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Questions and Answers
What is the primary characteristic of acute periapical periodontitis?
What is the primary characteristic of acute periapical periodontitis?
What common feature is observed during the clinical diagnosis of acute periapical periodontitis?
What common feature is observed during the clinical diagnosis of acute periapical periodontitis?
Which of the following is NOT an etiology of periapical lesions?
Which of the following is NOT an etiology of periapical lesions?
What histopathological feature is typical of acute apical periodontitis?
What histopathological feature is typical of acute apical periodontitis?
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In the context of acute periapical abscess, what is a common result if the irritant is not removed?
In the context of acute periapical abscess, what is a common result if the irritant is not removed?
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What treatment option is typically recommended if inflammation is due to occlusal trauma?
What treatment option is typically recommended if inflammation is due to occlusal trauma?
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Which symptom is typically absent in a tooth affected by acute periapical periodontitis?
Which symptom is typically absent in a tooth affected by acute periapical periodontitis?
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Which of the following conditions can lead to acute apical abscess formation?
Which of the following conditions can lead to acute apical abscess formation?
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What is a common clinical feature of a tooth associated with a periapical granuloma?
What is a common clinical feature of a tooth associated with a periapical granuloma?
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Which of the following symptoms is typically associated with a periapical granuloma?
Which of the following symptoms is typically associated with a periapical granuloma?
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What characteristic does the radiographic appearance of a periapical granuloma usually have?
What characteristic does the radiographic appearance of a periapical granuloma usually have?
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What histopathological feature is NOT typically found in a periapical granuloma?
What histopathological feature is NOT typically found in a periapical granuloma?
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Which treatment is recommended for a periapical granuloma?
Which treatment is recommended for a periapical granuloma?
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What complication can develop from a periapical granuloma?
What complication can develop from a periapical granuloma?
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What is a characteristic feature of chronic osteomyelitis?
What is a characteristic feature of chronic osteomyelitis?
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Which type of cells are found in the granulation tissue of a periapical granuloma?
Which type of cells are found in the granulation tissue of a periapical granuloma?
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What is a common location for an abscess related to maxillary molars and premolars to discharge?
What is a common location for an abscess related to maxillary molars and premolars to discharge?
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Which microorganism is NOT mentioned as a contributor to cellulitis?
Which microorganism is NOT mentioned as a contributor to cellulitis?
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What differentiates cellulitis from an abscess in clinical terms?
What differentiates cellulitis from an abscess in clinical terms?
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What complication may arise if cellulitis associated with maxillary teeth spreads towards the eye?
What complication may arise if cellulitis associated with maxillary teeth spreads towards the eye?
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What is a primary treatment for an abscess related to a mandibular molar?
What is a primary treatment for an abscess related to a mandibular molar?
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What is one characteristic symptom of cellulitis?
What is one characteristic symptom of cellulitis?
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Which of the following is a factor in the etiology of cellulitis?
Which of the following is a factor in the etiology of cellulitis?
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What is the outcome when infection erodes through the bone?
What is the outcome when infection erodes through the bone?
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What is the most common cause of acute suppurative osteomyelitis?
What is the most common cause of acute suppurative osteomyelitis?
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Which of the following is NOT a predisposing factor for osteomyelitis?
Which of the following is NOT a predisposing factor for osteomyelitis?
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What is a characteristic sign of acute suppurative osteomyelitis in patients?
What is a characteristic sign of acute suppurative osteomyelitis in patients?
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Which area of the jaw is more frequently involved in acute osteomyelitis?
Which area of the jaw is more frequently involved in acute osteomyelitis?
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What causes the firm swelling in the affected area of acute suppurative osteomyelitis?
What causes the firm swelling in the affected area of acute suppurative osteomyelitis?
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When do radiographic changes typically appear in cases of acute suppurative osteomyelitis?
When do radiographic changes typically appear in cases of acute suppurative osteomyelitis?
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Which of the following is associated with acute inflammation as part of the pathology in osteomyelitis?
Which of the following is associated with acute inflammation as part of the pathology in osteomyelitis?
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What is the role of osteoclastic activity in acute suppurative osteomyelitis?
What is the role of osteoclastic activity in acute suppurative osteomyelitis?
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What histological feature is observed in acute osteomyelitis?
What histological feature is observed in acute osteomyelitis?
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Which clinical feature is most commonly associated with chronic osteomyelitis?
