Neutrophils cause localized tissue destruction and recruit osteoclasts and odontoclasts, which

cause resorption of bone. At this stage, the periodontal space widens and a periapical lucency
develops; these sequelae are radiographically visible (Fig 2f) (2).
Neutrophils continue to destroy invading bacteria and are gradually replaced by delayed-
phase adaptive immune cells such as lymphocytes, plasma cells, and macrophages (4,18).
The persistent inflammatory reaction stimulates the formation of granulation tissue; when a
fibrous capsule encases the periapical lesion, a periapical granuloma forms (18).

Periapical cysts occur when released cytokines stimulate proliferation of epithelial rests
within the periodontal ligament (rests of Malassez), forming an epithelium-lined cavity and
resulting in resorption of periapical bone (19). This commonly occurs in men 30–50 years of
age (7).

The term periapical abscess is applied when a periapical granuloma or cyst becomes
reinfected and microbes once again travel from the necrotic pulp and out of the apical
foramen.