This document discusses various pulpal and periapical pathologies including pulpitis, reversible and irreversible pulpitis, chronic hyperplastic pulpitis, chronic apical periodontitis, periapical cysts, periapical abscesses, osteomyelitis, proliferative periostitis, dry socket, cellulitis, and Ludwig's angina. It provides details on symptoms, radiographic findings, histopathology, treatment options, and complications for each condition.

1. Pulpal and Periapical Pathoses Pulpal Pathology
& Osteomyelitis • Pulpitis
– Similar characteristics with other inflammatory lesions
– Difference: Confined area
– Dilatation, edema, strangulation of capillary flow,
vessel damage, inflammation and necrosis
– Mechanical, Thermal, Chemical, Bacterial
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Pulpitis Pulpitis
• Acute or chronic • Reversible
• Subtotal or generalized • Irreversible
• Infected or sterile • Chronic hyperplastic
Reversible Pulpitis Reversible Pulpitis
Temperature extremes, sweet or sour food • Pain DOES NOT occur without stimulation
–Mild to moderate pain • Subsides seconds after removal of stimulus
–Sudden • EPT: lower levels than tooth control
–Short duration
• No mobility, no sensitivity to percussion
• If stimulus continuous irreversible
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2. Irreversible Pulpitis Irreversible Pulpitis
• Early • Late
– Sharp, severe pain upon thermal stimulation – Pain increases in intensity
– Pain continues after removal of stimulus – Throbbing pressure (night owl)
– COLD uncomfortable (also warm and sweet) – Heat increases pain
– Spontaneous or continuous – Cold MAY PROVIDE RELIEF
– EPT: lower levels – EPT: HIGHER OR NO RESPONSE
– Pain can be localized – Usually no mobility or sensitivity to percussion
– Patient may be able to point to the offending tooth – If the inflammation spreads beyond the apical area you may
• With increasing discomfort, patient may be unable get sensitivity to percussion
Irreversible Pulpitis Chronic hyperplastic pulpitis
• NO BLACK OR WHITE • Pulp polyp
• Patients may have no symptoms • Large exposure
• Severe pulpitis and abscess formation may be • Children or youth
asymptomatic • Deciduous teeth
• Mild pulpitis may cause excruciating pain • Hyperplastic granulation tissue that can become
epithelialized from shedding epithelial cells
• Open apex decreases the chances of pulpal necrosis
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3. Chronic apical periodontitis
Chronic localized osteitis
So-called dental granuloma
True dental granuloma
Chronic localized osteitis Chronic localized osteitis
• Apical inflammatory lesion
• Asymptomatic, pain or sensitivity if acute
• Defensive reaction exacerbation occurs
• Bacteria in the pulp and spread of toxins • No mobility or significant sensitivity to percussion
• Defense in the beginning • Soft tissue overlying lesion may be tender
• With time the reaction less effective • No response on EPT or thermal tests
• Can arise after quiescence of periapical abscess, • X-ray: Radiolucency, circumscribed or ill-defined,
or may develop as initial periapical pathosis usually small; root resorption may be present
• Static or development of periapical cyst
Chronic localized osteitis Chronic localized osteitis
• RCT • Repeat RCT
• Lesion may fail to heal because of • Periapical surgery and retrofill
– Cyst formation
• Histopathologic examination because
– Inadequate RCT
– You must have a record
– Root fracture
– The patient may not have periapical inflammatory lesion
– Periapical foreign material
after all
– Periodontal disease
– Maxillary sinus penetration
– Fibrous scar (no bone fill)
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4. Periapical Cyst
• Rests of Malassez
• Crevicular epithelium
• Sinus epithelium
• Lateral location (perio or pulpal disease)
• Residual cyst
• No symptoms generally
• Mobility may be present
• NO RESPONSE
Periapical Cyst
• Well-defined radiolucency with sometimes
sclerotic border
• Size or shape of radiolucency cannot differentiate
between osteitis or granuloma and cyst
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6. Periapical Abscess
• Can be the initial pathosis
• Usually carious teeth but also trauma
• Acute apical periodontitis (acute localized osteitis)
may or may not proceed abscess formation
– Usually non-vital tooth
– Tooth may be vital in cases of trauma
• Occlusal contacts, or wedging a foreign object
Periapical Abscess Periapical Abscess
• Symptomatic or asymptomatic
• People talk about acute and chronic abscesses • Phoenix abscess (acute exacerbation of chronic inflammatory
process)
• THEY ARE MISINFORMING YOU
• Initially tenderness that can be relieved by pressure
• IN ABSCESSES YOU HAVE ACUTE
• With progression more intense pain, extreme sensitivity to
INFLAMMATION. (PERIOD) percussion, extrusion of tooth and swelling of tissues
• No Response to cold or EPT
• General symptoms
Periapical Abscess
• Thickening of apical periodontal ligament
• Ill-defined radiolucency
• No alterations detected sometimes
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7. Periapical Abscess
MAY LEAD TO:
–OSTEOMYELITIS
–CELLULITIS
Periapical Abscess Periapical Abscess
• If sinus tract develops you may have presence of
little mass on the alveolus or palate or soft tissues • Histopathology
or skin with an opening.