Which clinical feature is most commonly associated with chronic osteomyelitis?
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What is often a consequence of long-term low-grade inflammation in chronic osteomyelitis?
What is often a consequence of long-term low-grade inflammation in chronic osteomyelitis?
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Which type of osteomyelitis has a predominant local bone reaction over the infection itself?
Which type of osteomyelitis has a predominant local bone reaction over the infection itself?
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What is a common site for chronic osteomyelitis?
What is a common site for chronic osteomyelitis?
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What characterizes the histopathological features of chronic osteomyelitis?
What characterizes the histopathological features of chronic osteomyelitis?
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Which of the following is a type of chronic sclerosing osteomyelitis?
Which of the following is a type of chronic sclerosing osteomyelitis?
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What is often present in acute osteomyelitis but absent in chronic low-grade osteomyelitis?
What is often present in acute osteomyelitis but absent in chronic low-grade osteomyelitis?
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What is a characteristic feature of chronic intra-bony mild bacterial infection?
What is a characteristic feature of chronic intra-bony mild bacterial infection?
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Which age group is primarily affected by chronic osteomyelitis with proliferative periostitis?
Which age group is primarily affected by chronic osteomyelitis with proliferative periostitis?
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What radiographic appearance is associated with chronic osteomyelitis with proliferative periostitis?
What radiographic appearance is associated with chronic osteomyelitis with proliferative periostitis?
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What is a common clinical feature of focal sclerosing osteomyelitis?
What is a common clinical feature of focal sclerosing osteomyelitis?
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What histopathological feature can be seen in chronic osteomyelitis with proliferative periostitis?
What histopathological feature can be seen in chronic osteomyelitis with proliferative periostitis?
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What can initiate focal condensing osteitis?
What can initiate focal condensing osteitis?
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Which of the following features distinguishes focal sclerosing osteomyelitis from other conditions?
Which of the following features distinguishes focal sclerosing osteomyelitis from other conditions?
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What is a typical finding in the radiographic assessment of chronic intra-bony mild bacterial infection?
What is a typical finding in the radiographic assessment of chronic intra-bony mild bacterial infection?
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Study Notes
Disease of periapical tissue
- Periapical area: The area surrounding the apical foramen of the dental root.
- Periapical lesions: Inflammation around the apical foramen of the dental root.
- Etiology of periapical lesions:
- Pulpitis
- Traumatic injury
- Deep seated restorations
- Infection from periodontal disease through gingival crevice
- Use of unsterilized instruments during root canal treatment
- Strong chemical antiseptic application during root canal treatment
Periapical Periodontitis
- Inflammation of the PDL around the apical portion of the root.
- Types:
- Acute periapical periodontitis
- Chronic periapical periodontitis
Acute periapical periodontitis
- Painful inflammation of the periodontium due to trauma, irritation, or infection through the root canal.
- Pulp status (vital or nonvital) is irrelevant.
- Also known as symptomatic apical periodontitis.
- Tooth is tender to percussion and pain can make tooth closure difficult.
- Etiology (vital tooth): occlusal trauma, wedging of foreign body, blow on teeth, orthodontic pressure.
- Etiology (nonvital tooth): sequelae of pulpitis, during root canal therapy (forcing irrigating, extension obturating material through apical foramen, perforation of root, over instrumentation).
- Clinical features:
- Hot/cold doesn't cause pain.
- Slight tooth extrusion.
- Tenderness on mastication due to inflammatory edema in PDL.
- Severe pain due to external pressure on sensitized nerves.
- Clinical diagnosis: preapical test (tender to percussion).
- Radiographical feature: widening of PDL space.
- Histopathological features:
- Acute inflammatory reaction with engorged blood vessels and neutrophils.
- Transient inflammation if caused by acute trauma.
- Bone resorption if irritant is not removed.
- Abscess formation with bacterial infection (acute preapical/alveolar abscess).
Acute periapical abscess (Dentoalveolar abscess)
- Acute suppurative process of the dental periapical region.
- Accumulation of acute inflammatory cells at the apex of a nonvital tooth.
- Etiology:
- Infection (following pulpitis, hematogenous spread)
- Traumatic injury
- Pulp necrosis
- Mechanical/chemical manipulation in RCT.
- Frequently, an exacerbation of chronic infection (periapical granuloma, "phoenix abscess").
