6. periapical pathology.pdf

Periapical Pathology MOHAMMAD ALRASHDAN BDSc,MSD,DCD,MRACDS,FDS RCSEd 2/11/2023 Objectives To describe the different types of periapical pathologic conditions To list down the clinical and radiographic features of periapical pathologic conditions To describe key histopathologic features of peri...

Periapical Pathology MOHAMMAD ALRASHDAN BDSc,MSD,DCD,MRACDS,FDS RCSEd 2/11/2023 Objectives To describe the different types of periapical pathologic conditions To list down the clinical and radiographic features of periapical pathologic conditions To describe key histopathologic features of periapical pathologic conditions To outline the principles of management of periapical pathologic conditions GWhats pareaysfs.in mmatminz Periapical granuloma/ chronic apical periodontitis 6 a mass of chronically or subacutely inflamed granulation tissue at the apex of a nonvital tooth inresponsetochronicinflamm represents a defensive reaction secondary to the presence of microbial infection in the root canal with spread of related toxic products into the apical zone apex Early stage: acute apical periodontitis, radiographic alterations are w nochangein x absent ray Later, neutrophils produce prostaglandins that activate osteoclasts to resorb bone iiiis.inii iii E iH.fm Periapical granuloma/ chronic apical periodontitis ggggyynu Chronic lesions are generally asymptomatic with variable radiographic changes Per May progress from periapical abscess FromAcute Chronic A May progress to periapical cyst formation or phoenix abscess due to changes in pulp infection- with reappearance of symptoms Q Clinical and radiographic featuresOf AcuteApicalPeriodontitis Q.wph.int ntfatYf Acute apical periodontitis- constant dull, throbbing pain In Acute APeriowedo iNegativeResponse sina.me d if Negative response to vitality testing or reveals a delayed positive result G whendgefhis.inPAA 10 pain on biting or percussion is present, and no obvious radiographic alterations are noted  If the acute inflammatory process evolves into a chronic pattern, then the associated symptoms diminish of Clinical and radiographic features Periapical granuloma is easy generally asymptomatic, no response to vitality testing, no tenderness to percussion or mobility Periapical radiolucencies are widely variable, DDx. Periapical cyst, abscess f 00 of Histopathologic features Granuloma I Periapica inflamed granulation tissue surrounded by a fibrous connective tissue wall whatsalsofound variably dense lymphocytic infiltrate A.ggnfcyre Russel bodies: scattered eosinophilic globules of gamma globulin Pyronine bodies: clusters of lightly basophilic particles Treatment and prognosis ofPeriapial Grauno ma the goal of endodontics is to reduce the microbial load we decide if wego w RCT Vs extraction depending on restorability of tooth thecase NSAIDs for symptomatic cases If we did RCT requires regular F/U at 1-2 years to monitor healing Quality of RCT and coronal restoration is of high importance ItRequiresretreatmetaeister Re-RCT and periapical surgery Periapical cyst/ radicular cyst Q whatsa PA cyst comprises a fibrous connective tissue wall lined by epithelium with a lumen containing fluid and cellular debris K Residual (periapical) cyst: periapical inflammatory tissue that is not curetted at the time of tooth removal s ssuesieffitkemmit.IE from develops I in Clinical and radiographic features clinically PA cysts are generally asymptomatic unless acutely inflamed me cysts in PA Radiographically mimic PA granuloma and neither the size nor the shape is specific for PA cysts diagnosis Root resorption is common loss of the lamina dura is seen along the adjacent root with a rounded radiolucency encircling the affected tooth apex May involve deciduous teeth especially bifurcation area Lateral radicular cyst discrete radiolucency along the lateral aspect of the root Before surgical exploration of laterally positioned radiolucencies, a thorough evaluation of the periodontal status and vitality of adjacent teeth should be performed Residual periapical cyst extracted Whenextraction is done fyou 14hcurettage Histopathologic features Common to the 3 types of inflammatory radicular cysts lined by stratified squamous epithelium, which may demonstrate exocytosis, spongiosis, or hyperplasia scattered mucous cells or areas of ciliated pseudostratified columnar epithelium may be seen Treatment and prognosis RCT (regardless of the cyst size) Vs extraction F/U is always recommended cysts periapical surgery for lesions exceeding 2 cm and those associated with teeth not suitable for conventional endodontics Residual periapical cysts must be excised to rule out other lesions All inflammatory foci in the area of a lateral radicular cyst should be eliminated and the patient followed up 5Yh Periapical abscess fftAbasss caused by this us accumulation of acute inflammatory cells at the apex of a nonvital tooth May represent the initial presentation of an acute inflammation or acute exacerbation of a chronic periapical inflammatory