Pulpal and Periapical Inflammatory Disease PDF

Pulpal and Periapical Inflammatory Disease Pulpitis Inflammation of dental pulp Most common cause: caries Other causes: trauma, heat (as during restorative procedures), restorative materials, abrasion, attrition, erosion  Pulpitis Most common cause is caries approachi...

Pulpal and Periapical Inflammatory Disease Pulpitis Inflammation of dental pulp Most common cause: caries Other causes: trauma, heat (as during restorative procedures), restorative materials, abrasion, attrition, erosion  Pulpitis Most common cause is caries approaching or extending into the pulp chamber Pulpitis Extension of caries close to or into the pulp chamber causes inflammation of pulp (pulpitis) Pulpitis Pulpitis appears as increased redness (inflammation) at coronal aspect of pulp chamber AAE Recommended Terminology Reversible pulpitis (pulpalgia) Irreversible pulpitis  Symptomatic  Asymptomatic  Hyperplastic pulpitis  Internal resorption  Pulpal calcification Pulp necrosis Previously treated/initiated AAE Recommended Terminology You will learn about the forms of pulpitis in Endodontics courses We will consider the periapical inflammatory lesions that arise from pulpal necrosis Periapical Inflammation Inflammation arising in the apical periodontium Sequelae of pulpal inflammation or death Reaction to bacteria in the root canal Toxic metabolites of bacteria and degenerating cells incite inflammation Good correlation between histology and symptoms Periapical Inflammation  Periapical Inflammation Why does the pulp die as a result of pulpitis?  Inflammation causes “tumor” (swelling) of the tissue  Most soft tissues can swell up with no problem  But the pulp is enclosed by dentin  When it swells up, it is compressed against hard tissue  Blood vessels become occluded  Tissue becomes necrotic Periapical Inflammation  Periapical Inflammation Toxic products of bacteria and degenerating cells in pulp induce inflammation in PDL at the apices of the roots  Periapical Inflammation: AAE Classification Symptomatic apical periodontitis Asymptomatic apical periodontitis  Periapical granuloma  Periapical (radicular) cyst Acute apical abscess  Sequellae of acute apical abscess Chronic apical abscess Periapical scar (fibrous healing defect)  Periapical Inflammation: Other Lesions Residual periapical granuloma/cyst Condensing (sclerosing) osteitis  Residual condensing (sclerosing) osteitis Periostitis ossificans Osteomyelitis  Periapical Inflammation: AAE Classification Symptomatic apical periodontitis Asymptomatic apical periodontitis  Periapical granuloma  Periapical (radicular) cyst Acute apical abscess  Sequellae of acute apical abscess Chronic apical abscess Periapical scar (fibrous healing defect)  Symptomatic Apical Periodontitis: Acute Apical Periodontitis Inflammation of the apical periodontium Usually from dead pulp but can result from any pulp problem Can result from hyperocclusion Pain to pressure or percussion (biting) because inflamed tissue is compressed against hard tissues (root and lamina dura) Pain can be spontaneous dentalorg.com Usually no thermal sensitivity (pulp is usually at least partially necrotic) May have thermal sensitivity if some pulp is vital (e.g., multirooted teeth) Symptomatic Apical Periodontitis: Acute Apical Periodontitis Symptomatic Apical Periodontitis: Acute Apical Periodontitis Radiography: Slight widening of PDL Radiography: May have a small periapical radiolucency Histology: Neutrophils and edema, no pus Why is it so painful?? Treatment: Endodontic therapy or extraction Symptomatic Apical Periodontitis: Acute Apical Periodontitis  Periapical Inflammation: AAE Classification Symptomatic apical periodontitis Asymptomatic apical periodontitis  Periapical granuloma  Periapical (radicular) cyst Acute apical abscess  Sequellae of acute apical abscess Chronic apical abscess Periapical scar (fibrous healing defect)  Asymptomatic Apical Periodontitis: Chronic Apical Periodontitis  Periapical inflammation and destruction of apical tissues  Results from pulp necrosis (no response on pulp testing)  No pain or discomfort to thermal changes  No pain or discomfort to percussion or pressure:  Pressure of inflamed PDL resorbs the lamina dura  Inflammatory process spreads into delicate medullary bone Asymptomatic Apical Periodontitis: Chronic Apical Periodontitis Chronic inflammation at apex of non-vital tooth Occurs over long time (chronic) Produces