Definition of Periapical DiseaseDefinition of Periapical Disease
Periapical diseasesPeriapical diseases are ´´an inflammatory conditionsare ´´an inflammatory conditions
occuring around the apex of a tooth caused by a necroticoccuring around the apex of a tooth caused by a necrotic
Inflammation around a root end is known asInflammation around a root end is known as ´´apical´´apical
Structures around the apical foramen constitute theStructures around the apical foramen constitute the
´´´´periapical regionperiapical region´´´´
Structures surrounding the apex of tooth roots are knownStructures 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 closeLesions 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 radiographicPeriapical 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 byMost periapical diseases are caused by
dead pulps.dead pulps.
Most, but not all, pulpal disease is causedMost, 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-bacterialThe remainder are caused by non-bacterial
pulpal deaths caused, for example trauma.pulpal deaths caused, for example trauma.
The products of bacterial invasion and pulpThe 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 periapicalThe signs and symptoms of periapical
disease are related to inflammationdisease are related to inflammation
Being inflammatory in origin, periapicalBeing inflammatory in origin, periapical
diseases manifest with the signs anddiseases manifest with the signs and
symptoms of acute or chronic inflammation.symptoms of acute or chronic inflammation.
However, there is no consistent relationshipHowever, there is no consistent relationship
between patient´s symptoms and histologicbetween patient´s symptoms and histologic
Radiographic Features of PeriapicalRadiographic Features of Periapical
Most periapical lesions manifest asMost periapical lesions manifest as
sharply-defined radiolucencies.sharply-defined radiolucencies.
Most, but not all, periapical lesions destroyMost, but not all, periapical lesions destroy
bone around the tooth apex resulting inbone around the tooth apex resulting in
radiolucent defects on radiographicradiolucent defects on radiographic
examination of the area.examination of the area.
Because it takes several days for enoughBecause it takes several days for enough
bone destruction to produce a radiolucentbone destruction to produce a radiolucent
lesion, the earliest periapical lesions maylesion, the earliest periapical lesions may
not be detected in a radiograph.not be detected in a radiograph.
The more long-lived ones will causeThe more long-lived ones will cause
enough bone destruction to produce aenough bone destruction to produce a
radiolucency that can be easily detected inradiolucency that can be easily detected in
a radiograph.a radiograph.
As will be seen, most periapical lesion areAs will be seen, most periapical lesion are
small and well- circumscribed.small and well- circumscribed.
It is uncommon for these lesions toIt is uncommon for these lesions to
become large, to spread, or to breakbecome large, to spread, or to break
through the surrounding cortical bonythrough the surrounding cortical bony
Acute Apical PeriodontitisAcute Apical Periodontitis
Acute Inflammatory Periapical DiseasesAcute Inflammatory Periapical Diseases
A common condition accompanied byA common condition accompanied by
excruciating pain, a necrotic pulp, andexcruciating pain, a necrotic pulp, and
radiographic thickening of the apicalradiographic thickening of the apical
periodontal ligament space, treatmentperiodontal ligament space, treatment
requires pulp extirpation or toothrequires pulp extirpation or tooth
Acute inflammation may extend into theAcute inflammation may extend into the
periapical tissuesperiapical tissues
Excruciating is associated with acuteExcruciating is associated with acute
pulpitis, it is also associated withpulpitis, it is also associated with
extension of the acute inflammatoryextension of the acute inflammatory
process into the periapical tissues creatingprocess into the periapical tissues creating
acute apical periodontitisacute apical periodontitis
While bacterial infection and necrotic pulpWhile bacterial infection and necrotic pulp
are responsible for the onset of mostare responsible for the onset of most
cases of AAP, it may also be acases of AAP, it may also be a
complication of initial endodontic therapy.complication of initial endodontic therapy.
In these cases, machanical cleansing ofIn these cases, machanical cleansing of
the root cannals forces irritating debris intothe root cannals forces irritating debris into
the periapical tissues initiating an acutethe periapical tissues initiating an acute
inflammatory response there .inflammatory response there .
Pain is the presenting symptom, it may bePain is the presenting symptom, it may be
provoked by percussionprovoked by percussion..
The patient may also sense that theThe 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 patientOften the pain is so diffuse that the patient
cannot localize it.cannot localize it.
The dentist can usually locate theThe dentist can usually locate the
offending tooth by the crude but effectiveoffending tooth by the crude but effective
technique of tapping (percussion) on onetechnique of tapping (percussion) on one
tooth after another until the patienttooth after another until the patient
experiances pain.experiances pain.
