in dental cysts. Oral Surg Oral Med Oral Pathol 1963;16:
1465–73.
8. Sjogren U, Mukohyama H, Roth C, et al. Bone-resorbing activity from cholesterol-
exposed macrophages due to enhanced expression of interleukin-1alpha. J Dent
Res 2002;81:11–6.
9. Hansson GK. Inflammation, atherosclerosis, and coronary artery disease. N Engl J
Med 2005;352:1685–95.
10. Fruchart JC, Nierman MC, Stroes ES, et al. New risk factors for atherosclerosis and
patient risk assessment. Circulation 2004;109(suppl 1):15–9.
11. McMahan CA, Gidding SS, Fayad ZA, et al. Risk scores predict atherosclerotic lesions
in young people. Arch Intern Med 2005;165:883–90.
12. Strong JP, Malcom GT, McMahan CA, et al. Prevalence and extent of atherosclerosis
in adolescents and young adults: implications for prevention from the Pathobiolog-
ical Determinants of Atherosclerosis in Youth Study. JAMA 1999;281:727–35.
13. Stedman’s Medical Dictionary for the Health Professions and Nursing, 6th ed.
Philadelphia: Wolter Kluwer Health/Lippincott, Williams and Wilkins; 2008.
14. Ross R. Atherosclerosis—an inflammatory disease. N Engl J Med 1999;340:115–26.
15. Nestruck AC, Davignon J. Risks for hyperlipidemia. Cardiol Clin 1986;4:47–56.
16. Yamazaki M, Cheng J, Hao N, et al. Basement membrane-type heparan sulfate
proteoglycan (perlecan) and low-density lipoprotein (LDL) are co-localized in
granulation tissues: a possible pathogenesis of cholesterol granulomas in jaw cysts.
J Oral Pathol Med 2004;33:177–84.
1480 Slutzky-Goldberg et al.
View publication stats
17. Metzger Z. Macrophages in periapical lesions. Endod Dent Traumatol 2000;16:1–8.
18. de Chevigny C, Dao TT, Basrani BR, et al. Treatment outcome in endodontics: the
Toronto study—phase 4: initial treatment. J Endod 2008;34:258–63.
19. Setzer FC, Boyer KR, Jeppson JR, et al. Long-term prognosis of endodontically treated
teeth: a retrospective analysis of preoperative factors in molars. J Endod 2011;37:21–5.
20. Keys A. Seven Countries: A Multivariate Analysis of Health and Coronary
Disease. Cambridge, MA: Harvard University Press; 1980.
21. Bobryshev YV. Monocyte recruitment and foam cell formation in atherosclerosis.
Micron 2006;37:208–22.
22. Pasqualini D, Bergandi L, Palumbo L, et al. Association among oral health, apical
periodontitis, CD14 polymorphisms, and coronary heart disease in middle-aged
adults. J Endod 2012;38:1570–7.
23. Lin SK, Kok SH, Lee YL, et al. Simvastatin as a novel strategy to alleviate periapical
lesions. J Endod 2009;35:657–62.
24. Lai EH, Hong CY, Kok SH, et al. Simvastatin alleviates the progression of periapical
lesions by modulating autophagy and apoptosis in osteoblasts. J Endod 2012;38:
757–63.
25. Libby P. Current concepts of the pathogenesis of the acute coronary syndromes.
Circulation 2001;104:365–72.
26. Kinlay S, Selwyn A. Effects of statins on inflammation in patients with acute and
chronic coronary syndromes. Am J Cardiol 2003;91:9B–13B.
27. Shadmehr E, Khademi A. Effect of Simvastatin on kinetics of osteoprotegrin/receptor
activator nuclear kappa B Ligand mRNA expression in periapical lesions. Int Endod J
2013. Mar 14. doi: 10.1111/iej.12101. [Epub ahead of print].
28. Ng YL, Mann V, Gulabivala K. A prospective study of the factors affecting outcomes of
nonsurgical root canal treatment: part 1: periapical health. Int Endod J 2011;44:
583–609.
29. Sjogren U, Hagglund B, Sundqvist G, et al. Factors affecting the long-term results of
endodontic treatment. J Endod 1990;16:498–504.
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