obvious radiographic changes in bone Two histologic lesions:  Periapical granuloma  Periapical (radicular) cyst Asymptomatic Apical Periodontitis: Chronic Apical Periodontitis Asymptomatic Apical Periodontitis: Chronic Apical Periodontitis  Asymptomatic Apical Periodontitis: Chronic Apical Periodontitis Periapical granuloma  Can be a sequela of acute apical periodontitis  Can arise de novo as chronic inflammatory lesion from the beginning  Can progress to periapical cyst Asymptomatic Apical Periodontitis: Chronic Apical Periodontitis Periapical granuloma  Radiography: widened PDL, resorption of lamina dura; may cause root resorption  Periapical radiolucency forms; indistinct margins at first, well-defined with time  Histology: granulation tissue, chronic inflammatory cells  Why is this lesion NOT painful??  Treatment: endodontic therapy or extraction Asymptomatic Apical Periodontitis: Chronic Apical Periodontitis Periapical granuloma Asymptomatic Apical Periodontitis: Chronic Apical Periodontitis Periapical granuloma Asymptomatic Apical Periodontitis: Chronic Apical Periodontitis Periapical granuloma = granulation tissue It is not a true granuloma! Asymptomatic Apical Periodontitis: Chronic Apical Periodontitis Periapical granuloma NO!  Asymptomatic Apical Periodontitis: Chronic Apical Periodontitis Periapical cyst  Cyst: Pathological cavity lined by epithelium  Also called radicular cyst  Arises in pre-existing periapical granuloma  Proliferation of epithelial rests of Malassez in PDL  Same features as periapical granuloma  Mostlyasymptomatic; may be mildly painful to percussion  Not sensitive to thermal stimuli (pulp is necrotic) Asymptomatic Apical Periodontitis: Chronic Apical Periodontitis Periapical cyst Epithelial rest of Malassez  Asymptomatic Apical Periodontitis: Chronic Apical Periodontitis Periapical cyst  Radiography: indistinguishable from periapical granuloma on conventional radiographs  Larger periapical lesions (> 2 cm) more likely to be periapical cysts  Histology: hyperplastic stratified squamous epithelial cyst lining, supported by chronically inflamed granulation tissue  Treatment: endodontic therapy or extraction Asymptomatic Apical Periodontitis: Chronic Apical Periodontitis Periapical cyst Asymptomatic Apical Periodontitis: Chronic Apical Periodontitis Periapical cyst Asymptomatic Apical Periodontitis: Chronic Apical Periodontitis Periapical cyst  Asymptomatic Apical Periodontitis: Chronic Apical Periodontitis Periapical cyst Hyperplastic stratified Cholesterol slits from squamous epithelium epithelial cells Asymptomatic Apical Periodontitis: Chronic Apical Periodontitis  Periapical Inflammation: AAE Classification Symptomatic apical periodontitis Asymptomatic apical periodontitis  Periapical granuloma  Periapical (radicular) cyst Acute apical abscess  Sequellae of acute apical abscess Chronic apical abscess Periapical scar (fibrous healing defect) Acute Apical Abscess  Abscess: localized collection of pus, usually painful and swollen  Periapical inflammation caused by pulpal infection and necrosis  Rapid onset of spontaneous pain  Extremely painful on percussion  Pus formation, causing swelling in the buccal vestibule, lingual/palatal area, or in a fascial space Acute Apical Abscess Radiography: Slight to moderate widening of PDL (depending on duration) May produce radiolucency (depending on duration) Histology: Neutrophils, edema, pus Treatment: Endodontic therapy or extraction MUST establish drainage of pus Acute Apical Abscess Acute Apical Abscess Masses of neutrophils and pus in PDL  Periapical Inflammation: AAE Classification Symptomatic apical periodontitis Asymptomatic apical periodontitis  Periapical granuloma  Periapical (radicular) cyst Acute apical abscess  Sequellae of acute apical abscess Chronic apical abscess Periapical scar (fibrous healing defect)  Sequelae of Acute Apical Abscess: Dentoalveolar Abscess Abscess is confined to the alveolar process by the muscle attachments Does not spread into the fascial spaces  Sequelae of Acute Apical Abscess: Parulis (Gingival Abscess) Pressure of abscess can produce fistula Fistula can perforate cortex, elevate periosteum Parulis: granulation tissue with numerous acute and chronic inflammatory cells producing a nodular gingival enlargement resulting from acute apical abscess Also known as “gum boil” Sequelae of Acute Apical Abscess: Parulis (Gingival Abscess) Sequelae of Acute Apical