Periapical Diseases Handout PDF 2024-2025 - Dr. Safaa El-Baz

ORAL PATHOLOGY DISEASES OF THE PERIAPICAL TISSUES 2022 ─ 2023 Dr. Safaa El-Baz Lecturer, Oral Pathology Department, The British University in Egypt B.Sc. M.Sc. Ph.D. Oral & Maxillofacial P...

ORAL PATHOLOGY DISEASES OF THE PERIAPICAL TISSUES 2022 ─ 2023 Dr. Safaa El-Baz Lecturer, Oral Pathology Department, The British University in Egypt B.Sc. M.Sc. Ph.D. Oral & Maxillofacial Pathology, Cairo University  Diseases of the Pulp and Periapical Tissues Chapter outline I. Sequalae of dental caries II. Pathology of the periapical area Classification of periapical diseases 1. Dental sclerosis (condensing osteitis) (chronic focal sclerosing osteomyelitis) 2. Apical periodontitis (acute and chronic) 3. Periapical abscess (acute and chronic) 4. Periapical granuloma 5. Periapical cyst (see cyst chapter) III. Main differences between pulp diseases and periapical diseases Dr. Safaa El-Baz |Lecturer of Oral Pathology Department | the British University in Egypt 1  Diseases of the Pulp and Periapical Tissues I. Sequalae of dental caries Dr. Safaa El-Baz |Lecturer of Oral Pathology Department | the British University in Egypt 2  Diseases of the Pulp and Periapical Tissues II. Pathology of the periapical area 1. Dental sclerosis (condensing osteitis) 2. Apical periodontitis (acute and chronic) 3. Periapical abscess (acute and chronic) 4. Periapical granuloma 5. Periapical cyst (see later in Cyst chapter) DENTAL SCLEROSIS (CONDENSING OSTEITIS) (CHRONIC FOCAL SCLEROSING OSTEOMYELITIS) Definition Condensing osteitis is a periapical inflammatory disease that results from a localized sclerotic reaction (harder and denser bones) to a dental related infection. Etiology The associated tooth may be carious or contains a large restoration, and is often associated with a non- vital tooth, however in some cases the related tooth may be vital. The sclerotic reaction results from infection of periapical tissues of a good patient immunity and a low- grade inflammatory stimulus, which causes more bone production rather than bone destruction. Clinical & Radiographic features Condensing osteitis is largely asymptomatic (no swelling and no pain), but the patient may complain from mild pain. Primarily occurs in jaw area near the root apices of molars. Young to older adults are the most affected. This condition is usually discovered during a routine dental visit with X-rays. The lesion appears as a radiopacity blended with the surrounding bone in the periapical area separated from the periodontal ligament space. Treatment for condensing osteitis is removal of the underlying cause. Once the affected tooth has been treated, the bone lesions associated with this condition may resolve over time, with partial healing also possible. Dr. Safaa El-Baz |Lecturer of Oral Pathology Department | the British University in Egypt 3  Diseases of the Pulp and Periapical Tissues APICAL PERIODONTITIS Definition Acute apical periodontitis refers to a localized acute inflammatory change of the periodontium — the tissue that surrounds teeth— related to the apex of the tooth. Etiology It may result from: Traumatic occlusion due to high spot restoration, rapid OR Acute pulpitis OR Necrotic pulp ortho or bruxism in normal pulp or reversible pulpitis Clinical features History: The patient may give a history of recent dental visit, pain due to previous pulpitis, and the associated tooth may be carious, restored or discolored due to death of the pulp. The tooth is extruded by a minute amount and the bite fall more heavily on it (due to formation of inflammatory exudate in the periodontal ligament area). The pain is severe even to mere touch (as the condition is acute) and localized by the patient (because periodontal ligament proprioceptors are triggered). Hot or cold substances do not cause pain in the tooth. Response to pulp tester: responding (vital tooth) or may be not responding (non-vital tooth due to pulp necrosis). No facial oedema or alveolar tenderness or other reactions develop (as apical periodontitis remains a localized apical inflammatory change). Radiographic features At first no changes (as rapid onset, and the bone changes need time to develop). Then, immediately around the apex: * Lamina dura may appear slightly hazy. * Periodontal space may be slightly widened. Histopathology Acute apical periodontitis is a typical acute inflammatory reaction localized to the apex with engorged blood vessels and packing of the tissue with neutrophils. Management A. If normal pulp or reversible pulpitis B. If irreversible pulpitis or pulp necrosis remove irritant only root canal treatment # Antibiotics should not be given for acute periodontitis as immediate dental treatment is enough to either eliminate the source of infection or drain the exudate. Dr. Safaa El-Baz |Lecturer of Oral Pathology Department | the British University in Egypt 4  Diseases of the Pulp and Periapical Tissues PERIAPICAL ABSCESS Definition It is a suppurative condition (i.e., pus formation) of the periapical area of non-vital tooth. The periapical abscess might