periapical pathosis

1. DIFFERENTIAL DIAGNOSIS
OF
PERI APICAL
RADIOLUCENCIES

2. • CLASSIFICATION
TRUE FALSE
TRUE PERIAPICAL RADIOLUCENCIES:-
PULPOPERIAPICAL RADIOLUCENCIES
DENTIGEROUS CYST
PCOD
PERIODONTAL DISEASE
TRAUMATIC BONE CYST
NON RADICULAR CYST
MALIGNANT TUMORS

3. PSEUDO PERIAPICAL RADIOLUCENCIES:-
ANATOMIC RADIOLUCENCIES

4. ANATOMIC
RADIOLUCENCIES
• False periapical radiolucencies are produced by
anatomic varients that do not contact the apex
of the tooth.
• These radiolucencies may be shifted from the
periapex by taking additional periapical
radiographs at different angle.
• If radiolucencies are anatomic in origin,a
comparision with the radiographs of the
opposite side frequently reveals an identical
situation.

5. • MANDIBLE
1.Mandibular foramen
2.Mandibular canal
3.Mental foramen
4.Lingual foramen
5.Submandibular fossa
6.Mental fossa
7.Midline symphysis
• MAXILLA
1.Intermaxillary suture
2.Incisive foramen
3. Nasal fossa

10. APICAL PERIODONTITIS
• Apical periodontitis is the inflammation of
the periodontal ligament around the root
apex.
• It is of 2 types :-
Acute
Chronic

11. ACUTE APICAL
PERIODONTITIS
• Definition:-Acute apical periodontitis is a painful inflammation of
periodontium as a result of trauma, irritation [or] infection through root
canal regardless of whether pulp is vital or non-vital.
• ETIOLOGY:-
In a vital tooth:
Occlusal trauma
Wedging of foreign object b/w the teeth
Blow to the teeth

12. • In a non-vital tooth:
As a sequlae to pulpitis
Iotrogenic
Forcing of medicaments
Extension of obturating material
Over instrumentation during cleaning &
shaping

13. Clinical features
pain
Tooth is slightly elevated from the socket
Tenderness on percussion
Tooth may be slightly sore or may become
sore on percussion
Thermal changes does not induce pain.

14. RADIOGRAPHIC FEATURES
• Slight widening of PDL

15. • DIFFERNTIAL DIAGNOSIS
Acute alveolar abscess-
Histologically
 Treatment:-Root canal treatment.

16. PERI APICAL GRANULOMA
• Most common type of pathologic radiolucency
C/F :-
• Tooth is non vital
• It sounds dull on percussion due to granulation tissue at the
apex.
• Pt complains of mild pain on chewing.
• R/F
• Well circumscribed rl surrounding apex
• Involved tooth may reveal deep rest`ns extensive caries.
• Swelling or expansion of cortical plates is unusual.

18. Differential diagnosis
Radicular cyst:- Cyst is larger than
granuloma but it is may not always right.
If radiolucency is1.6cm or more it is more
likely to be cyst.
 Surgical defects:-previous history should
taken
 PCOD:-pulp is vital & frequently involves
lower anteriors
 TRAUMATIC BONE CYST:-pulp vital,
mostly seen in lower posteriors,LD intact

19. TREATMENT
ROOT CANAL TREATMENT
EXTRACTION OF EFFCTED TOOTH

20. ABSCESS
• Abscess is an localised collection of pus
surrounded by an area inflammed tissue in
which hyperemia & infiltration of leucocytes
is mark
• ETIOLOGY:- trauma
• chemical or mechanical irritation
• pulpal infection

21. ACUTE PERIAPICAL ABSCESS
Clinical features:-
Deep caries
Pain & mobility
discoloration
fever & lymphadenopathy
tender on percussion

22. CHRONIC PERIAPICAL
ABSCESS
• CLINICAL FEATURES:-
non-vital tooth
pain may present
swelling
sinus opening
vestibular tenderness
tender on percussion

24. RADIOGRAPHIC FEATURES
• LOCATION:- present at the apex of
involved tooth
• PHERIPHERY:-ill defined
• INTERNAL STRUCTURE:-radiolucent
• SURROUNDING STRUCTURES:-loss of
LD in the peri apical region

26. DIFFERENTIAL DIAGNOSIS
• PERIODONTAL ABSCESS
• NON –ODONTOGENIC CYST

27. MANAGEMENT
• Analgesics
• Antibiotics
• Root canal treatment
• Extraction

28. PERI APICAL CYST
CLINICAL FEATURES:-
usually asymptomatic
mostly seen in maxillary incisors
if large produces swelling

30. RADIOGRAPHIC FEATURES
• LOCATION:-Presents at apex of tooth
• PHERIPHERY & SHAPE:-well defined
pheriphery with cortical border, outline is
curved or circular
• INTERNAL STRUCTURE:-Radiolucent
• EFFECT ON SURROUNDING
STRUTURES:-If cyst is large,displacement &
resorption of adjacent tooth may occur

32. DIFFERENTIAL DIAGNOSIS
• peri apical granuloma
• pcod
• traumatic bone cyst
• mandibular infected buccal cyst

33. MANAGEMENT
• ROOT CANAL THERAPY
• EXTRACTION
• FOR LARGE CYST WHERE BONE DESTROYED
1.surical ennucleation
2. surgical ennucleation & restoration of defect
with graft
3. marsupilization
4. Decompression
5.decompression with delayed ennucleation
6.creation of a common chamber with maxillary
sinus or nasal cavity

35. PERI APICAL SCAR
• Peri apical scar is a dense fibrous tissue
situated at the periapex of non vital tooth.
Features :-
well circumscribed radiolucency i.e.,
more or less round resembles
granuloma/cyst & it is usually small.
mostly in anterior of maxilla.
rl remains constant in size/ shrink
slightly.

