Periapical Periodontitis Overview

Periapical Periodontitis

• Inflammation of periodontal ligament and other tissues around the tooth apex
• 3 main causes:
  • Spread of infection following death of the pulp (pulpitis)
  • Extrusion of antiseptics through apex during root canal treatment
  • High filling or biting suddenly on a hard object

Acute Periapical Periodontitis

• Clinical findings:
  • History of pulpitis
  • Escape of exudate into periodontal ligament causes a small amount of tooth extrusion
  • Pain and infection localized, tender to touch
  • Tooth not vital, and not responsive to vitality tests, unless pulpal necrosis limited to single canal in multirooted tooth
  • Intense throbbing pain
  • Abscess can develop
  • Can spread in tissue planes causing facial swelling
  • Rarely local lymphadenopathy
  • Very rarely osteomyelitis or cellulitis
• Radiographically:
  • No bone resorption, only widening of periodontal ligament space
• Pathology (cause): Acute inflammation
• Management:
  • Endodontic treatment
  • Extraction
  • Open drainage through skin or mouth if needed due to abscess causing swelling

Chronic Periapical Periodontitis

• Clinical features:
  • 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
• Radiographically:
  • Diagnosed on identification of a periapical radiolucency
• Pathology:
  • Chronic inflammation (macrophages, lymphocytes, plasma cells)
  • Granulation tissue
• Sequelae:
  • Periapical granuloma
  • In some cases, subsequent radicular cyst
  • Acute exacerbation with suppuration/abscess, cellulitis, and sinus formation
  • Very rarely focal sclerosing osteitis

Periapical Granuloma

• Clinical features:
  • 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 pulpal necrosis is limited to a single canal in a multirooted tooth
• Radiographic features:
  • Tooth shows loss of apical lamina dura
  • Bone resorption appearing as a radiolucency that may be circumscribed or ill-defined
  • Size: Small (2cm) or Large
  • Root resorption can be seen rarely
• Pathological features:
  • Granulation tissue
  • Neutrophils, lymphocytes, plasma cells, histiocytes, multinucleated giant cells
  • Cholesterol clefts and haemosiderin
  • Small foci of acute inflammation with focal abscess formation may be seen
  • Surrounding fibrous wall
  • Bone resorption
  • Tooth can be resorbed but generally more resistant than bone

Focal Sclerosing Osteitis

• Abnormal bone growth and lesions that may result from tooth inflammation or infections
• Can cause harder, denser bones
• Most occur in lower premolar and molar areas
• Localized pain
• Radiographically:
  • Does not exhibit a radiolucent border
• Treatment:
  • RCT or tooth extraction - 85% of cases resolve after this
  • Residual area of condensing osteitis known as a bone scar