be acute or chronic. Etiology It may result from: a. extension of infection from pulp tissue. b. acute exacerbation of periapical granuloma. Pathogenesis Decayed broken down tooth Infection following pulpitis Traumatic injury Pulp necrosis allow bacterial ingress from pulp through the apex to the periapical tissue (involves the periodontal ligament and alveolar bone) vasodilatation and extravasation of inflammatory fluid infiltrate if severe persisting irritant (intense or highly virulent microorganism) Acute inflammation; vasodilatation and extravasation of inflammatiory fluid infiltrate followed by leucocytic (mainly neutrophil) infiltration necrosis of cells and leucocytes, then release of proteolytic enzymes and pus formation Acute periapical abscess pus stimulates osteoclastic activity and alveolar bone resorption, leading to submucosal extension of pus and thereby swelling if irritant of low intensity or draining pus through a sinus tract Chronic periapical abscess Dr. Safaa El-Baz |Lecturer of Oral Pathology Department | the British University in Egypt 5  Diseases of the Pulp and Periapical Tissues Clinical features I. Systemic manifestations Acute onset of pain, redness and hotness. Fever, malaise, lymphadenitis and leukocytosis may be present. II. Local manifestations The offending tooth: usually shows a deep caries or restoration The pain is intense (as the condition is acute) and localized by the patient (because periodontal ligament proprioceptors are triggered). Feeling of fullness and tooth elongation. due to presence of Pain on percussion. pus in the periapical area. No response to pulp tester (i.e., non-vital due to pulp necrosis). Swelling (due to bone resorption and submucosal pus). The abscess may point intraorally or extraorally. Once draining occurs, the conditions turn chronic and pain subsides. Chronic periapical abscess Mild pain or slight discomfort with mastication or on percussion (due to draining of pus through a sinus tract). The patient may express salty taste. Radiographic features The periapical abscess differs radiographically according to the duration pf the lesion, as follows: In the early stages: Later on; no changes (because of the Then; lesion appears as hazy or ill- rapid onset, and the bone widening in the periodontal defined periapical changes need time to membrane space occur. radiolucent area. develop). In case of Chronic periapical abscess: Large ill-defined periapical radiolucent area. Dr. Safaa El-Baz |Lecturer of Oral Pathology Department | the British University in Egypt 6  Diseases of the Pulp and Periapical Tissues Histopathology The periapical abscess is formed of: A central area containing pus (necrotic tissue plus dead and living acute inflammatory cells; neutrophils). The surrounding area show vasodilated blood vessels and dense inflammatory cells (mainly neutrophils) and a thick fibrous wall. Decalcified Section showing periapical abscess Management 1. open access to drain pus 2. endodontic treatment through root canal Dr. Safaa El-Baz |Lecturer of Oral Pathology Department | the British University in Egypt 7  Diseases of the Pulp and Periapical Tissues * Recrudescent (Phoenix) abscess Definition A phoenix abscess is an acute exacerbation of a chronic periapical lesion (chronic apical periodontitis, chronic abscess, granuloma or cyst). Etiology & Pathogenesis * immediately following root canal treatment. * inadequate debridement during the endodontic procedure. * untreated necrotic pulp (chronic apical periodontitis). shift in balance between virulence of microorganisms and body resistance: * stimulation of the residual microbes in the root canal space (high virulence) * lowering of the host defense sudden worsening of the symptoms of a chronic periapical lesion. Clinical & Radiographic features Similar to periapical abscess except for large ill-defined periapical radiolucency. Management 2. Antibiotics (to control spread of infection) 1. Repeat endodontic treatment OR tooth extraction Dr. Safaa El-Baz |Lecturer of Oral Pathology Department | the British University in Egypt 8  Diseases of the Pulp and Periapical Tissues PERIAPICAL GRANULOMA Definition It is a localized mass of chronic inflamed granulation tissue located at the apex of a non-vital tooth. Periapical granuloma is not a true granuloma due to the fact that it does not contain granulomatous inflammation; however, the common term used periapical granuloma is misnomer. According to its location, periapical granuloma could be: 1. periapical: around the apical foramen 2. Lateral: related to an accessory root canal 3. Inter-radicular: most commonly odontoiatrogenic perforation or less commonly related to an accessory root canal in the furcation area Etiology It may arise from: 1. Extension of low-grade pulpitis 2. Infection through gingival cervice 3. Trauma 4. Hematogenous infection 5. Odontoiatrogenic: *Deep seated restorations. *Faulty procedures in endodontic therapy (such as: mechanical perforation, use of non-sterile root canal instruments, and application of strong antiseptics in root canal treatment). Pathogenesis