Etiology of periradiculardiseasesBacterial:Untreated pulpal infection leading to total pulp necrosis if untreated , irritants leak into periapical region forming periapical pathologies. TraumaFactors related to root canal procedures:Cause inflammatory response due to the extirpation of the pulp, intra canal medicaments or the improper manipulation of instruments.
Grossman’s Classification1.Acute periradicular diseaseA. Acute alveolar abscess.B. Acute apical periodontitis: i. vital.ii. Non vital.2. Chronic Acute periradicular disease with areas of rarefaction :a. Chronic alveolar abscess.b. Granuloma.c. Cyst.3. Condensing ostitis.4. External root resorption.5. Diseases of the periradicular tissue of non – endodontic origin.
ACUTE APICAL PERIODONTITISAcute apical periodontitis is definedas painful inflammation of theperiodontuim around the apex ofthe root as a result of trauma,irritation or infection through theroot canal regardless of whetherthe pulp is vital or non vital. AAPis microscopic rather thanroentgenographic, symptomaticrather than visible.
Etiology of AAPa. In vital tooth, is due to occlusaltrauma, high point in restoration orwedging the object between teeth.b. In non vital tooth, is due to egress ofbacteria toxins from necrotic pulps,c. Iatrogenic causes can beoverinstrumentation, and extrusion ofobturating materials
Signs and Symptoms of AAP1-Clinical features of AAP are moderate to severespontaneous discomfort as well as pain duringmastication or occlusal contact.2- tooth is tender to percussion.3- no respond to vitality test unless the pulp is vital.4- no swelling5- usually no radiographic sign and intact lamina dura butsome times their is widening of periodontal ligamentspace .
Treatment of AAPa-Adjustment of occlusion (when there isevidence of hyper occlusion),b-Endodontic therapy to remove theirritants , a pathologic pulp or release ofexudate usually results in periradicularreliefc- prescribe analgesicsd- in certain situation extraction isalternative to endodontic therapy.
Acute periapical abscess localized accumulation of pus at the apex of a non vital tooth.Etiology: Extension of pulp infection to periapical area. Fracture of tooth with pulp exposure. Accidental perforation of apical foramen during RCT. Secondary bacterial invasion into pre-exesting periapical granuloma or cyst.
Acute periapical abscess, con’tClinical features: Tooth is non vital. Constant throbbing pain Localized as the tooth becomes increasingly tenderto percussion. Increase pain with chewing. Swelling (palpable, fluctuant). Mobility may or may not be present.
Acute periapical abscess, con’t-Clinical features: Tooth may be in hyper occlusion; tooth feels longer than others Gum boil Patient may have systemic symptoms(e.g. fever, enlarged lymph nodes)
Acute periapical abscess, con’tRadiographic features:Thickening of the periodontal ligament space iscommon.
Acute periapical abscess, con’tTreatment: Drainage of the abscess should be initiated as ea as possible This may include: Non surgical RCT. Incision and drainage. Extraction Prescribe antibiotics and analgesics
CHRONIC APICAL PERIODONTITISChronic apical periodontitis is defined asasymptomatic lesion of periodontuimaround the apex of the root that destroyalveolar bone proper (lamina dura)usually results from pulpal necrosis andusually is a sequel to AAP Histologicallythis lesion is categorized as a granulomaor cyst.
Etiology of CAPa- is due to egress of bacteria toxins fromnecrotic pulps,b- un treated acute apical periodontitis
Signs and Symptoms of CAP1- usually no pain during mastication orocclusal contact.2- little or no sensitivity to percussion.3- no respond to vitality test4- no swelling5- usually no tooth mobility6-Radiographic features range frominterruption of the lamina dura toextensive destruction of periradicular andinterradicular tissues.
Treatment of CAPa-Endodontic therapy to remove incitingirritants (necrotic pulp) and completeobturation usually result in resolution ofCAPb- in the case of unrestorable toothextraction followed by curettage of apicallesion is the best therapy.
Periapical granulomaIt is one of the most sequelae of pulpitis, it is a localized mass of granulation tissue around the root apex of non vital tooth.Clinical features: Most of cases are asymptomatic but sometimes pain and sensitivity are seen when acute exacerbation occurs. Tooth is not sensitive to percussion. No response to electrical or thermal pulp tests. Mostly lesions are discovered on routine radiographic examination.
