Diseases of the pulp & peri apical tissues 2009


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Dental education - definitions of various conditions and presentations of endodontically involved teeth

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Diseases of the pulp & peri apical tissues 2009

  1. 1. 1 Diseases of the Pulp & Peri-apical Tissues An encounter between root canal infection and host response Prepared by Dr Lea Foster 3 1 2 1 e.g. Shallow caries, leaking rest. Persistent irritation Bacterial invasion Irreversible pulpitis Reversible pulpitis Reversible pulpitis
  2. 2. 2 Reversible Pulpitis Vital pulp Local areas of inflamed tissue – will heal after irritant is removed Restore caries, re-do leaking rest., treat exposed dentine Symptoms can be misleading On thermal stimulation – may be no, to very intense sharp response Reversible pulpitis Symptoms – Patient often reports sens. to cold foods/drinks Signs Tests Cold: increased response compared to normal Possible slight sens. to percussion Radiography Normal appearance – normal perio. ligament width 4 Reversible pulpitis Irreversible pulpitis Irreversible Pulpitis Pulp is vital but severely inflamed Healing is unlikely with conservative treatment Pulp necrosis and infection in the root canal is the likey outcome if conservative treatment is attempted If untreated will lead to apical periodontitis Irreversible Pulpitis Symptoms – can be misleading May be asymptomatic? 26 – 60% cases 4 See this reference for more detail on how this can occur If symptomatic – tooth is very sensitive to thermal changes Cold, hot and pain will often linger after stimulation4 See this reference for more detail on how this can occur The longer it has been symptomatic, the more severe the pain & any history of spontaneous pain – more likely irreversible pulpitis
  3. 3. 3 Irreversible pulpitis Signs and symptoms Tests Cold: increased response Hot: increased response Lingering pain after thermal stimulation Spontaneous pain Radiographic signs Normal or possible widened ligament The more long-standing the condition the more potential for inflammation of apical tissues 1 a) Clinically normal No symptoms No signs Normal PDL width No loss of lamina dura No loss of bone density periapically No resorption of dentine Responds WNL to tests Clinically normal Thin PDL Apical Periodontitis Peri-apical tissue reactions are directly related to the bacterial invasion of the root canal5 b) Apical periodontitis Acute 1.Primary - 1° 2.Secondary - 2° (or acute exacerbation) Chronic 1.Granuloma 2.Condensing osteitis Inflammation of the periapical tissues
  4. 4. 4 1 e.g. Shallow caries, leaking rest. Irreversible pulpitis Reversible pulpitis Granuloma OR Condensing Osteitis Persistent irritation Bacterial invasion 1° Acute apical periodontitis In only on instance can be sterile – bruxism OR if bacteria are involved Occurs when bacteria invade the root canal for the first time Bacterial invasion is a dynamic encounter with host tissue Host tissue can mobilise barriers anywhere inside the pulp space More long-standing lesion – greater likelihood for bacteria to gain ground 1° Acute apical periodontitis Signs & symptoms Tooth becomes tender to percussion (TTP) Tooth may still display signs of irreversible pulpitis Tooth may be unresponsive to thermal/electric testing (completely non- vital) Radiographically – normal PDL or Slightly widened 1° Acute apical periodontitis Slightly widened PDL 7 1 4 2° Acute apical periodontits Acute exacerbation of a chronic condition Pulp completely non-vital TTP No response to thermal or electric testing 7
  5. 5. 5 Chronic apical periodontits Apical granuloma Tooth is often symptom free but may have low grade symptoms that come and go Tooth gives no response to thermal or electric tests May exhibit slight TTP Granulation tissue Fibrous tissue – black arrows 8 Granulation tissue Fibrous tissue Granulation tissue Accumulation of neutrophils - microabscess 8 Chronic apical periodontits Condensing osteitis A possible response to long-standing irreversible pulpitis or a non-vital infected pulp space Condensing osteitis Signs and symptoms May have mildly heightened sensitivity to thermal stimuli (irreversible pulpitis) May have no response to thermal / electric stimuli (non-vital) May or may not have sensitivity to percussion Radiopaque lesion associated with root apices
  6. 6. 6 c) Periapical cyst True cyst Pocket cyst 1 Periapical cysts Cyst - a sequel to a peri-apical granuloma Not every apical granuloma will become a cyst Pocket cyst – thought to have the potential to heal with conventional RCT True cyst – thought to require surgical treament to excise the lesion 29-43% contain cholesterol crystals – may prevent spontaneous repair 1 Cholesterol crystals CT – connective tissue NT – necrotic tissue D – dentine CC – cholesterol crystals 9 Cysts Signs & symptoms Similar to other Chronic lesions TTP or maybe not Tender to palpation over buccal/labial aspect of alveolus or maybe not Tooth not responsive to thermal/electric stimuli Clearly demarcated, rounded lesion associated with apex of tooth d) Periapical abscess Acute abscess 1. Primary (1°) 2. Secondary (2°) Chronic abscess (with sinus)