– Well delineated accumulation of PMNs, exudate,
• Buccal surface cellular debris, necrotic material, bacteria
• Maxillary laterals, palatal roots of molars and
mandibular 2nd and 3rd molars may drain lingual
• PUS
• Less symptoms because of drainage
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8. Osteomyelitis
Osteomyelitis
• True osteomyelitis is uncommon
• Acute or chronic – Odontogenic infection or fracture
• Different form osteoradionecrosis – Associated with ANUG Noma
• Variations • Acute
– Focal or diffuse sclerosing – Symptoms of acute inflammation
– Proliferative periostitis – Fever, leukocytosis, lymphadenopathy, significant
– Alveolar osteitis (dry socket) sensitivity, swelling; sequestrum, involucrum
• Chronic
– May arise without acute phase
Osteomyelitis Acute osteomyelitis
• Predisposing factors
– Chronic systemic diseases • Insufficient time for reaction by the body
– Immunocompromised status • Spreads in the medullary spaces
– Tobacco use, alcohol abuse, drug abuse • X-ray: Spectrum (No lesion ill-defined radiolucency)
– Diabetes mellitus
• Sequestrum
– Infections
• Involucrum
– Tumors or tumor-like processes
Acute osteomyelitis Acute osteomyelitis
• Fever • Antibiotics and drainage
• Leukocytosis • Penicillin, clindamycin, cephalexin, gentamycin
• Lymphadenopathy • Sequestra should be removed
• Swelling
• Sensitivity
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9. Chronic osteomyelitis
• May arise without acute phase
• Granulation tissue
• Scar formation
• Reservoir of bacteria
• Antibiotics do not reach easily the area
• Aggressive management
Chronic osteomyelitis Chronic osteomyelitis
• Features similar to acute • Intravenous antibiotics
• Patchy, ill-defined radiolucencies • Removal of necrotic bone
• Radiopaque sequestra (pts. can loose significant bone • Immobilization of jaws
proper) • Hyperbaric oxygen
• Periosteal bone reaction
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10. Condensing Osteitis
• Teeth have pathosis or restoration
• Sclerotic bone
• No clinical expansion
• Density without lucent border
• Vs. osteosclerosis: Not separated from apex
Osteosclerosis
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11. Proliferative periostitis
• Garrè osteomyelitis (wrong term)
• Periosteal reaction
• Children
• Caries, dental inflammatory disease
• Occlusal or lateral oblique radiographs show
opaque laminations like onion skin
Onion-skin
Proliferative Periostitis
Cellulitis
Dry socket (alveolar osteitis) • Spread of abscess in fascial planes of soft tissues
• Destruction of blood clot in the socket of an • Ludwig’s angina
extracted tooth – Submandibular region
• Fibrinolysis and formation of kinins pain – Lower molars
• Causes – Trauma, lacerations, peritonsillar infections
– Inexperience – Extension to pharyngeal and mediastinal spaces
– Trauma • Cavernous sinus thrombosis
– Oral contraceptives – Maxillary molars and premolars
– Smoking – Maxillary sinus, infratemporal fossa, orbit
– Estrogens cavernous sinus at the cranial vault
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12. Cellulitis Cellulitis
• Spread of abscess in fascial planes of soft tissues • Ludwig’s angina
• Ludwig’s angina – Maintenance of airway
– Swelling: floor of mouth, tongue, submandibular region – Antibiotic treatment
– Woody tongue and bull neck – Surgical drainage
• Cavernous sinus thrombosis – Tracheostomy
– Edematous periorbital enlargement • Cavernous sinus thrombosis
– Protrusion and fixation of eyelid and pupil dilatation – Antibiotics
• Blindness – Extraction of tooth
– CNS involvement, sometimes brain abscess – Corticosteroids to avoid vascular collapse from pituitary
– Deepening stupor, delirium dysfunction
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