Periapical granuloma, con’tRadiographic features: -initial stage shows widening of periodontalligament space. -lesions may be will circumscribedor poorly defined radiolucent area ofvarying size aroundroot apex. -log standing periapical granulomashows varying degree of root resorption.
Periapical granuloma, con’tTreatment: In restorable tooth, root canal therapy. In non-restorable tooth, extraction followed by curettage of all apical soft tissue.
Radicular cyst: It is defined as an odontogenic cyst of Inflammatory origin that is preceded by a chronic periapical granuloma and stimulation of cell rests of malaseez present in the periodontal membrane.
Radicular cyst:, con’tClinical features: The cyst is frequently asymptomatic and sometimes it is discovered when periapical radiographs are taken of teeth with non-vital pulps. These cysts are painless unless infected. However, complain of pain is also observed in patient without any evidence of infection.
Radicular cyst:, con’tclinical features: Occasionally, a sinus may lead from cyst cavity to the oral mucosa. It may be bony hard if cortex is intact, crepitate as the bone thins, or rubbery and fluctuant if the bone is destroyed. The involved tooth usually found to be non-vital, discolored, fractured or failed root canal.
Radicular cyst: , con’tRadiographic features: Radiccular cyst appears as round, pear or ovoid shaped radiolucency, outlined by a narrow rodioopaque margin
Periapical cyst, con’t Treatment: The source (i.e., necrotic pulp) should be removed by full pulpectomy (i.e., root canal therapy) or extraction of the offended tooth, and the cyst should be enuclated.
Radicular cyst, con’t Endodontic Treatment:- Peripheral lesions including radicular cysts are eliminated once the causative agents are removed. radicular cysts can undergo resolutions following Root Canal Treatment & dont require surgical intervention. It is suggested that insertion of file or other root canal instrument beyond the apical foramen (for 1-2mm) produces transitory acute inflammation which may destroy epithelial lining of radicular cyst & convert it into granuloma. Thus, leading to its resolutions.
CHRONIC APICAL ABSCESS (SUPPURATIVE APICAL PERIODONTITIS)Chronic apical abscess is Also classified assuppurative apical periodontitis(SAP), it ischronic (asymptomatic) apical abscessthat penetrate through bone and softtissue to form a sinus tract stoma on theoral mucosa and it is actually results froma long-standing lesion.
Etiology of CAAa- has a pathogenesis similar to that ofacute apical abscess, It also resultsfrom pulpal necrosis.b- it is usually associated with chronicapical periodontitis that has formed anabscess.
Signs and Symptoms of CAA1- is usually asymptomatic except whenthere is occasional closure of the sinuspathway, which can cause pain.2- detected by presence of sinus tract toapex of involved tooth.3- little or no sensitivity to percussion.4- no respond to vitality test5- no swelling6-Radiographic features rang frommoderate to extensive destruction ofperiradicular and interradicular tissues.
Treatment of CAAa-Endodontic therapy to remove incitingirritants (necrotic pulp) and this will lead toresolution of sinus tract.b- in the case of unrestorable toothextraction followed by curettage of apicallesion is the best therapy.
CONDENSING OSTEITISCondensing osteitis(focal sclerosingosteomyelitis) is a rare proliferativeinflammatory response to an irritant and itis a variant of chronic (asymptomatic)apical periodontitis represents an increasein trabecular bone in response topersistent irritation.
Signs and SymptomsDepending on the cause (pulpitis or pulpalnecrosis),It’s may be either asymptomatic orassociated with pain.It’s may or may not respond to vitality test.It’s may or may not be sensitive to palpationor percussion.Radiographically, the presence of a diffuseconcentric arrangement of radiopacityaround the root of a tooth ispathognomonic.
Treatmenta-Root canal treatment, whenindicated, may result in completeresolution of condensing osteitisb- in the case of unrestorable toothextraction followed by curettage of apicallesion is the best therapy.
BIBLIOGRAPHY Endodontics. Ingle. 2002. 5th edition. Textbook of Endodontics. Nisha Garg, Amit Garg. 2007.1st edition.