38. 5.SURGICAL DEFECT
It is an area that fails to fill in with osseous tissue after surgery.
Seen periapically after root resection procedures when both
labial & lingual plates have been destroyed.
Mucosal scar due to previous surgery.
R/F
Usually round in app, smoothly contoured,well defined
borders.
Rl not more than 1cm in diameter.
D/D
SCAR

40. OSTEOMYELITIS
• Defined as inflammation of bone & marrow
components.
• Streptococci, staphy.aureus, staphy.albus &
anaerobes like bacteroides, prevotella.
Predisposing factors:-
Fractures due to trauma.
Road traffic accidents.
Gun shot wounds &Radiation damage
Pagets disease & osteopetrosis
Sys cond. Leukemia,malnutn,diabetes

41. • Clinical features:-
30 to 80 yrs.
Mostly seen in mandible.
Tooth is non-vital may be associated
with acute/chronic periapical abscess.
Sinus is seen mucosa & skin.

42. RADIOGRAPHIC FEATURES
• LOCATION:-Post.body of mandible.
• Periphery & shape ;-Irregularly shaped with
poor or ragged borders.
• Internal struc:-Radiolucent.
• Effect on surrounding struc:-LD lost.
Can stimulate either resorption /
formation of bone.

45. DIFFERENTIAL DIAGNOSIS
• CHRONIC ALVEOLAR ABSCESS
• EOSINOPHILIC GRANULOMA
• PAGETS DISEASE

46. HYPERPLASIA OF MAXILLARY
SINUS LINING
• It appear as grey shadows that may be dome
shaped in maxillary sinus floor
• Radicular cyst can pouch into the sinus &
may show a thin curved radioopaque rim of
bone seperating the cyst from the sinus
cavity

47. DENTIGEROUS CYST
• It is an odontogenic cyst assosiated with
crown of unerupted tooth
CLINICAL FEATURES:-
Clinical examination reveals a
missing tooth & a hard swelling results in
facial asymmetry

48. RADIOGRAPHIC FEATURES
• LOCATION:-Present above the crown of
involved tooth
• PHERIPHERY:-Well defined
• INTERNAL STRUCTURE:-Radiolucent
except for crown of unerupted
• SURROUNDING STRUCTURES:-Can
displace & resorb the adjacent teeth

51. DIFFERENTIAL DIAGNOSIS
• HYPERPLASTIC FOLLICLE
• OKC
• CYSTIC AMELOBLASTOMA

52. MANAGEMENT
• Smaller lesions can surgically removed
• Larger lesions –insertion of surgical drain or
marsupilization

53. PERIAPICAL CEMENTO OSSEOUS
DYSPLASIA
• SYNONYMS:- Sclerosing cementum
Periapical osteo fibrosis
Fibrocementoma
Periapical fibrosarcoma
ETIOLOGY:- Trauma or Local irritation

54. • CLINICAL FEATURES:-
. Mostly present in mandibular anterior
region
. No history of pain/sensitivity
. Occasionally lesion near the mental foramen
and impinge on mental nerve & produces
pain /parasthesia /even anaesthsia
.Tooth have vital pulp

55. RADIOGRAPHIC FEATURES
• LOCATION:-Apex of the tooth
• PHERIPHERY:-Well defined
• INTERNAL STRUTURE:-Radiolucent
surrounded by hyperostotic border
• Loss of lamina dura

57. DIFFERENTIAL DIAGNOSIS
• TRAUMATIC BONE CYST
• CEMENTOBLASTOMA
• MANAGEMENT:- Surgical
ennucleation

58. TRAUMATIC BONE CYST
• SYNONYMS:- Solitory cone cyst
Hemorrhagic cyst
Extravasation cyst
Unicameral bone cyst
Simple bone cyst
Idiopathic bone cyst
ETIOLOGY:- Trauma

59. • CLINICAL FEAATURES:-
Mostly seen in young persons
More male predilection
Present mostly in posterior mandible
Occasional tender on percussion

60. RADIOGRAPHIC FEATURES
• LOCATION:-mandible posterior part
• PHERIPHERY:-well defined delicate cortex
to ill defined border that blends into
surrrouding structure
• INTERNAL STRUCTURE:-total radiolucent
• SURROUNDING STRUTURE:-sometimes
root resorption & displacement may present

62. DIFFERENTIAL DIAGNOSIS
• pcod
• radicular cyst
• median mandibular cyst

63. MANAGEMENT
• Conservative opening into the lesion &
careful curettage of the lining this usually
initiates the bleeding & subsequent healing

64. NON ODONTOGENIC CYST
• incisive canal cyst
• midpalatine cyst
• median mandibular cyst
• primordial cyst

66. Malignant tumours
• Squamous cell carcinoma
• Malignant tumors of minor salivary gland
• Osteolytic sarcoma
• Chondrosarcoma
• Melanoma
• Reticulum cell sarcoma
• Multiple myeloma

67. • FEATURES:-
More common in middle & old age
May be pain
Involve may retain their vitaliity
Advance cases :-tooth migration, loosening ,
tipping, spreading
Gingival bleeding may also present
paresthesia/anesthesia of the soft tissues
Expansion of jaw in advanced cases

68. RADIOGRAPHIC FEATURES
• Well defined or poorly defined radiolucency
or a large ragged well defined radiolucent
tumor
• Root resorption & band like widening of
periodontal ligament space

71. MANAGEMENT:-
Proper diagnosis has to be done to
treat the affected tooth .
Extensive management is
recommended if microscopic study of
periapical tissue after root resection is
diagnosed as malignancy.

72. Thank
You