Clinical Features (general)
- History of previous pulpitis.
- Large carious cavity or filling often present.
- Thermal stimulation doesn't cause pain (due to pulp necrosis).
- Exudate escape into PDL causing tooth symptoms:
- Extremely painful.
- Extremely sensitive to percussion.
- Slightly extruded from its socket.
- Intense throbbing pain as pus forms.
- Systemic manifestations at this stage (gingiva red, tender; no swelling as confined in bone; lymphadenitis and fever may be present).
Radiographic features
- Amorphous, irregular radiolucent area in the periapical region of the root.
- Abscesses: dense, almost solid masses of neutrophils (pus cells) mixed with inflammatory exudate, cellular debris, necrotic material, bacterial colonies, or histiocytes.
- Dilated blood vessels in PDL and bone marrow space.
- Bone marrow inflammatory infiltration.
- Surrounding bone shows resorption and degeneration of osteocytes.
Treatment
- Selective grinding if occlusal trauma is the cause.
- Extraction or RCT to drain exudate.
- Antibiotic administration.
- Analgesics.
- Opening of the pulp chamber to drain the abscess; apicectomy, or extraction.
Chronic periapical abscess
- Chronic condition or sequela of acute infection.
- No acute symptoms.
- Tooth felt high in socket.
- Intra-oral sinus formation.
- Salty taste.
Microscopically
- Pus cavity: chronic inflammatory cells (lymphocytes, plasma cells, macrophages).
- Fibrous tissue + newly formed capillaries (rare PMNLs).
- Fibrous capsule at the periphery.
Periapical granuloma
- Localized granulation tissue mass surrounding the apical foramen of the nonvital tooth.
- Most common periapical lesion.
- Result of pulp death, and bacterial toxin diffusion through canals into periradicular tissue.
- Lateral or accessory canals lead to lateral granuloma.
Etiology (general)
- Death of the pulp.
- Infection through the gingival crevice.
- Trauma.
- Hematogenous infection.
- Odonto-iatrogenic.
Clinical features (general)
- Non-vital tooth.
- Slightly tender on percussion (edema and inflammation of apical periodontal ligament).
- Minimal symptom presentation.
- Mild pain with solid food.
- Slightly extruded from its socket.
- Sensitivity due to hyperemia, edema, and PDL inflammation.
- Asymptomatic in many cases.
- No perforation of bone or oral mucosa (except with acute exacerbation).
Radiographic features
- Rounded radiolucent area (5-10mm), well-defined margins in the periapical region.
- Thin radiopaque line of sclerotic bone sometimes outlining the lesion.
- Varying degrees of root resorption with long-standing lesions.
Histopathological features (periapical granuloma)
- Hyperemia + edema of PDL.
- Granulation tissue (fibers, fibroblasts, endothelium, chronic inflammatory cells, blood vessels).
- Capsule of fibrous tissue firmly attached to the cementum (during tooth extraction).
- Foam cells (macrophages + lipid material).
- Cholesterol crystals (empty clefts from processing).
- Epithelial rests (rests of Malassez).
Treatment (periapical granuloma)
- Apicectomy with root canal treatment.
Osteomyelitis
- Acute or chronic inflammatory process in medullary or cortical bone spaces that extends away from the initial involvement site (usually a bacterial infection).
Classification of osteomyelitis
- Acute suppurative osteomyelitis
- Chronic suppurative osteomyelitis
- Chronic low-grade osteomyelitis and osteitis (sclerosing);
- Focal sclerosing osteomyelitis (focal condensing osteitis)
- Chronic osteomyelitis with proliferative periostitis (Garré's osteomyelitis, periostitis ossificans)
Etiology of osteomyelitis
- Dental infection is the most common cause.
- Jaw fracture infection.
- Gunshot wounds.
- Hematogenous spread.
Predisposing factors for osteomyelitis
- Radiation damage
- Paget's disease
- Osteoporosis
- Systemic diseases (malnutrition, acute leukemia, uncontrolled diabetes, sickle cell anemia, chronic alcoholism)
Pathogenesis (Acute osteomyelitis)
- Rapidly destructive inflammatory process within bone and bone marrow.
- Due to virulent bacteria strain.
- Spreads through bone medullary spaces (often associated with virulent bacteria and/or reduced host immune resistance)
Pathology (Acute osteomyelitis)
- Acute inflammation of marrow tissue.