Extension of the acute inflammatoryExtension of the acute inflammatory
response into the periodontal ligamentresponse into the periodontal ligament
explains both tooth elevation and tapping-explains both tooth elevation and tapping-
induced paininduced pain
Usually there are very few radiographicUsually there are very few radiographic
features accompanying acute apicalfeatures accompanying acute apical
AAP arises so quickly, probably within anAAP arises so quickly, probably within an
hour or two, that bone destruction and itshour or two, that bone destruction and its
resulting radiographic changes may not beresulting radiographic changes may not be
Sometimes, however, widened periodontalSometimes, however, widened periodontal
ligament around the apex may produce aligament around the apex may produce a
radiolucent thickening there.radiolucent thickening there.
Microscopic features include a localizedMicroscopic features include a localized
acute inflammatory exudate with dilatedacute inflammatory exudate with dilated
capillaries, and neutrophilscapillaries, and neutrophils
The pulp will die making extirpation orThe 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 extractionit follows that pulp extirpation or extraction
is the appropriate therapy for it.is the appropriate therapy for it.
If the lesion resulted from endodonticIf 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 theopen the canal to allow drainage or, if the
canal filling has been completed, enter thecanal filling has been completed, enter the
periapical area surgically to debride theperiapical area surgically to debride the
APICAL PERIODNTITISAPICAL PERIODNTITIS
Inflammation of periapical regionInflammation of periapical region
Causes: 1,Causes: 1, Trauma-direct blow to theTrauma-direct blow to the
2,2, Chemicals- Passage ofChemicals- Passage of
chemical irritants throughchemical irritants through
the apical foramen during the usethe apical foramen during the use
of drugs in treatment of deep cavities, andof drugs in treatment of deep cavities, and
pulp lesionspulp lesions
3,3, Bacterial toxins, bacterialBacterial toxins, bacterial
infections-in dental caries, pulp lesions.infections-in dental caries, pulp lesions.
The response to apical irritans can beThe response to apical irritans can be
acute or chronic-acute or chronic-
1. Most commonly balance between body1. Most commonly balance between body
resistance and noxious agent–granulomaresistance and noxious agent–granuloma
2.2. noxious stimuli ornoxious stimuli or ↓ body resistance–↓ body resistance–
suppurative apical periodontitissuppurative apical periodontitis
3. chronic lesion may develop apical cyst.3. chronic lesion may develop apical cyst.
Acute Apical PeriodontitisAcute Apical Periodontitis
Pulp disease (deep caries), bacterialPulp disease (deep caries), bacterial
toxins, bacterial irritations-passage oftoxins, bacterial irritations-passage of
instruments beyond the canal whichinstruments beyond the canal which
may push some irritants as necrotic,may push some irritants as necrotic,
pulp tissue, bacteria, or dentinepulp tissue, bacteria, or dentine
fragments into periodontal ligament.fragments into periodontal ligament.
1.1. Periodontal stagePeriodontal stage hyperemia ofhyperemia of
blood vessels and oedema inblood vessels and oedema in
2.2. Endosseus stageEndosseus stage the bone isthe bone is
envolved first by hyperemia of vesselsenvolved first by hyperemia of vessels
then by leukocytic infiltration andthen by leukocytic infiltration and
finally by pus formationfinally by pus formation
3.3. Subperiostal stageSubperiostal stage pus beneath thepus beneath the
periosteum-subperiostal abscessperiosteum-subperiostal abscess
4.4. Submucous stageSubmucous stage pus in soft tissue-pus in soft tissue-
submucous abscesssubmucous abscess
Clinical featuresClinical features
Generally- Rapid onset, acute pain, toothGenerally- Rapid onset, acute pain, tooth
sensitive to touch, massive swelling.sensitive to touch, massive swelling.
Periodontal stage-Periodontal stage- the tooth is painful tothe tooth is painful to
touch by eating, bite slightfeeling oftouch 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, strongPatient wants to extract the tooth, strong
feeling of elevated toothfeeling of elevated tooth
Subperiosteal stage-Subperiosteal stage- throbbing painthrobbing pain
increasing in intensity, the tooth isincreasing in intensity, the tooth is
extremly sensitive to touch, swellingextremly sensitive to touch, swelling
area is sensitivearea is sensitive
Submucous stage-Submucous stage- decrease of painfuldecrease of painful
History (painful symptoms) sensitivity toHistory (painful symptoms) sensitivity to
touch, tooth in supraocclusion, facetouch, tooth in supraocclusion, face
asymetry due to swelling, lymph nodeasymetry due to swelling, lymph node
involvement, tenderness to percussion,involvement, tenderness to percussion,
X-ray: vary from widen periodontal spaceX-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,
Apical AbscessApical Abscess
Acute pulpal-periapical inflammation mayAcute pulpal-periapical inflammation may
enlarge into anenlarge into an abscessabscess
Pain associated with AAP is sufficient toPain 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 patientsIt is also usually the case that the patients
defenses are capable of localizing thedefenses are capable of localizing the
infection to the periapical regioninfection to the periapical region
The acute inflammatory reaction mayThe acute inflammatory reaction may
enlarge forming an abscess (apicalenlarge forming an abscess (apical
abscess, dento-alveolar abscess)abscess, dento-alveolar abscess)
Abscesses are caused by virulentAbscesses are caused by virulent
organisms and decreased immunologicorganisms and decreased immunologic
Apical abscesses are caused by necroticApical abscesses are caused by necrotic
Abscess formation suggests that theAbscess formation suggests that the
microorganism responsible is virulent ormicroorganism responsible is virulent or
the patients immunologic defenses arethe patients immunologic defenses are
Apical abscesses are painfulApical abscesses are painful
Fever, leukocytosis, and neutrophilia areFever, leukocytosis, and neutrophilia are
commonly present.commonly present.
