Acute apical periodontitisAcute apical periodontitis(parodontitis apicalis acuta)(parodontitis apicalis acuta)

(etiology, calssification, clinical (etiology, calssification, clinical features, dg., diff. Dg. )features, dg., diff. Dg. )

Definition of Periapical DiseaseDefinition of Periapical DiseasePeriapical diseasesPeriapical diseases are ´´an inflammatory conditions are ´´an inflammatory conditions occuring around the apex of a tooth caused by a necrotic occuring around the apex of a tooth caused by a necrotic pulp´´pulp´´Inflammation around a root end is known as Inflammation around a root end is known as ´´apical ´´apical periodontitis´´periodontitis´´Structures around the apical foramen constitute the Structures around the apical foramen constitute the ´´´´periapical regionperiapical region´´´´Structures surrounding the apex of tooth roots are known Structures surrounding the apex of tooth roots are known collectively as the ´´collectively as the ´´periapical tissuesperiapical tissues´´, they consist of ´´, they consist of the periodontal ligament and the alveolar bone.the periodontal ligament and the alveolar bone.Lesions produced by periapical infection are in close Lesions produced by periapical infection are in close proximity to the apices of the teeth.proximity to the apices of the teeth.Periapical lesions are recognized by their radiographic Periapical lesions are recognized by their radiographic appearance and the symptoms they produce.appearance and the symptoms they produce.

Etiology of Periapical DiseaseEtiology of Periapical Disease

Most periapical diseases are caused by Most periapical diseases are caused by dead pulps.dead pulps.

Most, but not all, pulpal disease is caused Most, but not all, pulpal disease is caused by bacterial invasion from dental caries or, by bacterial invasion from dental caries or, less commonly, cracked teeth. less commonly, cracked teeth.

The remainder are caused by non-bacterial The remainder are caused by non-bacterial pulpal deaths caused, for example trauma.pulpal deaths caused, for example trauma.

The products of bacterial invasion and pulp The products of bacterial invasion and pulp necrosis initiate most periapical diseases.necrosis initiate most periapical diseases.

Clinical Features of Periapical DiseaseClinical Features of Periapical Disease

The signs and symptoms of periapical The signs and symptoms of periapical disease are related to inflammationdisease are related to inflammation

Being inflammatory in origin, periapical Being inflammatory in origin, periapical diseases manifest with the signs and diseases manifest with the signs and symptoms of acute or chronic inflammation.symptoms of acute or chronic inflammation.

However, there is no consistent relationship However, there is no consistent relationship between patient´s symptoms and histologic between patient´s symptoms and histologic findings.findings.

Radiographic Features of Periapical Radiographic Features of Periapical DiseaseDisease

Most periapical lesions manifest as Most periapical lesions manifest as sharply-defined radiolucencies.sharply-defined radiolucencies.Most, but not all, periapical lesions destroy Most, but not all, periapical lesions destroy bone around the tooth apex resulting in bone around the tooth apex resulting in radiolucent defects on radiographic radiolucent defects on radiographic examination of the area.examination of the area.Because it takes several days for enough Because it takes several days for enough bone destruction to produce a radiolucent bone destruction to produce a radiolucent lesion, the earliest periapical lesions may lesion, the earliest periapical lesions may not be detected in a radiograph.not be detected in a radiograph.

The more long-lived ones will cause The more long-lived ones will cause enough bone destruction to produce a enough bone destruction to produce a radiolucency that can be easily detected in radiolucency that can be easily detected in a radiograph. a radiograph.

As will be seen, most periapical lesion are As will be seen, most periapical lesion are small and well- circumscribed.small and well- circumscribed.

It is uncommon for these lesions to It is uncommon for these lesions to become large, to spread, or to break become large, to spread, or to break through the surrounding cortical bony through the surrounding cortical bony platesplates

Acute Apical PeriodontitisAcute Apical Periodontitis

Acute Inflammatory Periapical DiseasesAcute Inflammatory Periapical Diseases

A common condition accompanied by A common condition accompanied by excruciating pain, a necrotic pulp, and excruciating pain, a necrotic pulp, and radiographic thickening of the apical radiographic thickening of the apical periodontal ligament space, treatment periodontal ligament space, treatment requires pulp extirpation or tooth requires pulp extirpation or tooth extraction.extraction.

Acute inflammation may extend into the Acute inflammation may extend into the periapical tissuesperiapical tissues

Excruciating is associated with acute Excruciating is associated with acute pulpitis, it is also associated with extension pulpitis, it is also associated with extension of the acute inflammatory process into the of the acute inflammatory process into the periapical tissues creating periapical tissues creating acute apical acute apical periodontitisperiodontitis

While bacterial infection and necrotic pulp While bacterial infection and necrotic pulp are responsible for the onset of most are responsible for the onset of most cases of AAP, it may also be a cases of AAP, it may also be a complication of initial endodontic therapy.complication of initial endodontic therapy.

