Pulpitis and Osteomyelitis Quiz

Pulpal and Periapical Inflammatory Disease

• Pulpal disease, also known as pulpitis, is inflammation of the dental pulp.
• The most common cause of pulpitis is caries.
• Other causes include trauma, heat during restorative procedures, restorative materials, abrasion, attrition, and erosion.
• Caries extending into the pulp chamber causes pulpitis.
• Pulpitis can be identified by increased redness (inflammation) at the coronal aspect of the pulp chamber.

AAE Recommended Terminology

• Types of pulpitis include reversible pulpitis (pulpalgia), irreversible pulpitis, symptomatic pulpitis, and asymptomatic pulpitis.
• Other related pulpal conditions include hyperplastic pulpitis, internal resorption, pulpal calcification, pulp necrosis, and previously treated/initiated pulpitis.
• Endodontic courses will further explore pulpitis.

Periapical Inflammation

• Periapical inflammation occurs in the apical periodontium as a result of pulpal inflammation or death.
• Root canal bacteria and their toxins along with degenerating cells initiate the inflammation.
• A strong correlation exists between inflammation histology and symptoms.

Periapical Inflammation: Why the pulp dies from pulpitis?

• Pulp tissue swelling occurs due to inflammation, which compromises blood vessels.
• Pulp tissues are enclosed in dentin and are therefore compressed when inflamed, which impedes blood flow to the pulp.
• Occluded blood vessels lead to necrotic pulp tissue.

Periapical Inflammation: AAE Classification

• Types of periapical inflammation include symptomatic apical periodontitis, asymptomatic apical periodontitis, periapical granuloma, periapical (radicular) cyst, acute apical abscess, sequelae of acute apical abscess, chronic apical abscess, and periapical scar (fibrous healing defect).
• Other periapical lesions include residual periapical granuloma/cyst, condensing (sclerosing) osteitis, residual condensing (sclerosing) osteitis, periostitis ossificans, and osteomyelitis.

Symptomatic Apical Periodontitis: Acute Apical Periodontitis

• This condition is inflammation of the apical periodontium.
• It can result from a dead or compromised pulp.
• Hyperocclusion can also cause pain from pressure/percussion.
• Pain can be spontaneous (occurs without any external stimulus).
• Thermal sensitivity may occur if some pulp tissue remains vital.

Radiographic and Histologic Characteristics of Acute Apical Periodontitis

• Radiography typically reveals slight widening of the PDL and a small periapical radiolucency

• Histological examination reveals neutrophils and edema, with no evidence of pus formation.

Asymptomatic Apical Periodontitis: Chronic Apical Periodontitis

• Periapical inflammation and destruction of apical tissues stem from necrotic pulp tissue with no response on pulp testing.

• Patients do not experience pain on thermal changes or percussion.

Periapical Granuloma

• A periapical granuloma is a chronic inflammatory lesion.
• It can result from an acute apical periodontitis or arise de novo.
• It is granular tissue, not a true granuloma.
• Radiographic features are widened PDL and resorption of lamina dura, potentially causing root resorption.
• The lesion may be indistinct at first, but margins become well-defined with time. Inflammation histology finds chronic inflammatory cells in the granuloma.
• The lesion usually is not painful.

Periapical Cyst

• A periapical cyst is a pathological cavity lined with epithelium.
• It's also known as a radicular cyst.
• It originates in pre-existing periapical granulomas due to Malassez rests proliferation in the PDL, primarily in response to pulpal necrosis.
• Radiographically, it appears indistinguishable from a granuloma but may be larger (greater than 2 cm).
• Histologically, it consists of a hyperplastic stratified squamous epithelial cyst lining supported by chronically inflamed connective tissue.
• Usually asymptomatic.

Acute Apical Abscess

• An abscess is a localized collection of pus.
• Painful swelling is associated with periapical inflammation caused by pulpal infection/necrosis.
• Rapid onset of pain with spontaneous pain.
• Severe pain on percussion is common.
• Pus formation can cause swelling in buccal, lingual/palatal, or fascial spaces.
• Radiography may show slight to moderate widening of the PDL and/or a radiolucency (depending on duration).
• Histology reveals neutrophils, edema, and pus formation.
• Drainage of pus is critical in treating this condition

Sequelae of Acute Apical Abscess

• Sequelae of acute apical abscess include: dentoalveolar abscess, parulis (gingival abscess), skin or palatal parulis, cellulitis (phlegmon), buccal space abscess, ludwig angina, and cavernous sinus thrombosis.
• These conditions vary based on the spread of the infection through adjacent tissues.

Chronic Apical Abscess

• Gradual onset inflammation and necrosis, with or without pain.
• Pus formation and drainage through a fistula occur, usually with a purulent exudate.
• Treatment alleviates pain by draining the pus.
• Radiographic examination usually reveals a radiolucent lesion similar to chronic apical periodontitis with granulation tissue and sinus tracts.

Periapical Scar (Fibrous Healing Defect)

• Periapical scar forms from the healing process, with dense collagen formation.
• Cortical plate loss increases formation likelihood.
• Apicoectomy often precedes formation.
• Periapical scar radiography is similar to periapical granuloma.
• The tissue is dense, hyalinized fibrous tissue with scanty vasculature and lacks inflammatory components.
• No treatment is needed.

Residual Periapical Granuloma/Cyst

• These lesions may remain after tooth extraction.
• They are common for solitary radiolucencies in the alveolar process.

Condensing Osteitis

• Also known as sclerosing osteitis, it's a chronic periapical response to pulpal necrosis/pulpitis.
• May develop as a mild inflammatory reaction, variant of chronic apical periodontitis.
• Promotes bone formation.
• Typically develops in teens and young adults
• Usually asymptomatic.
• Radiography shows an irregular homogenous radiopacity at the tooth apex
• Histology finds dense sclerotic bone, with scant inflammatory cells.

Periostitis Ossificans

• Periosteal tissue proliferation and bone formation in response to prior periapical inflammation, typically involving the mandibular molars or premolars.
• Usually asymptomatic but presents with bony hard swelling over the inferior or buccal aspect of the mandible.
• Radiography typically displays faintly radiopaque thickening along the cortex (periosteum)
• Treatment is often endodontic therapy or extraction
• Cosmetic surgery is not typically necessary

Osteomyelitis

• Inflammation of bone medullary spaces, commonly associated with odontogenic infections (including periodontitis), or with immunodeficiencies (e.g., HIV, diabetes).
• Can be acute or chronic in presentation.
• Acute osteomyelitis is characterized by pain, fever, leukocytosis, lymphadenopathy, possible paraesthesia, histology of neutrophils and pus, and necrotic bone.
• The early clinical image reveals diffuse thinning of trabeculae producing a radiolucency with indistinct borders
• Chronic osteomyelitis is a sequela to the acute phase or present de novo with variable pain, jaw enlargement, sinus tract, and/or fracture.
• Pus formation in chronic cases, with possible sequestrum formation.
• Histology finds chronically or subacutely inflamed fibrous tissue, and sequestrum of nonviable bone.
• Treatment typically involves infection source removal, drainage, and prolonged IV antibiotic therapy, potentially necessitating sequestrectomy.

Treatment of Pulpal and Periapical Conditions

• Treatment of pulpal and periapical conditions varies by the specific condition.
• Pulpal treatments include endodontic therapy or tooth extraction.
• Periapical treatments include endodontic therapy or tooth extraction, or pus drainage as appropriate.