15 Periapical and endo-associated pathology

Question 1

Pulpitis etiology

Answer 1

caries, trauma, dental restorative procedures (sometimes only the blood vessels are inflammed)

Question 2

Pulpitis symptoms

Answer 2

pain (ex. traumatic occlusion can cause hyperemia and the dilation of blood vessels–>this incresaes intrapulpal pressure leading to the perception of pain)

Question 3

Chronic hyperplastic pulpitis characteristics

Answer 3

Also called pulp polyp. Large carious lesion including exposure of the pulp. The pulp grows out from inside the tooth to produce a red soft tissue mass in the crown area. Very sensitive. Treatment: endo or extraction

Question 4

Reversible pulpitis (definition)

Answer 4

A clinical diagnosis based on subjective and objective findings indicating that the inflammation should resolve and the pulp return to normal.

Question 5

Reversible pulpitis (characteristics)

Answer 5

Pain on hot and cold stimulation (more often cold than hot)
Pain fades away rapidly after stimulus is removed
Variable intensity of the pain (therefore intensity of pain is not a good indicator differentiating between reversible and irreversible pulpitis)
Intermittent, not always present or reproducible
Radiographic appearance normal
Treatment: remove cause if identifiable and time for resolution

Question 6

Symptomatic irreversible pulpitis (definition)

Answer 6

A clinical diagnosis based on subjective and objective findings indicating that the vital inflamed pulp is incapable of healing. Additional descriptors: lingering thermal pain, spontaneous pain, referred pain.

Question 7

Symptomatic irreversible pulpitis (characteristics)

Answer 7

(soft rule-more often has sensitivity to hot than reversible pulpitis)
Pain typically lingers with removal of stimulus
Mild and intermittent to excruciating, intense pain
Pain can be stimulated by: Hot and cold, chewing pressure, percussion
Pain may be spontaneous
Lying down may precipitate “spontaneous” pain
Pain may be continuous
Radiographs may show slight widening of the periodontal ligament (inflammation in the pulp has exited the apex of the tooth causing inflammation in the PDL space)
Treatment: endo or extraction

Question 8

Asymptomatic irreversible pulpitis (definition)

Answer 8

A clinical diagnosis based on subjective and objective findings indicating that the vital inflamed pulp is incapable of healing. Additional descriptors: no clinical symptoms but inflammation produced by caries, caries excavation, trauma.

Question 9

Pulp necrosis

Answer 9

A clinical diagnostic category indicating death of the dental pulp. The pulp is usually nonresponsive to pulp testing.

Question 10

Pulp necrosis (characteristics)

Answer 10

Death of the pulp tissue due to overwhelming inflammation in a confined environment
Tooth may appear discolored (RBCs–>hemosiderin–>dentinal tubules–>discoloration)
Variable symptoms: No pain through intense pain
Often sensitive to percussion
Radiographs typically show thickening of the periodontal ligament area or destruction of bone in the periapical region

Question 11

Describe the most common etiology of periapical lesions.

Answer 11

> 95% are from the result of pulpal inflammation (pulpitis) that progresses to pulp necrosis.

Question 12

What is the most common periapical pathology?

Answer 12

Periapical granuloma

Question 13

Describe the clinical and radiographic features of pulpal pathology

Answer 13

Clinical - no response to hot and cold stimulli or electric pulp testing, tenderness to percussion and mastication may still be present. Radiographic - widening of the PDL space at root apex, longer duration lesions produce circumscribed, symmetric, radiolucent defect at apex in alveolar bone.

Question 14

What four conditions should always be part of the differential diagnosis when apical radiolucent lesions are seen radiographically?