In these cases, machanical cleansing of In these cases, machanical cleansing of the root cannals forces irritating debris into the root cannals forces irritating debris into the periapical tissues initiating an acute the periapical tissues initiating an acute inflammatory response there .inflammatory response there .

Pain is the presenting symptom, it may be Pain is the presenting symptom, it may be provoked by percussionprovoked by percussion..

The patient may also sense that the The patient may also sense that the affected tooth is higher than nearby ones.affected tooth is higher than nearby ones.

Often the pain is so diffuse that the patient Often the pain is so diffuse that the patient cannot localize it.cannot localize it.

The dentist can usually locate the The dentist can usually locate the offending tooth by the crude but effective offending tooth by the crude but effective technique of tapping (percussion) on one technique of tapping (percussion) on one tooth after another until the patient tooth after another until the patient experiances pain.experiances pain.

Extension of the acute inflammatory Extension of the acute inflammatory response into the periodontal ligament response into the periodontal ligament explains both tooth elevation and tapping-explains both tooth elevation and tapping-induced paininduced pain

Usually there are very few radiographic Usually there are very few radiographic features accompanying acute apical features accompanying acute apical

periodontitisperiodontitisAAP arises so quickly, probably within an AAP arises so quickly, probably within an hour or two, that bone destruction and its hour or two, that bone destruction and its resulting radiographic changes may not be resulting radiographic changes may not be evident.evident.Sometimes, however, widened periodontal Sometimes, however, widened periodontal ligament around the apex may produce a ligament around the apex may produce a radiolucent thickening there.radiolucent thickening there.Microscopic features include a localized Microscopic features include a localized acute inflammatory exudate with dilated acute inflammatory exudate with dilated capillaries, and neutrophilscapillaries, and neutrophils

The pulp will die making extirpation or The pulp will die making extirpation or extraction necessaryextraction necessary

Since the source of AAP is a necrotic pulp, Since the source of AAP is a necrotic pulp, it follows that pulp extirpation or extraction it follows that pulp extirpation or extraction is the appropriate therapy for it.is the appropriate therapy for it.

If the lesion resulted from endodontic If the lesion resulted from endodontic therapy, the endodontist will usually re-therapy, the endodontist will usually re-open the canal to allow drainage or, if the open the canal to allow drainage or, if the canal filling has been completed, enter the canal filling has been completed, enter the periapical area surgically to debride the periapical area surgically to debride the region region

APICAL PERIODNTITISAPICAL PERIODNTITISInflammation of periapical regionInflammation of periapical region

Causes: 1, Causes: 1, Trauma-direct blow to theTrauma-direct blow to the

toothtooth

2, 2, Chemicals- Passage of Chemicals- Passage of

chemical irritants throughchemical irritants through

the apical foramen during the use the apical foramen during the use of drugs in treatment of deep cavities, and of drugs in treatment of deep cavities, and pulp lesions pulp lesions

3, 3, Bacterial toxins, bacterial Bacterial toxins, bacterial infections-in dental caries, pulp lesions.infections-in dental caries, pulp lesions.

The response to apical irritans can be acute The response to apical irritans can be acute or chronic-or chronic-

1. Most commonly balance between body 1. Most commonly balance between body resistance and noxious agent–granuloma resistance and noxious agent–granuloma formation.formation.

2. 2. noxious stimuli or noxious stimuli or ↓ body resistance–↓ body resistance–suppurative apical periodontitissuppurative apical periodontitis

3. chronic lesion may develop apical 3. chronic lesion may develop apical cyst.cyst.

Acute Apical PeriodontitisAcute Apical Periodontitis

Aetiology:Aetiology:

Pulp disease (deep caries), bacterial Pulp disease (deep caries), bacterial toxins, bacterial irritations-passage of toxins, bacterial irritations-passage of instruments beyond the canal which instruments beyond the canal which may push some irritants as necrotic, may push some irritants as necrotic, pulp tissue, bacteria, or dentine pulp tissue, bacteria, or dentine fragments into periodontal ligament.fragments into periodontal ligament.

StagesStages

1. 1. Periodontal stage Periodontal stage hyperemia of hyperemia of blood vessels and oedema in blood vessels and oedema in periodontiumperiodontium

2. 2. Endosseus stage Endosseus stage the bone is the bone is envolved first by hyperemia of vessels envolved first by hyperemia of vessels then by leukocytic infiltration and then by leukocytic infiltration and finally by pus formationfinally by pus formation

3. 3. Subperiostal stage Subperiostal stage pus beneath the pus beneath the periosteum-subperiostal abscessperiosteum-subperiostal abscess

4. 4. Submucous stage Submucous stage pus in soft tissue-pus in soft tissue-submucous abscesssubmucous abscess

Clinical featuresClinical featuresGenerally- Rapid onset, acute pain, tooth Generally- Rapid onset, acute pain, tooth sensitive to touch, massive swelling.sensitive to touch, massive swelling.

