1) The periradicular tissue contains apical root cementum, periodontal ligaments, and alveolar bone. Untreated pulpal infection can lead to total pulp necrosis and periapical pathologies as irritants leak into the periradicular region. 2) Periradicular pathologies include acute and chronic apical periodontitis, acute and chronic apical abscesses, granulomas, cysts, and condensing ostitis. Signs and symptoms vary but generally include pain, swelling, and radiographic evidence of bone loss. 3) Treatment involves removing the source of irritation through root canal treatment or extraction and surgically addressing any associated periradicular lesion if present.

3. Introduction
 The periradicular tissue contains :
- apical root cementum.
- periodontal ligaments.
- alveolar bone.

4. Etiology of periradicular
diseases
Bacterial:
Untreated pulpal infection leading to total pulp
necrosis if untreated , irritants leak into
periapical region forming periapical
pathologies.
 Trauma
Factors related to root canal procedures:
Cause inflammatory response due to the
extirpation of the pulp, intra canal
medicaments or the improper manipulation of
instruments.

5. CLASSIFICATION OF
PERIRADICULAR PATHOLOGIES

6. Grossman’s Classification
1.Acute periradicular disease
A. 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.

7. ACUTE APICAL
PERIODONTITIS
Acute apical periodontitis is defined
as painful inflammation of the
periodontuim around the apex of
the root as a result of trauma,
irritation or infection through the
root canal regardless of whether
the pulp is vital or non vital. AAP
is microscopic rather than
roentgenographic, symptomatic
rather than visible.

8. Etiology of AAP
a. In vital tooth, is due to occlusal
trauma, high point in restoration or
wedging the object between teeth.
b. In non vital tooth, is due to egress of
bacteria toxins from necrotic pulps,
c. Iatrogenic causes can be
overinstrumentation, and extrusion of
obturating materials

9. Signs and Symptoms of
AAP
1-Clinical features of AAP are moderate to severe
spontaneous discomfort as well as pain during
mastication or occlusal contact.
2- tooth is tender to percussion.
3- no respond to vitality test unless the pulp is vital.
4- no swelling
5- usually no radiographic sign and intact lamina dura but
some times their is widening of periodontal ligament
space .

10. Treatment of AAP
a-Adjustment of occlusion (when there is
evidence of hyper occlusion),
b-Endodontic therapy to remove the
irritants , a pathologic pulp or release of
exudate usually results in periradicular
relief
c- prescribe analgesics
d- in certain situation extraction is
alternative to endodontic therapy.

11. 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.

12. Acute periapical abscess, con’t
Clinical features:
 Tooth is non vital.
 Constant throbbing pain
 Localized as the tooth becomes increasingly
tender
to percussion.
 Increase pain with chewing.
 Swelling (palpable, fluctuant).
 Mobility may or may not be present.

13. 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)

14. Acute periapical abscess, con’t
Radiographic features:
Thickening of the periodontal ligament space is
common.

15. Acute periapical abscess, con’t
Treatment:
 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

16. CHRONIC APICAL
PERIODONTITIS
Chronic apical periodontitis is defined as
asymptomatic lesion of periodontuim
around the apex of the root that destroy
alveolar bone proper (lamina dura)
usually results from pulpal necrosis and
usually is a sequel to AAP Histologically
this lesion is categorized as a granuloma
or cyst.

17. Etiology of CAP
a- is due to egress of bacteria toxins from
necrotic pulps,
b- un treated acute apical periodontitis

18. Signs and Symptoms of
CAP
1- usually no pain during mastication or
occlusal contact.
2- little or no sensitivity to percussion.
3- no respond to vitality test
4- no swelling
5- usually no tooth mobility
6-Radiographic features range from
interruption of the lamina dura to
extensive destruction of periradicular and
interradicular tissues.

19. Treatment of CAP
a-Endodontic therapy to remove inciting
irritants (necrotic pulp) and complete
obturation usually result in resolution of
CAP
b- in the case of unrestorable tooth
extraction followed by curettage of apical
lesion is the best therapy.

20. Periapical granuloma

21. Periapical granuloma
It 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.

22. Periapical granuloma, con’t
Radiographic features:
 -initial stage shows widening of periodontal
ligament space.
 -lesions may be will circumscribed
or poorly defined radiolucent area of
varying size around
root apex.
 -log standing periapical granuloma
shows varying degree of root resorption.

23. Periapical granuloma, con’t
Treatment:
 In restorable tooth, root canal therapy.
 In non-restorable tooth, extraction followed by
curettage of all apical soft tissue.

24. Radicular Cyst

25. 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.

26. Radicular cyst:, con’t
Clinical 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.

27. Radicular cyst:, con’t
clinical 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.

28. Radicular cyst: , con’t
Radiographic features:
 Radiccular cyst appears as round,
pear or ovoid shaped radiolucency,
outlined by a narrow rodioopaque
margin

29. 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.

30. 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 &
don't 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.

31. CHRONIC APICAL ABSCESS
(SUPPURATIVE APICAL
PERIODONTITIS)
Chronic apical abscess is Also classified as
suppurative apical periodontitis(SAP), it is
chronic (asymptomatic) apical abscess
that penetrate through bone and soft
tissue to form a sinus tract stoma on the
oral mucosa and it is actually results from
a long-standing lesion.

32. Etiology of CAA
a- has a pathogenesis similar to that of
acute apical abscess, It also results
from pulpal necrosis.
b- it is usually associated with chronic
apical periodontitis that has formed an
abscess.

33. Signs and Symptoms of CAA
1- is usually asymptomatic except when
there is occasional closure of the sinus
pathway, which can cause pain.
2- detected by presence of sinus tract to
apex of involved tooth.
3- little or no sensitivity to percussion.
4- no respond to vitality test
5- no swelling
6-Radiographic features rang from
moderate to extensive destruction of
periradicular and interradicular tissues.

34. Treatment of CAA
a-Endodontic therapy to remove inciting
irritants (necrotic pulp) and this will lead to
resolution of sinus tract.
b- in the case of unrestorable tooth
extraction followed by curettage of apical
lesion is the best therapy.

35. CONDENSING OSTEITIS
Condensing osteitis(focal sclerosing
osteomyelitis) is a rare proliferative
inflammatory response to an irritant and it
is a variant of chronic (asymptomatic)
apical periodontitis represents an increase
in trabecular bone in response to
persistent irritation.

36. Etiology
a-IRREVERSIBLE PULPITIS
b-PULPAL NECROSIS

37. Signs and Symptoms
Depending on the cause (pulpitis or pulpal
necrosis),
It’s may be either asymptomatic or
associated with pain.
It’s may or may not respond to vitality test.
It’s may or may not be sensitive to palpation
or percussion.
Radiographically, the presence of a diffuse
concentric arrangement of radiopacity
around the root of a tooth is
pathognomonic.

38. Treatment
a-Root canal treatment, when
indicated, may result in complete
resolution of condensing osteitis
b- in the case of unrestorable tooth
extraction followed by curettage of apical
lesion is the best therapy.

39. BIBLIOGRAPHY
 Endodontics. Ingle. 2002. 5th edition.
 Textbook of Endodontics. Nisha Garg,
Amit Garg. 2007.1st edition.