6. Pathology Of Periapical Periodontitis Flashcards
LOs
- Describe the features of acute and chronic inflammation in the context of the periapical tissues
- List and explain the causes and sequelae of periapical periodontitis
- Describe the histopathological features of periapical periodontitis and its sequelae and correlate this with the clinical and radiological features
what is periapical periodontitis?
*Inflammation of periodontal ligament and other tissues around tooth apex
causes of periapical periodontitis?
*Usually due to spread of infection following death of the pulp
*Extrusion of antiseptics through apex during root canal treatment
*A high filling or biting suddenly on a hard object
sometimes causes an acute usually transient periapical periodontitis
Acute periapical periodontitis clinical findings
*History of pulpitis
*Escape of exudate into periodontal ligament causes a small amount of tooth extrusion
*Pain well localized: Tender to touch / percussion
*Tooth not vital and not responsive to vitality tests unless pulpal necrosis limited to single canal in multirooted tooth
*As inflammation becomes more severe there can be intense throbbing pain
*Infection usually remains localised
*Abscess can develop
*Can spread in tissue planes causing facial swelling
*Rarely local lymphadenopathy
*Very rarely osteomyelitis or cellulitis
Acute periapical periodontitis
what you’ll see radiographically and pathologically
Radiology
*Bone resorption not had time to happen so only
radiographic change may be widening of
periodontal ligament space
Pathology
*Acute inflammation
- see acute inflammatory cells EG neutrophils
Management of acute
periapical periodontitis
*Endodontic treatment
*Extraction
*Open drainage through skin or mouth if
needed due to abscess causing swelling
Chronic periapical periodontitis clinical findings
*Low grade infection
*May follow acute periapical periodontitis
*Tooth is not vital, unless very rarely pulpal necrosis is limited to a single canal in a multirooted tooth
*Symptoms may be minimal
*Can be tender to percussion
Chronic periapical periodontitis
what you’ll see radiographically and pathologically?
Radiology
*Often diagnosed on identification of a periapical
radiolucency
Pathology
*Chronic inflammation and granulation tissue
Chronic periapical periodontitis Sequelae
(diseases that may occur later due to the original disease - Chronic periapical periodontitis)
*Periapical granuloma and in some cases
subsequently radicular cyst
*Acute exacerbation with suppuration/abscess,
cellulitis and sinus formation
*Very rarely focal sclerosing osteitis
Treatment of chronic periapical periodontitis
*Extraction of tooth or root canal treatment
*A radicular cyst may need to be enucleated
(conservative removal of cyst)
Periapical granuloma (make Q’s)
*Most asymptomatic
*May be history of pulpitis
*But can have coexisting pulpitis and therefore be
symptomatic
*Tooth is not vital and will not be responsive to
vitality tests unless the pulpal necrosis is limited to
a single canal in a multirooted tooth
Radiographic features of periapical granulomas
- periapical granulomas are asymptomatic, so usually need radiograph to identify
*75% of apical inflammatory lesions
*Most discovered on routine radiographs
*Tooth shows loss of apical lamina dura
*Bone resorption appearing as a radiolucency that
may be circumscribed or ill-defined
*Size variable:
- Small barely perceptible to 2 cm
- Larger lesions may represent radicular cysts
- Can’t definitely distinguish from a radicular cyst on size alone
*Root resorption can be seen rarely
- but roots are more difficult to resorb than bone
Pathology of periapical granuloma
*Don’t confuse with granulomatous inflammation as in TB and Sarcoidosis etc. A periapical granuloma is not granulomatous inflammation
*See chronically inflamed granulation tissue at apex of a nonvital tooth
- see some chronic inflammation cells (lymphocytes, macrophages), granulation tissue
*Defensive reaction secondary to the presence of
bacteria in the root canal with spread of related toxins into the apical zone
*Granulation tissue
*Neutrophils, lymphocytes, plasma cells, histiocytes (macrophages) multinucleated giant cells
*Cholesterol clefts and hemosiderin (result of breakdown of RBCs - appears as brown pigmented tissue)
*Small foci of acute inflammation with focal abscess formation may be seen but do not warrant the diagnosis of periapical abscess (an abscess is an exudate consisting of neutrophils, the liquefied debris of necrotic cells and oedema fluid)
*Surrounding fibrous wall
*Bone resorption
*Tooth can be resorbed but generally more resistant than bone
Relation of periapical granulomas to apical
scar
*Defect created by periapical inflammatory lesions may rarely heal by filling with dense fibrous tissue rather than normal bone
- These fibrous periapical scars occur most frequently when both facial and lingual cortical plates have been lost
- upper molar
- has amalgam filling
- swelling
- puss extruding from gingivae
- swelling = abscess
- puss is coming out from the sinus NOT the maxillary sinus BUT the ‘sinus’ = draining pathway of the abscess through the oral mucosa
- draining sinus and abscess
- swollen gingivae
- yellow material = puss
- diagram = draining pathway of abscess through sinus tract
- can see radiolucency around apices of these teeth
LEFT IMAGE
- single rooted tooth has well defined small apical radiolucency
- no evidence of caries BUT perhaps trauma which resulted in loss of vitality
RIGHT IMAGE
- resorption of root
- tooth has large occlusal restoration
- loss of vitality of tooth and subsequent pulptis was due to carious process
PERIAPICAL GRANULOMA
LEFT IMAGE
- root canal treatment
- apical radiolucency
- likely suffered pulpitis that was treated by endodontic treatment
- perhaps the endodontic treatment was unsuccessful and a periapical granuloma has formed
RIGHT IMAGE
- retained root
- adjacent to that tooth with large surface loss due to caries
- periapical radiolucencies = periapical granulomas
- 2nd premolar apex has radiolucency
- is a periapical granuloma
- it is mental foramen NOT periapical granuloma
- make sure to know anatomy so can tell difference
1st molar
- carious cavity
- small apical granuloma
- radiopacity around apex of 1st premolar
tooth root with periapical granuloma