Answer 14

Periapical granuloma, apical periodontal cyst (AKA radicular cyst, periapical cyst), periapical abscess, periapical scar

Question 15

Periapical granuloma: description and etiology

Answer 15

The most common periapical pathosis!
Accumulation of inflammatory (granulation tissue-highly vascular present in healing stages of inflammation) tissue at the periapex in response to noxious products of pulp necrosis
Chronic inflammation, not acute!!
May be found in transition from periapical abscess and/or apical periodontal cyst
Clinical presentation: Most are asymptomatic, Tooth not typically mobile
Usually not sensitive to percussion

Question 16

periapical granuloma: radiographic presentation and treatment

Answer 16

Radiographic presentation: Most are discovered on routine radiographic survey
-Radiolucent lesion
-Variable size
-Symmetrical
-Well defined
-Punched out border most often
-May be somewhat diffuse
-Loss of lamina dura at the root tip in the area of the radiolucency
-Root resorption can be seen
Treatment:
-Conventional endodontic treatment
-Surgical endodontic treatment
-Extraction

Question 17

apical periodontal cyst: description and etiology

Answer 17

Also called Periapical Cyst or Radicular Cyst
Inflammatory stimulation of epithelial remnants of Hertwig’s epithelial root sheath results in epithelial proliferation and cyst formation
Clinical presentation:
Typically asymptomatic
Usually not mobile
Displacement of the affected or adjacent teeth can occur
Usually do not produce clinically noticeable enlargement of the alveolar bone

Question 18

apical periodontal cyst: radiographic presentation

Answer 18

Radiographic presentation: (if the lesion is larger than a nickel it is probably a cyst and not a granuloma) if there is a corticated border to the lesion rather than a punched out lesion you are more likely looking at a cyst—you will still see some loss of lamina dura
Often discovered on routine radiographic survey
Radiolucent lesion, variable size, may show static behavior or very slow growth, symmetrical, well-defined, punched out border most often
Loss of lamina dura in the area of the lesion is usually present
Root resorption can be seen

Question 19

apical periodontal cyst: variations in radiographic presentation

Answer 19

Variations in radiographic presentation:
Classic pattern
Lesion surrounds the root tip
Lateral apical periodontal cyst (especially lateral incisors though any tooth can have one)
Found on the side of the root rather than right at the root tip
Probably arises in association with a lateral root canal
Residual apical periodontal cyst
Cyst remains following extraction of the tooth (cyst will persist until epithelium is disrupted some endodontists purposely try to pass a very small file through the apex to disturb the epithelial lining if it is a cyst)

Question 20

apical periodontal cyst: treatment

Answer 20

Conventional endodontic treatment
Surgical endodontic treatment
Extraction

Question 21

periapical abscess description and etiology

Answer 21

Acute inflammation due to pulpal necrosis with spread of noxious products into the periapical region
Transition from periapical granuloma and/or apical periodontal cyst is possible
Clinical presentation:
May be symptomatic or asymptomatic
Symptomatic:
Pain on percussion, mastication, and/or palpation over the periapical region
Intensity of pain may vary from mild to severe
Tends to increase in severity with time however
Swelling in the periapical region or vestibule may accompany it
It is an active infection—systemic symptoms may be noted
Headache, malaise, fever, chills
Asymptomatic:
Painless
Swelling in the periapical region or vestibule may accompany it

Question 22

periapical abscess radiographic presentation and treatment

Answer 22

Radiographic findings (symptomatic or asymptomatic)
May not produce any obvious radiographic changes
Radiolucent lesion may be present
Often ill-defined
Thickening of the periodontal ligament space also is possible
Treatment: Conventional endodontic therapy, extraction, analgesics to control pain

Question 23

periapical scar description

Answer 23

Arises due to scar formation in the site of a healing periapical granuloma, apical periodontal cyst, or periapical abscess
Typically occurs when there has been destruction of cortical bone on both the buccal and lingual aspects of the involved tooth
Most common following surgical endodontic therapy

Question 24

Sinus tract emptying to the skin surface

Answer 24

Typically an enlarged nodular mass
Red lesion with other shades of yellow, white, purple mixed in
Mandibular teeth most commonly

Question 25

What are the two types of cellulitis typically associated with dental infections?

Answer 25

Ludwig’s angina & Cavernous sinus thrombosis

Question 26

Ludwig’s angina description

Answer 26

Typically results from abscess of a mandibular molar tooth, rapid swelling of the sublingual (elevates tongue), submandibular and submental areas. May extend to the spaces around the throat and close off airway - death can occur.

Question 27

Sinus thrombosis description

Answer 27

Results from abscess of a maxillary anterior or premolar tooth, canine is most often the source of infection. Painful swelling involves periorbital tissues (eyelids, conjunctiva).

