Chapter 3 - Periapical Lesions Flashcards by Jessica Ash

3 types of pulpitis

Reversible

Irreversible

Chronic Hyperplastic

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Chronic Hyperplastic Pulpitis

Inflammation causes the pulpal tissue to bulge up and out into the crown

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4 most likely Periapical Pathologies

Periapical Granuloma

Apical periodontal cyst

Periapical Abscess

Bone scar

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What is the most common and most likely periapical pathology?

Periapical granuloma

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What is the LEAST common periapical pathology?

Bone Scar

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Sequelae of Periapical Pathology (4)

Sinus Tract

Osteomyelitis

Condensing Osteitis

Cellulitis

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Parulis“Gum Boil”

Intraoral sinus tract exit - on oral mucosa

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Osteomyelitis

Chronic or acute infection of the bone - bone marrow

Bacterial infection

Results in:

* Expanding lytic destruction

* Suppuration

* Sequestra Formation - bone pieces floating in the infection

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Condensing Osteitis

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What is the earliest change in the periodontium resulting from periapical pathology.

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Periapical Granuloma

Most common periapical pathosis

Chronically inflamed granulation tissue - nonvital tooth

Usually asymptomatic

Histology - plasma cells and lymphocytes

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Phoenix Abscess

Secondary acute inflammatory changes within a periapicla granuloma

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Clinical Presentation of Periapical Granuloma

Asymptomatic

Tooth not typically mobile

Usually not sensitive to percussion

Does not respond to thermal or electrical pulp testing

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Periapical Granuloma Treatment

Conventional endodontic treatment

Surgical endodontic treatment

Extraction

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Periapical Periodontal Cyst

* Periapical cyst or Radicular Cyst*

Inflammatory stimulation of epithelium in the area – Rests of Malassez

Radiograhically –> Slow growth, punched out border

Histology –> Spiderweb pattern, epithelium lined

Patterns:

* Classical

* Lateral Apical Periodontal

* Residual apicl periodontal cyst

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Classical Pattern of Periodontal Cyst

Lesion surrounds the root tip

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Lateral Apical Periodontal Cyst

Lesion lateral to root tip

Lateral canal

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Residual Apical Periodontal Cyst

Toot was extracted but the cyst remains

Periapical abscess

Acute inflammatory cells at the apex of a nonvital tooth

Symptomatic or asymptomatic

Histology –> large accumulation of inflammation

Earlies manifestation with widening of the PDL - when pulpal involvement

Periapical abscess treatment

Endo Treatment

Extraction

Pain Killers

Periapical Scar

Defect created by periapical inflammatory lesions may fill with DENSE collagenous tissue

Common – Following surgical endodontic therapy

When facial and lingual cortical plates have been lost

Histology –> Collagen (all pink, no blue), Fibroblasts

RADIO-Translucent

Sequelae or Periapical Pathology (4)

Sinus Tract

Osteomyelitis

Cellulitis

Condensing Osteitis

Sinus Tract

Pus dissects through the bone – destroying the bone

Perforates the cortical plate of bone extending into soft tissue

Follows the path of least resistance

Drains purulent material – may be intermittent drainage

Location of tract depends on involved tooth and path of least resistance

Parulis (Gum boil)

Intraoral sinus tract exiting through oral mucosa

Hole with red halo

Pustule (large pimple)

*Fistula*

Cutaneous Sinus Tract

Cutaneous Sinus Tract **Enlarged Nodular Mass** Red lesion with shades of Yellow, White, Purple **_Mandibular teeth_** - most common

Osteomyelitis

_Acute_ or _Chronic_ inflammation in bone Bacterial Infection Results in: \* Expanding lytic destruction \* Suppuration (pus) \* Sequestra formation -- bone pieces floating around in the infection **arise after odontogenic infections or traumatic fracture** - not common in developed countries

Symptoms of acute infection of osteomyelitis

Fever Lymphadenopathy Sensitivity Soft tissue swelling **DOESN'T produce x-ray changes**

Involucrum

\*\* During acute infection fragments of necrotic bone may become surrounded by new vital bone \*\*

Cellulitis

Purulence perforates the cortex and **spreads diffusely through the overlying soft tissue** Unable to establish a drainage point Weaves through muscle bundles

Ludwig's Angina Cellulitis of the submandibular region No previous treatment has been performed, infection has persisted (Infection from mandibular molar tooth) Rapid swelling of sublingual, submandibular, and submental spaces Death can occur -- strangling **Woody Tongue** **Bull Neck**

Woody Tongue

Ludwig's Angina Sublingual involvment causes swelling and elevation of the tongue

Bull Neck

Ludwigs Angina Submandibular space spread causes enlargment and tenderness of the neck

Ludwig Angina Symptoms and Signs

**Obvious collections of pus are NOT present - no fistulas tract** Pain Restricted Neck movement Dysphagia, Dysphonia, Dysarthria Drooling Sore Throat Respiratory Obstruction SIGNS: Tachypnea,dyspnea, tachycardia, stridor, restlessness

Ludwig Angina Treatment

Call 911 Maintain airway incise and drain Antibiotic therapy Eliminate orginal focus of infection

Cavernous Sinus Thrombosis Abscess of a maxillary anterir or premolar tooth (**canine -** most common) \*Edematous periorbital enlargement -- swelling along the lateral border of the nose\*

Possibe sequelae of Cavernous Sinus Thrombosis

Protrusion and fixation of the eyeball Pupil dilation with photophobia Excessive lacrimation (tearing) Loss of sight in the involved eye **Meningitis** **Brain abscess** Death\*

Cavernous Sinus Thrombosis Treatment

Surgical drainage High dose antibiotics

**Condensing Osteitis** - Focal Sclerosing ostemyelitis Bone sclerosis associated with the apex of teeth with pulpitis **_Associated with inflammation_** - radiographically identical to idiopathic osteosclerosis No clinical expansion of bone

X ray changes of Condensing Osteitis

\* Increased radio-opacity near toot apex \* Thickened PDL or apical inflammatory lesion \* No radio-lucent border (distinguishes from focal cemento-osseous dysplasia) \* Not separated from apex (distinguishes from idopathic osteosclerosis)

Condensing osteitis vs cemento-osseous dysplasia

Xray of condensing osteitis has **NO radio-lucent border**

Condensing osteitis vs idopathic osteosclerosis

Condensing osteitis lesion is **NOT separated from apex**

Idiopathic osteosclerosis \*NOT associated with a carious tooth\* Normal tooth with radiolucent mass