Abscess: Parulis (Gingival Abscess) www.identalhub.com  Sequelae of Acute Apical Abscess: Skin or Palatal Parulis Abscess takes path of least resistance Depending on location, can point toward skin or palate Sequelae of Acute Apical Abscess: Skin or Palatal Parulis Sequelae of Acute Apical Abscess: Skin or Palatal Parulis intranet.tdmu.edu.ua  Sequelae of Acute Apical Abscess: Cellulitis (Phlegmon) If abscess is not drained it can spread through soft tissues Virulent organisms produce histolytic enzymes (e.g., hyaluronidase) Cellulitis: diffuse spread of acute inflammation through soft tissue and fascial planes Especially likely in immunosuppressed patients (HIV, diabetes, etc.) Cellulitis can progress to abscess formation  Sequelae of Acute Apical Abscess: Cellulitis and Buccal Space Abscess  Sequelae of Acute Apical Abscess: Ludwig Angina Cellulitis of submandibular, sublingual, and submental spaces Usually arises from necrotic mandibular teeth Can extend to lateral pharyngeal space, retropharyngeal space, or mediastinum Pocket Dentistry  Sequelae of Acute Apical Abscess: Ludwig Angina Elevation, enlargement, and protrusion of tongue (woody tongue) Enlargement and tenderness of neck (bull neck) Bilateral spread is common Respiratory obstruction secondary to laryngeal edema Treatment: drainage, antibiotics, remove cause (tooth) www.surgical-dentistry.info  Sequelae of Acute Apical Abscess: Cavernous Sinus Thrombosis Abscess in maxillary teeth perforates buccal cortex Spreads to maxillary sinus, pterygopalatine fossa or infratemporal fossa Reaches orbit through inferior orbital fissure Spreads to cavernous sinus at base of skull Emedicine Medscape  Sequelae of Acute Apical Abscess: Cavernous Sinus Thrombosis Abscess in anterior teeth can invade canine space Spreads to cavernous sinus through facial veins Caused by odontogenic infection in 10% of cases  Sequelae of Acute Apical Abscess: Cavernous Sinus Thrombosis Periorbital edema, proptosis of orbit Swelling along side of nose if canine space involved Can cause brain abscess, death Treatment: drainage, antibiotics Sequelae of Acute Apical Abscess: Cavernous Sinus Thrombosis  Periapical Inflammation: AAE Classification Symptomatic apical periodontitis Asymptomatic apical periodontitis  Periapical granuloma  Periapical (radicular) cyst Acute apical abscess  Sequellae of acute apical abscess Chronic apical abscess Periapical scar (fibrous healing defect)  Chronic Apical Abscess Periapical inflammation caused by pulpal infection and necrosis Gradual onset with little or no pain Pus formation with drainage through a fistula (purulent exudate) Drainage releases pressure, eliminating pain Much more likely than acute apical abscess to drain and relieve pain Chronic Apical Abscess  Chronic Apical Abscess Radiography: Radiolucent lesion similar to chronic apical periodontitis Histology: abscess surrounded by granulation tissue; sinus tract Treatment: endodontic therapy or extraction Chronic Apical Abscess  Periapical Inflammation: AAE Classification Symptomatic apical periodontitis Asymptomatic apical periodontitis  Periapical granuloma  Periapical (radicular) cyst Acute apical abscess  Sequellae of acute apical abscess Chronic apical abscess Periapical scar (fibrous healing defect)  Periapical Scar (Fibrous Healing Defect) Occasionally a chronic periapical lesion heals with dense collagen formation More likely if cortical plates are lost Can follow apicoectomy Can also occur with plates intact  Periapical Scar (Fibrous Healing Defect) Radiography: indistinguishable from periapical granuloma on conventional radiographs Histology: dense, hyalinized fibrous tissue with scanty vasculature, no inflammatory component Treatment: None If scar is suspected, periodic radiographs to monitor for change  Periapical Scar (Fibrous Healing Defect) Apicoectomy  Don’t Fall into the Trap! Dental papilla and follicle of developing teeth Mental foramen  Periapical Inflammation: Other Lesions Residual periapical granuloma/cyst Condensing (sclerosing) osteitis  Residual condensing (sclerosing) osteitis Periostitis ossificans Osteomyelitis  Residual Periapical Granuloma/Cyst Lesions can be left behind after extraction of tooth Most common diagnosis for solitary radiolucencies in alveolar process Residual Periapical Granuloma/Cyst Residual Periapical Granuloma/Cyst  Periapical Inflammation: Other Lesions Residual periapical granuloma/cyst Condensing (sclerosing) osteitis  Residual condensing (sclerosing) osteitis Periostitis ossificans Osteomyelitis  Condensing Osteitis Also called sclerosing osteitis Chronic periapical response to long-term pulpitis or pulpal necrosis Mild inflammatory reaction (variant of chronic apical periodontitis) Stimulates bone formation Usually in teens and young adults  Condensing Osteitis Most are asymptomatic Occasionally mild pain to percussion or palpation Radiography: Irregular homogeneous radiopacity at apices Often poorly defined, may be well defined Histology: dense sclerotic bone, scanty inflammatory cells Condensing Osteitis Condensing Osteitis Condensing Osteitis Condensing Osteitis Condensing Osteitis Treatment: Endodontic therapy or extraction Sometimes no treatment Most lesions remodel, but some remain  Periapical Inflammation: Other Lesions Residual periapical granuloma/cyst Condensing (sclerosing) osteitis  Residual condensing (sclerosing) osteitis Periostitis ossificans Osteomyelitis Residual Condensing Osteitis Can be left behind after extraction of tooth Most common diagnosis of solitary radiopacity in alveolar process Residual Condensing Osteitis What’s this? Residual Condensing Osteitis  Radiographic Signs of Pulpal Inflammation or Death Widening of apical PDL space Resorption of apical lamina dura Periapical radiolucency or radiopacity  Periapical Inflammation: Other Lesions Residual periapical granuloma/cyst Condensing (sclerosing) osteitis  Residual condensing (sclerosing) osteitis Periostitis ossificans Osteomyelitis  Periostitis Ossificans (“Garre’s Osteomyelitis”) Proliferation and ossification of periosteum Sequella of periapical inflammation in mandibular molars or premolars Usually affects children and young adults  Periostitis Ossificans (“Garre’s Osteomyelitis”) Usually asymptomatic Bony hard swelling over inferior border or buccal aspect of mandible Histology: inflammation of periosteum, layers of new woven bone parallel to cortex Often find trabeculae perpendicular to cortex as well  Periostitis Ossificans (“Garre’s Osteomyelitis”) Radiography: Faintly radiopaque thickening along cortex (periosteum) “Onion-skin” thickening representing ossification of periosteum Can be diffuse radiopacity (similar to fibrous dysplasia) Treatment: endodontics or extraction; cosmetic surgery NOT NEEDED Periostitis Ossificans Periostitis Ossificans Periostitis Ossificans Periostitis Ossificans Periostitis Ossificans What is “Garrè’s Osteomyelitis”? Used incorrectly as synonym for periostitis ossificans Garrè (1893) described cases of acute osteomyelitis, some causing bone enlargement Never mentioned “onion-skin” thickening of jaw Authors should read the references they cite!!  Periapical Inflammation: Other Lesions Residual periapical granuloma/cyst Condensing (sclerosing) osteitis  Residual condensing (sclerosing) osteitis Periostitis ossificans Osteomyelitis  Osteomyelitis Inflammation of bone medullary spaces Usually arises from odontogenic infection, periodontitis Not confined to apices Occurs in cases of immune dysfunction: AIDS, leukemia, diabetes, alcoholism, etc. Can occur in bone disease:  Pagetdisease  Osteopetrosis  Osteomyelitis Most common in men Large majority in the mandible Acute or chronic  Acute Osteomyelitis Pain, fever, leukocytosis, lymphadenopathy Occasional paraesthesia Histology: neutrophils and pus, necrotic bone, bacteria Radiography: few changes early -- diffuse thinning of trabeculae produces radiolucency with indistinct borders Acute Osteomyelitis USC  Chronic Osteomyelitis Sequella of acute phase, or de novo Variable pain, jaw enlargement, sinus tract, fracture Acute exacerbations common -- pus can form Histology: chronically or subacutely inflamed fibrous tissue, sequestra of non-viable bone, bacteria  Chronic Osteomyelitis USC www.exodontia.info  Chronic Osteomyelitis Radiography: Extensive “moth-eaten” indistinct radiolucencies Sclerotic radiopaque foci of sequestrated bone Chronic Osteomyelitis Chronic Osteomyelitis Chronic Osteomyelitis Chronic Osteomyelitis USC  Treatment of Osteomyelitis Acute: Remove cause of infection, establish drainage, antibiotics Chronic: Remove cause of infection, establish drainage, prolonged course of IV antibiotics, may need to remove sequestra  Remember --- Diagnosis of pulpal and periapical pathoses is based on signs and symptoms Must include pulpal and periapical diagnosis Don’t just treat the pain – identify the cause