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What is the primary characteristic of acute periapical periodontitis?

Painful inflammation of the periodontium (correct)

Absence of pain during mastication

Complete loss of vitality in the pulp

Widening of the PDL space

What common feature is observed during the clinical diagnosis of acute periapical periodontitis?

Pain in surrounding soft tissue only

Pain upon exposure to hot or cold substances

Absence of tenderness on percussion

Slight extrusion of the tooth from its socket (correct)

Which of the following is NOT an etiology of periapical lesions?

Teeth whitening procedures (correct)

Pulpitis

Deep seated restorations

Traumatic injury

What histopathological feature is typical of acute apical periodontitis?

Engorged blood vessels and neutrophil accumulation Signup and view all the answers

In the context of acute periapical abscess, what is a common result if the irritant is not removed?

Progressive bone resorption Signup and view all the answers

What treatment option is typically recommended if inflammation is due to occlusal trauma?

Selective grinding of the tooth Signup and view all the answers

Which symptom is typically absent in a tooth affected by acute periapical periodontitis?

Pain when exposed to hot or cold substances Signup and view all the answers

Which of the following conditions can lead to acute apical abscess formation?

Acute suppurative infection after a traumatic injury Signup and view all the answers

What is a common clinical feature of a tooth associated with a periapical granuloma?

The tooth is non-vital. Signup and view all the answers

Which of the following symptoms is typically associated with a periapical granuloma?

Minimal symptoms. Signup and view all the answers

What characteristic does the radiographic appearance of a periapical granuloma usually have?

Well-defined margins and rounded radiolucency. Signup and view all the answers

What histopathological feature is NOT typically found in a periapical granuloma?

Presence of cancerous cells. Signup and view all the answers

Which treatment is recommended for a periapical granuloma?

Apicectomy with root canal treatment. Signup and view all the answers

What complication can develop from a periapical granuloma?

Periapical cyst formation. Signup and view all the answers

What is a characteristic feature of chronic osteomyelitis?

Infection extending from the original site. Signup and view all the answers

Which type of cells are found in the granulation tissue of a periapical granuloma?

Neutrophils, lymphocytes, and plasma cells. Signup and view all the answers

What is a common location for an abscess related to maxillary molars and premolars to discharge?

Maxillary sinus Signup and view all the answers

Which microorganism is NOT mentioned as a contributor to cellulitis?

Staphylococcus aureus Signup and view all the answers

What differentiates cellulitis from an abscess in clinical terms?

Cellulitis tends to be diffuse and spreads through tissue spaces. Signup and view all the answers

What complication may arise if cellulitis associated with maxillary teeth spreads towards the eye?

Cavernous sinus thrombosis Signup and view all the answers

What is a primary treatment for an abscess related to a mandibular molar?

Administration of antibiotics and drainage Signup and view all the answers

What is one characteristic symptom of cellulitis?

Trismus Signup and view all the answers

Which of the following is a factor in the etiology of cellulitis?

Pericoronitis Signup and view all the answers

What is the outcome when infection erodes through the bone?

It can express itself in various locations depending on muscle attachment. Signup and view all the answers

What is the most common cause of acute suppurative osteomyelitis?

Dental infection Signup and view all the answers

Which of the following is NOT a predisposing factor for osteomyelitis?

Dental practices Signup and view all the answers

What is a characteristic sign of acute suppurative osteomyelitis in patients?

Severe, throbbing, deep-seated pain Signup and view all the answers

Which area of the jaw is more frequently involved in acute osteomyelitis?

Mandible Signup and view all the answers

What causes the firm swelling in the affected area of acute suppurative osteomyelitis?

Subperiosteal bone formation Signup and view all the answers

When do radiographic changes typically appear in cases of acute suppurative osteomyelitis?

After at least 10 days Signup and view all the answers

Which of the following is associated with acute inflammation as part of the pathology in osteomyelitis?

Thrombosis of vessels Signup and view all the answers

What is the role of osteoclastic activity in acute suppurative osteomyelitis?

Bone destruction Signup and view all the answers

What histological feature is observed in acute osteomyelitis?

Purulent exudate occupying marrow spaces Signup and view all the answers

Which clinical feature is most commonly associated with chronic osteomyelitis?

Swelling and increased tooth mobility in more active phases Signup and view all the answers

What is often a consequence of long-term low-grade inflammation in chronic osteomyelitis?

Formation of granulation tissue and bone destruction Signup and view all the answers

Which type of osteomyelitis has a predominant local bone reaction over the infection itself?

Chronic Low-Grade Osteomyelitis Signup and view all the answers

What is a common site for chronic osteomyelitis?

Posterior area of the mandible Signup and view all the answers

What characterizes the histopathological features of chronic osteomyelitis?

Chronically inflamed fibrous connective tissue replacing marrow Signup and view all the answers

Which of the following is a type of chronic sclerosing osteomyelitis?

Diffuse sclerosing osteomyelitis Signup and view all the answers

What is often present in acute osteomyelitis but absent in chronic low-grade osteomyelitis?

Suppuration and infiltration of marrow Signup and view all the answers

What is a characteristic feature of chronic intra-bony mild bacterial infection?

Presence of a dense mass of sclerotic bone trabeculae Signup and view all the answers

Which age group is primarily affected by chronic osteomyelitis with proliferative periostitis?

Children and young adults Signup and view all the answers

What radiographic appearance is associated with chronic osteomyelitis with proliferative periostitis?

Onion skin appearance Signup and view all the answers

What is a common clinical feature of focal sclerosing osteomyelitis?

Asymptomatic condition Signup and view all the answers

What histopathological feature can be seen in chronic osteomyelitis with proliferative periostitis?

Diffuse or patchy collections of lymphocytes Signup and view all the answers

What can initiate focal condensing osteitis?

Strong host defensive response or pulpal inflammation Signup and view all the answers

Which of the following features distinguishes focal sclerosing osteomyelitis from other conditions?

Localized but uniform radiodensity Signup and view all the answers

What is a typical finding in the radiographic assessment of chronic intra-bony mild bacterial infection?

Ill-defined diffuse radiopaque area Signup and view all the answers

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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