- Diseases of the pulp and periapical tissues can result from caries, trauma, or other injuries that lead to inflammation and necrosis. This summary will discuss pulpitis, periapical diseases, and osteomyelitis. - Pulpitis can be focal/reversible, acute, or chronic and results from inflammation of the pulp in response to injuries or irritants. Acute pulpitis causes severe pain while chronic pulpitis may be asymptomatic. - Periapical diseases like apical periodontitis, periapical granulomas, cysts, and abscesses occur when inflammation spreads from the pulp through the root canals into surrounding tissues. Left untreated, periapical abscesses

1. Diseases of the pulp and
periapical tissues

2. • Inflammatory disease due to interaction between tooth, diet and microflora(S.mutans)
• The interaction leads to inflammation and further causes necrosis of tissues.
• Source of inflammation: when necrotic pulp periapical inflammatory lesion.
osteomyelitis(spread to marrow)
• When it is from the surrounding soft tissues periodontal lesions.

3. ETIOLOGY
• Caries and periodontal disease (microbiological and chemical injury)
• Fracture of tooth, trauma, cracked tooth syndrome (physical injury)
• Inflammatory response for repair
• Bone resorption and formation imbalance

4. Pulpitis
• Focal reversible pulpitis
The tooth is sensitive to temperature changes(especially cold) and results in pain.
 Pain disappears on removal of stimuli.
Response in electrical pulp tester.(threshold is low)
Radiographic changes not present in the periapical region.
Treatment : excavate caries /restore defective filling.

5. • Acute pulpitis
Sequalae of focal reversible pulpitis or acute exacerbation of a chronic process.
Caused by a large carious lesion or restoration.
Severe pain elicited by thermal changes (both hot and cold)
Pain persists after removal of stimulus.
Intensity increases when patient lies down.
Responds to electrical pulp testing.(threshold is low)
Small entrance more pressure build-up and lancinating pain, but large carious lesion dull pain.
Pain on percussion only when inflammation or necrosis spreads beyond root apex. (in large
carious lesions there is slow progression)
Treatment : pulpotomy / RCT

6. • Chronic pulpitis
May result from progression of acute pulpitis.
Pain is absent and if present, it is dull and mild.
Large carious lesions.
Degeneration of nerves in the pulp.
Response is delayed in electrical pulp testing.(increased threshold)
Treatment : RCT/extraction.

7. • Chronic hyperplastic pulpitis
Also known as pulp polyp.
Develops from a chronic stage of pulpitis as an exuberant proliferation of pulp tissue.
Larger open carious lesions.(especially in molars)
Children and young adults affected.(high tissue resistance i.e inflammatory response)
Pinkish red globule protruding from pulp chamber.
Can be present for months.
Treatment : extraction of tooth and pulp extirpation.

8. Diseases of periapical tissues
• Infection form pulp spreads through the root canals to the periapical tissue.
• Causes: pulp necrosis due to caries or trauma, occlusal trauma from a high restoration, improper
endodontic treatment, chemical irritation from root canal medicaments.
• Can exist in acute and chronic forms and show reversibility.

9. • Acute apical periodontitis
• History of previous pulpitis.
• Inflammatory oedema in PDL, so the tooth is slightly elevated from the socket.
• Tenderness on touch or biting.
• Radiographic appearance- widening of pdl space.
Treatment : removal of occlusal trauma/ extraction of tooth/ RCT.

10. • Chronic apical periodontitis:
• Also known as periapical granuloma and is a sequalae of pulpitis or acute apical periodontitis.
• Localised mass of chronic granulation tissue formed in response to infection.
• Tooth elevated from socket non-vital on pulp testing.
• Lateral periapical granuloma can result from infection spread from accessory canals.
• Slightly tender to percussion and dull sound produced(because of granulation tissue in apex).
Many cases are asymptomatic.
• Radiographic features: widening of PDL space, a well-circumscribed
radiolucency at the apex sometimes. The periphery may or may not
show a thin radiopaque line.
• Some degree of root resorption can be seen
Treatment: extraction/ RCT with apicectomy.

11. Periapical cyst

13. • Periapical cysts are asymptomatic until infected.
• Teeth are non-vital(usually maxillary anterior teeth)
• Destroys surrounding bone and causes expansion of cortical plates.
• Long standing cyst can develop into an abscess, further into cellulitis or form a draining fistula.
• Larger than periapical granuloma.(>1cm)
Treatment : extraction of tooth and curettage/ RCT with apicectomy.