As the lesion enlarges, it may penetrate theAs the lesion enlarges, it may penetrate the
buccal or lingual cortical plates and expand intobuccal or lingual cortical plates and expand into
the surrounding soft tissues.the surrounding soft tissues.
Such extension may include the floor of theSuch 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 usualSoft tissue extension will show the usual
features of acute inflammation:features of acute inflammation:
swelling and warmthswelling and warmth
Unless a dentist intervenes, the abscess will drainUnless 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
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 (
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 withAbscesses may not be detected with
radiographs, they are composed of acuteradiographs, they are composed of acute
An apical abscess, like AAP, arises suddenly soAn 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 behowever, a faint, diffuse radiolucency may be
Abscesses are composed of an intense acuteAbscesses are composed of an intense acute
inflammatory reaction.inflammatory reaction.
In addition to the usual features of acuteIn 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 neutrophilsare likely to be seen, dead and dying neutrophils
and necrotic debris (suppuration) are alsoand necrotic debris (suppuration) are also
Establishing drainage and properEstablishing drainage and proper
antimicrobial therapy will cure mostantimicrobial therapy will cure most
In the absence of significant radiographicIn the absence of significant radiographic
changes, the dentist must rely on clinicalchanges, 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 isOnce the presence of an apical abscess is
suspected , vigorous treatment must besuspected , vigorous treatment must be
First, the source of the acute inflammatoryFirst, 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 beSecond, a bacterial culture of exudate must be
obtained and submitted to a laboratory for theobtained and submitted to a laboratory for the
purpose of identifying the offendingpurpose of identifying the offending
microorganism and determine the antibiotic mostmicroorganism 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 theIf the abscess has spread into the surroundingsurrounding
soft tissuessoft tissues, an incision and hrainage should be, an incision and hrainage should be
This procedure provides a source of exudate forThis procedure provides a source of exudate for
culture and sensitivity testing, and, allows for theculture 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 apicalThe main reason for treating apical
abscesses with vigor is to prevent spreadabscesses with vigor is to prevent spread
along the bone marrow spaces causing aalong the bone marrow spaces causing a
condition known ascondition known as osteomyelitis.osteomyelitis.
Ost. Is a very serious condition that canOst. Is a very serious condition that can
cause destruction of large sections of jawcause destruction of large sections of jaw
and be difficult to cure.and be difficult to cure.
Ost. May be the inevitable result ofOst. May be the inevitable result of
untreated pulpal or periapical infection.untreated pulpal or periapical infection.
Almost always, bacterial infection isAlmost always, bacterial infection is
Ost. More commonly affects the mandibleOst. More commonly affects the mandible
than the maxilla. Probably the maxillasthan 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 mandibleThere may be swelling of the mandible
and suppurative drainage into the oraland suppurative drainage into the oral
Because the Ost. Takes longer to developBecause the Ost. Takes longer to develop
than other acute inflammatory lesions,than other acute inflammatory lesions,
usually there are significant and specificusually there are significant and specific
radiographic changes.radiographic changes.
These include involvement of bone away fromThese include involvement of bone away from
the periapical region, indistinct outline (diffusethe periapical region, indistinct outline (diffuse
growth pattern) and combination ofgrowth pattern) and combination of
radiolucencies and radiopacities (mottledradiolucencies and radiopacities (mottled
radiographic apperarance)radiographic apperarance)
Microscopically shows bone destructionMicroscopically 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 boneInflammation induced bone resorption and bone
repair may proceed simultaneously.repair may proceed simultaneously.
It is this reaction that produces the mottledIt is this reaction that produces the mottled
radiographic features of Ost.radiographic features of Ost.