- Exudate spread along the marrow spaces.
- Vessel thrombosis due to compression.
- Bone necrosis.
- Necrotic tissue, dead cells, and pus from bacteria fill the bone marrow.
- Cortical bone involvement leading to further necrosis.
- Osteoclastic activity.
Clinical Features (Osteomyelitis)
- Most common site: posterior area of the mandible (more frequently than maxilla).
- Symptoms:
- Severe, throbbing, deep-seated pain.
- Swelling of affected area.
- External swelling due to inflammatory edema.
- Later, periosteum swelling with pus.
- Swelling becomes firm due to subperiosteal bone formation.
- Overlying gingiva red, swollen, and tender.
- Tenderness in associated teeth (might become loose with pus discharge).
- Difficulty opening mouth, swallowing.
- Enlargement and tenderness of regional lymph nodes.
- Anesthesia or pain/numbness of the lower lip is characteristic.
Radiographic changes (osteomyelitis)
- Appear at least 10 days post symptom onset.
- Trabecular pattern loss and radiolucent areas indicating bone destruction
- Ill-defined margins of these areas in the radiograph.
Histological features (osteomyelitis)
- Purulent exudate occupies marrow spaces in acute osteomyelitis.
- Reduced osteoblastic activity and increased osteoclastic resorption with osteocyte loss if bone necrosis (sequestum).
- Bacterial colonization and acute inflammatory cell infiltration (neutrophils).
Chronic osteomyelitis
- Commoner than acute osteomyelitis
- Persistent low-grade infection (associated with bone destruction and granulation tissue formation, but little suppuration)
- Similar predisposing factors to acute form, but local bone sclerosis is more likely.
Clinical feature (Chronic osteomyelitis)
- Posterior mandible most common site
- Low-grade pain
- Bad taste (pus drainage to the mouth through sinuses)
- Swelling, increased pain and discharge + increased mobility.
- Irregular, ill-defined areas.
Histopathological features (Chronic osteomyelitis)
- Chronically inflamed fibrous connective tissue filling intertrabecular area of bone.
- Scattered sequestra present
Chronic Low-Grade Osteomyelitis and Osteitis (Sclerosing Osteomyelitis)
- Osteomyelitis is small or caused by low virulence organisms (dominant clinical presentation is bone reaction to infection rather than infection itself)
- Suppuration and infiltration of marrow spaces by inflammatory cells are absent, and bacteria not readily cultivable.
- Types:
- Diffuse sclerosing osteomyelitis
- Focal sclerosing osteomyelitis
- Proliferative periostitis
Diffuse sclerosing osteomyelitis
- Diffuse bone reaction to low-grade inflammatory stimuli.
- Chronic intra-bony, mild bacterial infection creates mass of chronically inflamed granulation tissue.
- This stimulates sclerosis of surrounding bone.
- Dense mass of sclerotic bone trabeculae.
- Fibrotic marrow tissue.
- Bone marrow infiltrated with few lymphocytes and plasma cells
Focal sclerosing osteomyelitis (Focal condensing osteitis)
- Focal bony reaction to low-grade periapical/pulpal infections or unusually strong host defense response
- Commonly affects children and young adults
- Usually premolar/molar regions of the mandible
- Typically asymptomatic
- No jaw expansion
Radiographic features of focal sclerosing osteomyelitis
- Localized but uniform radiodensity (radiopaque) related to tooth (or periapical/maxillary area).
- Widened periodontal ligament spaces apparent.
Chronic osteomyelitis with proliferative Periostitis (Garré's osteomyelitis, Periostitis Ossificans)
- Hard bony swelling at the periphery of the jaw (periosteal osteosclerosis).
- Reactive vital bone rows parallel to each other, expanding the affected bone surface.
- Primarily affects children and young adults (no sex predominance).
- May present with vague pain and bony enlargement, frequently associated with mandibular first molar.
- Radiograph shows cortex duplication ("onion skin").
- Histopathological features:
- Supracortical, subperiosteal mass of parallel reactive new bone or osteoid with osteoblasts bordering bony trabeculae.
- Fibrous connective tissue between trabeculae.
- Diffuse/patchy lymphocytes and plasma cells.
- Small sequestra might be present.
Complications of periapical granuloma
- Painless (due to infected granuloma)
- Periapical cysts (develop from epithelial rests of Malassez proliferation).
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