Acute apical-periodontitis.25.mar.2013

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Acute apical-periodontitis.25.mar.2013

  1. 1. 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. )
  2. 2. 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 pulp´´pulp´´ Inflammation around a root end is known asInflammation around a root end is known as ´´apical´´apical periodontitis´´periodontitis´´ 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.
  3. 3. 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.
  4. 4. 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 findings.findings.
  5. 5. Radiographic Features of PeriapicalRadiographic Features of Periapical DiseaseDisease 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.
  6. 6. 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 platesplates
  7. 7. 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 extraction.extraction.
  8. 8. 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.
  9. 9. 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.
  10. 10. 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
  11. 11. Usually there are very few radiographicUsually there are very few radiographic features accompanying acute apicalfeatures accompanying acute apical periodontitisperiodontitis 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 evident.evident. 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
  12. 12. 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 regionregion
  13. 13. APICAL PERIODNTITISAPICAL PERIODNTITIS Inflammation of periapical regionInflammation of periapical region Causes: 1,Causes: 1, Trauma-direct blow to theTrauma-direct blow to the toothtooth 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.
  14. 14. 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 formation.formation. 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.
  15. 15. Acute Apical PeriodontitisAcute Apical Periodontitis Aetiology:Aetiology: 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.
  16. 16. StagesStages 1.1. Periodontal stagePeriodontal stage hyperemia ofhyperemia of blood vessels and oedema inblood vessels and oedema in periodontiumperiodontium 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
  17. 17. 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
  18. 18. 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
  19. 19. 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 symptomssymptoms
  20. 20. Diagnosis:Diagnosis: 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, pyrexiapyrexia X-ray: vary from widen periodontal spaceX-ray: vary from widen periodontal space to a large alveolar radiolucency.to a large alveolar radiolucency.
  21. 21. Differential diagnosisDifferential diagnosis Acute serous and purulent pulpitis,Acute serous and purulent pulpitis, abscessabscess
  22. 22. 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)
  23. 23. Abscesses are caused by virulentAbscesses are caused by virulent organisms and decreased immunologicorganisms and decreased immunologic rsponsesrsponses Apical abscesses are caused by necroticApical abscesses are caused by necrotic pulps.pulps. 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 impairedimpaired Apical abscesses are painfulApical abscesses are painful Fever, leukocytosis, and neutrophilia areFever, leukocytosis, and neutrophilia are commonly present.commonly present.
  24. 24. 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: redness,redness, 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.
  25. 25. 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
  26. 26. 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).
  27. 27. 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).
  28. 28. Abscesses may not be detected withAbscesses may not be detected with radiographs, they are composed of acuteradiographs, they are composed of acute inflammationinflammation 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 evident.evident. 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 prominent.prominent.
  29. 29. Establishing drainage and properEstablishing drainage and proper antimicrobial therapy will cure mostantimicrobial therapy will cure most abscessesabscesses 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 pursued.pursued. 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.
  30. 30. 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 performed.performed. 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.
  31. 31. 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 involved.involved.
  32. 32. 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 cavitycavity 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.
  33. 33. 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.

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