hyperemia and edema occur the pressure of of the the growing periodontal the body tries this granuloma on chronic ligament to wall off granulation the inflammation associated infection by tissue replaces surrounding extends into with chronic formation of the apical bone results in the periapical inflammatory granulation periodontal activation of area cells infiltrate tissue ligament osteoclasts and (chronic bone apical resorption periodontitis) Dr. Safaa El-Baz |Lecturer of Oral Pathology Department | the British University in Egypt 9  Diseases of the Pulp and Periapical Tissues Clinical features 1. The patient can identify the offending tooth and complains from mild pain (sometimes no pain) or slight discomfort on biting or chewing solid food (because the presence of proprioceptors in the periodontal ligament enables the patient to localize the affected tooth). 2. The patient feels that the tooth is elongated or extruded from its socket. 3. The tooth is sensitive to percussion (due to hyperemia, edema and inflammation of the apical periodontal ligament). 4. The tooth is not responding to pulp tester (non-vital tooth due to pulp necrosis). Radiographic features Well- defined radiolucent lesion related to the root apex with or without radiopaque margin. Size of periapical granuloma: ranges from 0.5 cm to 1.5 cm in diameter (not exceed 1.5 cm). Differential diagnosis: periapical granuloma should be differentiated mainly from periapical cyst. If the size of lesion is small (ranges from 0.5 cm to 1.5 cm in diameter): it may be periapical granuloma or small periapical cyst. If the size of lesion larger than 1.5 cm in diameter: The diagnosis of periapical granuloma will be excluded. Thereby, it may be a periapical cyst. If the size of lesion ranges from 0.5 cm to 1.5 cm in diameter: Cannot reliably differentiate dental granuloma from periapical cyst clinically / radiographically; need histological evaluation. Diagnosis confirmed with removal of lesion and submission for microscopic examination. Dr. Safaa El-Baz |Lecturer of Oral Pathology Department | the British University in Egypt 10  Diseases of the Pulp and Periapical Tissues Histopathology 1. The alveolar bone and the periodontal ligament in the periapical are replaced by the granulation tissue, which is comprised of: (1) newly formed blood vessels, (2) newly formed fibroblasts, and (3) newly formed collagen fibrils. 2. The granulation tissue is surrounded by fibrous connective tissue capsule firmly attached to cementum. Therefore, the whole granuloma is often removed attached to the extracted tooth. 3. Chronic inflammatory cell infiltrate (1) Lymphocytes and (2) plasma cells. 4. Cholesterol crystals are seen in microscopic sections as cholesterol clefts, because the xylol used in preparation of a histologic section dissolves the cholesterol crystals, leaving empty spaces called cholesterol clefts. Cholesterol crystals Cholesterol clefts in fresh smear in microscopic sections envelope with detached (dissolve in xylol) stamp empty spaces/clefts 5. These cholesterol clefts are surrounded by foreign body multinucleated giant cells. 6. Foam cells could be found, representing macrophages that engulf lipoid material. 7. In some granulomas, strands or islands of epithelium could be also found, which originates from the epithelial rest of Malassez. Proliferation and disintegration of this epithelium will give rise to an inflammatory periapical cyst. Sequelae a. When strands or islands of epithelium is proliferated and disintegrated, the periapical granuloma will give rise to an inflammatory periodontal cyst. b. If the balance between irritant and body resistance is disturbed at any time, the granuloma may break down to become an acute or chronic abscess. Dr. Safaa El-Baz |Lecturer of Oral Pathology Department | the British University in Egypt 11  Diseases of the Pulp and Periapical Tissues Management a. If the tooth is restorable: b. If the tooth is non-restorable: Endodontic Extraction treatment Dr. Safaa El-Baz |Lecturer of Oral Pathology Department | the British University in Egypt 12  Diseases of the Pulp and Periapical Tissues III. Main differences between pulp diseases and periapical diseases Main clinical and radiographic differences between pulp and periapical diseases pulp inflammatory diseases (Pulpitis) Periapical diseases Ability of the The patient may be unable to identify the The patient can identify the patient to offending tooth within the quadrant offending tooth localize the (Pain is not localized because the nerve (Pain is localized due to offending tooth supply of the pulp is only free nerve presence of proprioceptors endings). in the periodontal ligament) Feeling of tooth No tooth elongation The patient feels that the elongation tooth is elongated or extruded from the socket Sensitivity to Not sensitive sensitive percussion Response to responding (vital tooth) Not responding (non-vital pulp tester tooth due to pulp necrosis) Radiographically No periapical changes Periapical changes Dr. Safaa El-Baz |Lecturer of Oral Pathology Department | the British University in Egypt 13