lesion phoenix abscess Acute apical periodontitis may progress into periapical abscesscommonly in non-vital teeth or following trauma Clinical and radiographic features Clinically chronic Acute Acute Vs chronic- Symptomatic Vs asymptomatic PA abscesses become symptomatic when as the purulent material accumulates within the alveolus  The initial stages produce tenderness of the affected tooth then the pain becomes more intense, with extreme sensitivity to percussion, extrusion of the tooth, and swelling of the tissues The offending tooth is necrotic Systemic manifestations can be present Acute PA abscess does not show specific radiographic changes If Radiographicallys In Clinical and radiographic features The abscess spreads along the path of least resistance The purulence may extend through the medullary spaces away from the apical area, resulting in osteomyelitis, or it may perforate the cortex and spread diffusely through the overlying soft tissue (as cellulitis) Once an abscess is in soft tissue, it can cause cellulitis or may channelize through the overlying soft tissue Intra-oral Vs Extra-oral sinus tracts If a chronic path of drainage is achieved, a PA abscess typically becomes asymptomatic Purulent material Sessile swelling Draining sinus Parulis/ gum boil Cutaneous sinus Treatment and prognosis 0 Drainage and elimination of the focus of infection- even for asymptomatic abscesses In localized PA abscesses, symptoms will resolve within 48 hours Drainage through soft tissues is preferred over drainage through root canal Peri-operative NSAIDs Antibiotic use is limited to the medically compromised and patients with significant cellulitis or systemic manifestations Cellulitis Q hatscellulitis Acute and edematous spreading of abscess through fascial planes layersofsofttissue of the soft tissue Higher prevalence in medically compromised patients Two serious clinical complications: Ludwig angina and Cavernous sinus thrombosis Ludwig angina of Bilateral cellulitis of submandibular, sublingual and submental areas Risk of spread to retro-pharyngeal space and mediastinum Neck swelling, protrusion of tongue, air way compromise Dysphagia, dysphonia, drooling, sore throat, respiratory obstruction Fever, chills, leukocytosis, high ESR, NO pus formation Ludwig angina Airway maintenance observation, orotracheal intubation, fiber-optic nasotracheal intubation and tracheotomy o Resolution of infection elimination of the original focus of infection and IV antibiotic Penicillin ± clindamycin (or metronidazole) ± corticosteroids Cavernous sinus thrombosis Rupture • cavernous sinus is a group of thin-walled veins that are located lateral to the sella turcica and medial to the temporal bone • Cavernous sinus thrombosis can occur via an anterior or posterior maxillary teeth • edematous periorbital enlargement with involvement of the eyelids and conjunctiva Cavernous sinus thrombosis • Protrusion and fixation of the eyeball often are evident + swelling of the adjacent forehead and nose • lacrimation, photophobia, and loss of vision • Fever, chills, headache, sweating, tachycardia, nausea • signs of central nervous system (CNS) involvement and brain abscesses Cavernous sinus thrombosis • Rx. surgical drainage combined with high-dose antibiotic medications osteitismeans bonedensity aroundnots due to inflammation condensing had TeesEsityofbone 9 y Condensing osteitis (focal sclerosing osteomyelitis) in 11k Localized areas of bone sclerosis associated with the apices of teeth with pulpitis (from large carious lesions or deep coronal restorations) or pulpal necrosis Children and young adults localized, usually uniform zone of increased radiodensity adjacent to the apex of a tooth that exhibits a thickened periodontal ligament (PDL) space Mandibular premolar or molar area Differentiate from idiopathic osteosclerosis Condensing osteitis Condensing osteitis Idiopathic osteosclerosis Condensing osteitis Rx. resolution of the odontogenic focus of infection After extraction or appropriate endodontic therapy of the involved tooth, approximately 85% of cases of condensing osteitis will regress, either partially or totally Alveolar osteitis (dry socket) AfterExtraction BlootClotformsforhealingBut Premature fibrinolysis of the initial clot formed in the extraction socket areaisexposedmakingitfeeldry Risk factors: oral contraceptives, tobacco use, preoperative infection, difficult extraction, inexperienced surgeons, use of a local anesthetic with vasoconstrictor, and inadequate postoperative care Posterior Mandible at particular risk The affected extraction site is filled initially with a dirty gray clot that is lost and leaves a bare bony socket (dry socket). severe pain, foul odor, and (less frequently) swelling and lymphadenopathy develop 3 to 4 days after extraction of the tooth swellingof nodes Y j Alveolar osteitis (dry socket) Rx. Socket irrigation with normal saline Inspect for pathology/ foreign material NSAIDs Antiseptic dressing has eager I painrelif inhibitgrowth of bacteria Thank You 34