Question 28

Potential sequelae to localized lesions: sinus tract description

Answer 28

A “hole” with surrounding redness, an enlarged nodular mass (most are found on buccal aspect)

Question 29

Potential sequelae to localized lesions: osteomyelitis description

Answer 29

Periapical inflammation spreading into adjacent bone without drainage

Question 30

Potential sequelae to localized lesions: cellulitis description

Answer 30

Ludwig’s angina - rapid swelling can close off airway, death can occur. Cavernous sinus thrombosis - protrusion of eyeball, pupil dilation with photophobia, excessive lacrimation, loss of sight in the involved eye, meningitis, brain abscess, death is possible.

Question 31

Normal apical tissues

Answer 31

Teeth with normal periradicular tissues that are not sensitive to percussion or palpation testing. The lamina dura surrounding the root is intact, and the periodontal ligament space is uniform.

Question 32

Symptomatic apical periodontitis

Answer 32

Inflammation, usually of the apical periodontium, producing clinical symptoms including a painful response to biting and/or percussion or palpation. It might or might not be associated with an apical radiolucent area.

Question 33

Asymptomatic apical periodontitis

Answer 33

Inflammation and destruction of apical periodontium that is of pulpal origin, appears as an apical radiolucent area, and does not produce clinical symptoms.

Question 34

Acute apical abscess

Answer 34

An inflammatory reaction to pulpal infection and necrosis characterized by rapid onset, spontaneous pain, tenderness of the tooth to pressure, pus formation, and swelling of associated tissues.

Question 35

Chronic apical abscess

Answer 35

An inflammatory reaction to pulpal infection and necrosis characterized by gradual onset, little or no discomfort, and the intermittent discharge of pus through an associated sinus tract.

Question 36

Condensing osteitis

Answer 36

Diffuse radiopaque lesion representing a localized bony reaction to a low-grade inflammatory stimulus, usually seen at apex of tooth.

Question 37

A clinical diagnostic category in which the pulp is symptom-free and normally responsive to pulp testing.

Answer 37

Normal pulp

Question 38

A clinical diagnosis based on subjective and objective findings indicating that the inflammation should resolve and the pulp return to normal.

Answer 38

Reversible pulpitis

Question 39

A clinical diagnosis based on subjective and objective findings indicating that the vital inflamed pulp is incapable of healing. Additional descriptors: lingering thermal pain, spontaneous pain, referred pain.

Answer 39

Symptomatic irreversible pulpitis

Question 40

A clinical diagnosis based on subjective and objective findings indicating that the vital inflamed pulp is incapable of healing. Additional descriptors: no clinical symptoms but inflammation produced by caries, caries excavation, trauma.

Answer 40

Asymptomatic irreversible pulpitis

Question 41

A clinical diagnostic category indicating death of the dental pulp. The pulp is usually nonresponsive to pulp testing.

Answer 41

Pulp necrosis

Question 42

Teeth with normal periradicular tissues that are not sensitive to percussion or palpation testing. The lamina dura surrounding the root is intact, and the periodontal ligament space is uniform.

Answer 42

Normal apical tissues

Question 43

Inflammation, usually of the apical periodontium, producing clinical symptoms including a painful response to biting and/or percussion or palpation. It might or might not be associated with an apical radiolucent area.

Answer 43

Symptomatic apical periodontitis

Question 44

Inflammation and destruction of apical periodontium that is of pulpal origin, appears as an apical radiolucent area, and does not produce clinical symptoms.

Answer 44

Asymptomatic apical periodontitis

Question 45

An inflammatory reaction to pulpal infection and necrosis characterized by rapid onset, spontaneous pain, tenderness of the tooth to pressure, pus formation, and swelling of associated tissues.

Answer 45

Acute apical abscess

Question 46

An inflammatory reaction to pulpal infection and necrosis characterized by gradual onset, little or no discomfort, and the intermittent discharge of pus through an associated sinus tract.

Answer 46

Chronic apical abscess

Question 47

Diffuse radiopaque lesion representing a localized bony reaction to a low-grade inflammatory stimulus, usually seen at apex of tooth.

Answer 47

Condensing osteitis