Periodontal stage-Periodontal stage- the tooth is painful to the tooth is painful to touch by eating, bite slightfeeling of touch by eating, bite slightfeeling of elevated tooth in the socketelevated tooth in the socket

Endosseous stage-Endosseous stage- intensive pain, intensive pain, constant, throbbing, pressing pain.constant, throbbing, pressing pain.

Patient wants to extract the tooth, strong Patient wants to extract the tooth, strong feeling of elevated tooth feeling of elevated tooth

Subperiosteal stage-Subperiosteal stage- throbbing pain throbbing pain increasing in intensity, the tooth is increasing in intensity, the tooth is extremly sensitive to touch, swelling extremly sensitive to touch, swelling area is sensitivearea is sensitive

Submucous stage-Submucous stage- decrease of painful decrease of painful symptomssymptoms

Diagnosis:Diagnosis:

History (painful symptoms) sensitivity to History (painful symptoms) sensitivity to touch, tooth in supraocclusion, face touch, tooth in supraocclusion, face asymetry due to swelling, lymph node asymetry due to swelling, lymph node involvement, tenderness to percussion, involvement, tenderness to percussion, pyrexiapyrexia

X-ray: vary from widen periodontal space X-ray: vary from widen periodontal space to a large alveolar radiolucency.to a large alveolar radiolucency.

Differential diagnosisDifferential diagnosis

Acute serous and purulent pulpitis, Acute serous and purulent pulpitis, abscessabscess

Apical AbscessApical Abscess

Acute pulpal-periapical inflammation may Acute pulpal-periapical inflammation may enlarge into an enlarge into an abscess abscess Pain associated with AAP is sufficient to Pain associated with AAP is sufficient to require the patient to seek dental care.require the patient to seek dental care.It is also usually the case that the patients It is also usually the case that the patients defenses are capable of localizing the defenses are capable of localizing the infection to the periapical regioninfection to the periapical regionThe acute inflammatory reaction may The acute inflammatory reaction may enlarge forming an abscess (apical enlarge forming an abscess (apical abscess, dento-alveolar abscess)abscess, dento-alveolar abscess)

Abscesses are caused by virulent organisms Abscesses are caused by virulent organisms and decreased immunologic rsponsesand decreased immunologic rsponses

Apical abscesses are caused by necrotic Apical abscesses are caused by necrotic pulps.pulps.Abscess formation suggests that the Abscess formation suggests that the microorganism responsible is virulent or microorganism responsible is virulent or the patients immunologic defenses are the patients immunologic defenses are impairedimpairedApical abscesses are painfulApical abscesses are painfulFever, leukocytosis, and neutrophilia are Fever, leukocytosis, and neutrophilia are commonly present.commonly present.

As the lesion enlarges, it may penetrate the As the lesion enlarges, it may penetrate the buccal or lingual cortical plates and expand into buccal or lingual cortical plates and expand into the surrounding soft tissues.the surrounding soft tissues.

Such extension may include the floor of the Such extension may include the floor of the mouth, the palate, the face, and the neck.mouth, the palate, the face, and the neck.

Soft tissue extension will show the usual Soft tissue extension will show the usual features of acute inflammation:features of acute inflammation:

redness, redness,

swelling and warmthswelling and warmth

Unless a dentist intervenes, the abscess will drain Unless a dentist intervenes, the abscess will drain spontaneously exuding a purulent exudate.spontaneously exuding a purulent exudate.

A tooth abscess is normally not seeable, except as a lump - sometimes - as the tooth abscess exists under the skin and can only be seen, as such, by X-rays. Sometimes you may see a picture of a face with part of it swollen, again you are seeing the swelling under the skin, not actually seeing the tooth abscess as such - some of the swellings can be through the lymph glands trying to take the infection caused by the tooth abscess. On X-ray, the tooth abscess can be seen by a trained eye. Most pictures of a tooth abscess simply show a drawing of a tooth, a cavity leading into the soft pulp, and a colored area denoting the infection

Acute tooth abscess: Characterized by rapid, painful onset. Sleep and overall function may be disturbed due to symptoms involved. Swelling of gum tissue and surrounding areas my be present. It can be very difficult to find relief during the painful peak of a tooth abscess. Daily activities are often interrupted during this time

Any abscessed tooth has the potential to become a life threatening situation. Infection of a tooth in the lower jaw can cause swelling of the check and under the jaw bone. If the swelling under the jaw becomes too advanced, swallowing and breathing can become critically impaired (Ludwig's Angina).