  7. 7. 7 1° Acute Apical Abscess Signs & symptoms Tooth xt. sens. to percussion/touch No response to thermal/electric (non- vital) Tender to palpation over buccal tissues Possible radiographic lucency – widened ligament –diffuse appearance (unlike cyst) Accumulation of inflammatory exudate Develops as a sequel to primary acute apical periodontitis 2° Acute Apical Abscess Signs & symptoms Tooth xt. sens. to percussion/touch No response to thermal/electric (non- vital) Tender to palpation over buccal tissues Radiographic lucency – widened ligament – diffuse appearance (unlike cyst) Accumulation of inflammatory exudate Develops as a sequel to 2° acute apical periodontits or chronic apical periodontitis 7 Acute abscess (1° & 2°) The abscess is ‘pointing’ but has not drained yet Fluctuant swelling Chronic apical abscess With draining sinus Signs & symptoms Low grade symptoms Maybe slight TTP No response to thermal/electric tests Periodic bad taste in mouth May be slight to no tenderness to palpation 3
  8. 8. 8 e) Facial cellulitis Firm swelling Facial cellulitis May be a sequel to: 1° acute apical abscess 2° acute apical abscess Chronic abscess Instead of draining via sinus to oral cavity or externally onto the face, spreads along fascial planes of the face, head and neck Can have serious complications Systemic complications Osteomyelitis, Ludwig’s angina, Actinomycosis, Orbital cellulitis, Cavernous sinus thrombosis, Brain abscess, Mediastinitis, Neural complications When bacterial toxins enter blood stream – Septic shock, Bacteraemia, Septicaemia Cellulitis - radiographic appearance Tooth may or may not exhibit apical radiolucency Depends on whether it is a sequel to 1° apical abscess, 2° apical abscess Tooth will exhibit necrotic infected pulp or will be pulpless with infected root canal system Signs & symptoms Similar to those of apical abscess f) Extra-radicular infection Micro-organisms establish colonies on external root surface within the periapical region1 Sequqel to infected root canal system or previous RCT – extra-radicular species similar to those found in the root canal Signs & symptoms No symptoms or similar to those of apical abscess – acute or chronic Radiographic appearance similar to granuloma, abscess, cyst or peri-apical scar Extra-radicular infection Peri-apical actinomycosis
  9. 9. 9 Extra-radicular organisms found in the following situations Apical abscess, long-standing draining sinus, infected radicular cysts (esp. pocket cysts), peri-apical actinomycosis and with infected dentine pieces that have been displaced into apical periodontal tissues during RCT Extra-radicular infection Extra-radicular infection Diagnosed by histological examination of the tissue removed during apical surgery If symtoms persist after conventional RCT – extra-radicular infection or cyst must be suspected g) Foreign body reaction Inflammatory response to foreign material in peri-apical tissues Often root canal obturation material Other materials – talcum powder from gloves, cellulose fibres from paper points Not visible radiographically Appearance may be radiolucent lesion similar to inflammation from an infectious process Extruded obturation material does not always result in foreign body reaction Foreign body reaction Foreign body reaction to Cellulose FB – paper point RT – root tip EP – epithelium BP – bacterial plaque PC – plant cell 9 h) Periapical scar Neither disease or pathological condition Healing response without bone deposition following treatment of a lesion which has caused bone resorption Granuloma, cyst, abscess, extra-radicular infection or foreign body reaction10 Majority seem to be associated with surgical defects Appear as radio-lucencies located at a distance from the root apex Most commonly affected – upper laterals with ‘through and through’ defects – involving both palatal and labial cortical plates – heal with connective tissue ingrowth11
  10. 10. 10 References 1. Classification, diagnosis and clinical manifestations of apical periodontitis Paul V Abbott Endodontic Topics 2004:8:36-54 2. Sundqvist, Figdor Life as an Endodontic pathogen Endodontic Topics 2003, 6, 3-283. 3. Apical periodontitis: a dynamic encounter between root canal infection and host response p.N. Nair Periodontology 2000 1997:13:121-148 4. Pulpal diagnosis Sigurdsson Endodontic Topics 2003:5:12-25 5. Pulpal and periapical tissue responses in conventional and mono-infected gnotobiotic rats Kakehashi et.al. Oral Surg 1974:37:783-802 6. Bacteriological studies of neccrotic pulps Sundqvist Umea University Odontological Dissertations No. 7 1976 7. Urgent Care in the Dental Office: An Essential Handbook Terezhalmy, Geza T QuintessencePublishing (IL), 011998. 7.2.2). 8. Light microscopic study of periapical lesions associated with asymptomatic apical periodontitis S.L. Kabak, Y.S. Kabak, S.L. Anischenko Ann Anat 187 (2005) 185—194 9. Non-microbial etiology: foreign body reaction maintaining posttreatment apical periodontitis P.N. RAMACHANDRAN NAIR 10. Persistent Periapical radiolucencies of root-filled human teeth, failed endodontic treatments, and periapical scars Nair PNR, Sjo¨gren U, Figdor D, Sundqvist G.. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999: 87: 617–627 11. A multivariate analysis of the influence of various factors upon healing after endodontic surgery Rud J, Andreasen JO, Mo¨ller Jensen JE.. Int J Oral Surg 1972: 1: 258–271