Periapical Periodontitis
Dr. Fahed S.Habash.
2nd Semester, 2007
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Periapical periodontitis: -
Spreading of infection following death of the
pulp.
Resulting in tenderness of the tooth in its
socket.
Causes of apical periodontitis could be
infection (pulpitis), trauma, chemical
irritation.
The sequences of events as follows: caries
pulpitis death of the pulp (infected by
bacteria) apical periodontitis.
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Aetiology of periapical
periodontitis
Pulpitis and pulp necrosis:
• If pulpitis is untreated bacteria extend down the root canal
and through the apical foramina to cause periodontitis.
Trauma:
• Occlusal trauma, either from a high restoration or less
frequency associated with bruxism, may result in periapical
periodontitis .
Endodontic treatment:
• Mechanical instrumentation through the root apex as well as
chemical irritation from-root filling materials, may result in
inflamation of periapical area
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Acute apical periodontitis
Clinical features: -
Previous history pain due to previous pulpitis.
When apical periodontitis develops escape of
exudates into the periodontal ligament causes
the tooth to be extruded.
The tooth is at first uncomfortable, then more
tender, even to simple touch.
As inflammation becomes more severe and pus
starts to form, pain become more severe and
throbbing in character.
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At this stage the gingiva over the root is
red and tender, but there is no swelling
while inflammation is limited within the bone.
With time and when the exudates cannot
escape, distended the soft tissues to form a
swelling. (It subsides when the tooth is
extracted or the infection is drained).
The regional lymph nodes may be enlarged
and tender, but generally symptoms are
usually slight or absent.
Inflammation typically remains localized but
rarely further spread of infection can cause
cellulites or osteomyelitis.
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Radiographically: -
Radiographs give little information
because bony changes have had too short
time to develop.
Immediately around the apex the
lamina durra may appear slightly hazy
and the periodontal space may be slightly
widened.
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Pathology: -
Typical acute inflammatory reaction.
In the early acute lesion, the inflammatory
cells, mainly neutrophil are seen clustered
around the apex of a non-vital tooth.
The inflammatory cells are then spreading
around and into bone.
No enough time for significant bone
resorption to develop.
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Treatment
Extracted of the diseased tooth
removes the source of infection and
drains the exudate.
Alternative teratment is to retain the
tooth by endodontic treatment, which
could serve drainge for the infection.
Antibiotics should not be used for
simple acute periodontitis when the
immediate dental treatment is available.
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Chronic Apical Periodontitis
Low grade infection.
May follow acute infection that has
been inadequately drained and
incompletely resolved.
The tooth is non-vital and may be slightly
tender to percussion but otherwise
symptoms may be minimal. (mainly
recognized by a routine radiograph).
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Radiograpgically: -
Mainly recognized as a rounded area of
radiolucency at the apex of a tooth (an
apical granuloma) in a routine radiograph.
The area of radiolucency usually about
5mm in diameter and has some defined
margins, or sometimes poorly defined
margins.
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Possible complication of chronic
apical periodontitis: -
Periapical granuloma formation.
Radicular cysts formation.
Sinus formation.
Acute exacerbations.
Periapical abscess and spread of
inflammation.
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Pathology
Typical chronic inflammatory r x n.
This inflammatory r x n characterized by
lymphocytes macrophages and plasma cells.
The granulation tissue surrounded the area.
This inflammatory r x n occurs at the apex
of the non-vital tooth and an abscess cavity
formed and surrounded by a thick fibrous
wall densely infiltrated by inflammatory
cells, predominantly neutrophil.
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Periapical bone has been resobed and the bone
reoriented around the mass leaving a round
area of radiolucency.
Persistant infection……bone resorption………replaced by
inflamed granulation tissue
Epithehial proliferation may occur in apical
granuloma and this changes may lead to cyst
formation ( The most common cause of jaw
cysts).
In other cases the epithelium is destroyed by
the inflammation.
Periapical granulomas usually remain localized
within the bone.
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Occasionally there is a sinus formation, pus may
reach the surface by resorption of the bone
(usually on the buccal surface of the gingiva)
immediately over the apex of the tooth.
Granuulation tissue forms in response to the
irritation by pus and marks the opening of the sinus.
An uncommon complication, is the tracking of a sinus
onto the skin surface. This most frequently happens
on or near the chin as a result of a long-forgotten
death of a lower incisor.
Endodontic treatment causes the sinus to heal
remarkably quickly.
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