An infection of a top tooth may produce swelling in the check, side of the temple or under the eye. The gradual closing of the eye due to swelling and infection represents a dire situation (Cavernous Sinus Thrombosis).

Abscesses may not be detected with Abscesses may not be detected with radiographs, they are composed of acute radiographs, they are composed of acute

inflammationinflammationAn apical abscess, like AAP, arises suddenly so An apical abscess, like AAP, arises suddenly so there is little radiographic change.there is little radiographic change.If the lesion has been present long enough, If the lesion has been present long enough, however, a faint, diffuse radiolucency may be however, a faint, diffuse radiolucency may be evident.evident.Abscesses are composed of an intense acute Abscesses are composed of an intense acute inflammatory reaction.inflammatory reaction.In addition to the usual features of acute In addition to the usual features of acute inflammation, immature neutrophils (band cells) inflammation, immature neutrophils (band cells) are likely to be seen, dead and dying neutrophils are likely to be seen, dead and dying neutrophils and necrotic debris (suppuration) are also and necrotic debris (suppuration) are also prominent.prominent.

Establishing drainage and proper Establishing drainage and proper antimicrobial therapy will cure most antimicrobial therapy will cure most

abscessesabscesses

In the absence of significant radiographic In the absence of significant radiographic changes, the dentist must rely on clinical changes, the dentist must rely on clinical features to arrive at a proper diagnosis (pain, features to arrive at a proper diagnosis (pain, systemic features, suppuration)systemic features, suppuration)

Once the presence of an apical abscess is Once the presence of an apical abscess is suspected , vigorous treatment must be suspected , vigorous treatment must be pursued. pursued.

First, the source of the acute inflammatory First, the source of the acute inflammatory response must be identified and eliminated.response must be identified and eliminated.

Second, a bacterial culture of exudate must be Second, a bacterial culture of exudate must be obtained and submitted to a laboratory for the obtained and submitted to a laboratory for the purpose of identifying the offending purpose of identifying the offending microorganism and determine the antibiotic most microorganism and determine the antibiotic most effective in killing it (culture and sensitivity test)effective in killing it (culture and sensitivity test)

Finnaly, the dentist should prescribe an ATB.Finnaly, the dentist should prescribe an ATB.

If the abscess has spread into the If the abscess has spread into the surrounding surrounding soft tissuessoft tissues, an incision and hrainage should be , an incision and hrainage should be performed.performed.

This procedure provides a source of exudate for This procedure provides a source of exudate for culture and sensitivity testing, and, allows for the culture and sensitivity testing, and, allows for the removal of suppuration so that repair will follow.removal of suppuration so that repair will follow.

Acute OsteomyelitisAcute Osteomyelitis

The main reason for treating apical The main reason for treating apical abscesses with vigor is to prevent spread abscesses with vigor is to prevent spread along the bone marrow spaces causing a along the bone marrow spaces causing a condition known as condition known as osteomyelitis.osteomyelitis.Ost. Is a very serious condition that can Ost. Is a very serious condition that can cause destruction of large sections of jaw cause destruction of large sections of jaw and be difficult to cure.and be difficult to cure.Ost. May be the inevitable result of Ost. May be the inevitable result of untreated pulpal or periapical infection.untreated pulpal or periapical infection.Almost always, bacterial infection is Almost always, bacterial infection is involved.involved.

Ost. More commonly affects the mandible Ost. More commonly affects the mandible than the maxilla. Probably the maxillas than the maxilla. Probably the maxillas excellent blood supply is the difference.excellent blood supply is the difference.There is usually malaise (discomfort), There is usually malaise (discomfort), pain, fever, and leukocytosis.pain, fever, and leukocytosis.There may be swelling of the mandible There may be swelling of the mandible and suppurative drainage into the oral and suppurative drainage into the oral cavity cavity Because the Ost. Takes longer to develop Because the Ost. Takes longer to develop than other acute inflammatory lesions, than other acute inflammatory lesions, usually there are significant and specific usually there are significant and specific radiographic changes. radiographic changes.

These include involvement of bone away from These include involvement of bone away from the periapical region, indistinct outline (diffuse the periapical region, indistinct outline (diffuse growth pattern) and combination of growth pattern) and combination of radiolucencies and radiopacities (mottled radiolucencies and radiopacities (mottled radiographic apperarance)radiographic apperarance)

Microscopically shows bone destruction Microscopically shows bone destruction (osteoclasts) and bone deposition (osteoblasts) (osteoclasts) and bone deposition (osteoblasts) proceeding side by side. proceeding side by side.

So, it is in bone:So, it is in bone:

Inflammation induced bone resorption and bone Inflammation induced bone resorption and bone repair may proceed simultaneously.repair may proceed simultaneously.

It is this reaction that produces the mottled It is this reaction that produces the mottled radiographic features of Ost.radiographic features of Ost.