14. Periapical abscess
• If present with an extra-oral swelling it is called a dento-alveolar abscess.
• Results from an acute or chronic apical periodontitis.
• Acute exacerbation of a chronic periapical abscess is a phoenix abscess.
• In acute abscesses, tenderness of tooth present, but is relieved on applying pressure.
• Tooth extruded from socket.
• Confined to periapical region and can sometimes present wit regional lymphadenopathy and fever.
• In chronic abscesses, usually no symptoms, but a well-circumscribed area of suppuration is seen.
• Radiographic features: acute abscesses no radiographic findings. Chronic abscess show an ill-defined
radiolucency.
Treatment : drainage of abscess by RCT/extraction of tooth if not treated it can lead to osteomyelitis,
cellulitis, bacteraemia and fistulous tracts on the skin.

16. Osteomyelitis
• Inflammation of bone and marrow contents.
• Predisposing factors: trauma, RTA(fractures), gunshots, radiation damage, bone diseases,
malnutrition, DM, acute leukaemia, chronic alcoholism.
• Forms : acute, subacute, chronic
• Periapical abscesses, granulomas and cysts if not treated can lead to OM.
• Multiple organisms are involved(S.aureus, S.albus, streptococci, Bacteroides, Porphyromonas,
Prevotella)

18. • Acute/ subacute suppurative OM:
• Involves maxilla(localised) or mandible(diffuse and widespread)
• Clinical features: severe pain, trismus, parasthesia of lips(mandible), fever, regional
lymphadenopathy.
• Teeth are mobile and pus exudes from the gingiva.
• No swelling or redding of skin or mucosa until periostitis.
• Radiographic changes: radiolucent areas in bone begin to appear.
Treatment: debridement, drainage and antimicrobial therapy.

19. • Chronic suppurative OM
• Occurs due to inadequate treatment of acute OM or from a dental infection or from a
complication of radiation.
• All signs of acute OM present but milder.
• Acute exacerbations can occur.
• Suppuration may perforate bone, skin, mucosa and form a fistulous tract.
• Radiographic changes: areas of necrosed bone (sequestrum) surrounded by areas of new living
bone (involucrum).
Treatment : similar to acute OM, in addition hyperbaric oxygen therapy given in refractory cases.

21. • Chronic focal sclerosing OM
• Also called condensing osteitis.
• Tissue reaction to mild bacterial infection by proliferation of bone instead of destruction.
• Seen in children and young adults.
• Mild pain with infected pulp. No other symptoms.
• Radiographic features: well-circumscribed mass of sclerotic bone surrounding apex of tooth.
• Outline of tooth visible with widened PDL and intact lamina dura.
Treatment: extraction/RCT.

22. • Chronic diffuse sclerosing OM
• Cause is a diffuse periodontal disease.
• Presents as a proliferative reaction to a low-grade infection.
• Occurs in older population in the edentulous portion of the mandible.
• Acute exacerbations of the chronic form can occur and when they do, the present with, vague
pain, mild suppuration, spontaneous fistula formation on the mucosal surface.
• Radiographic features: diffuse, patchy sclerosis of bone(cotton-wool appearance). Can involve all
four quadrants.
Treatment: acute episodes treated with antibiotics. Difficult to treat. If teeth present it is extracted.

24. • Chronic osteomyelitis with proliferative periostitis
• Also Garre chronic non-suppurative sclerosing osteitis or periostitis ossificans.
• Thickening of periosteum with reactive bone formation in the periphery due to mild infection.
• Usually tibia affected and in the jaws most commonly in the mandible, especially in young adults.
• Toothache and bony hard swelling present.
• Reactive periostitis is due to overlying soft tissue infection which later involves the deeper
periosteum.(unlike from inward to outward spread)
• Radiographic features: onion skin appearance of periosteum. Radiopaque laminations of bone parallel
each other and the underlying cortex surface with radiolucent separations.
Treatment: RCT/extraction of involved tooth. No surgical intervention needed.

27. Space infections
• Structures in head and neck are separated by connective tissue barriers(fascia) and can be divided
into superficial and deep.
• Spaces are formed between these layers and are separated either by pus or blood filling up.
• Classification:
1. Primary maxillary spaces: canine, buccal, infratemporal
2. Primary mandibular spaces: submental, submandibular, sublingual, buccal.
3. Secondary fascial spaces: masseteric, pterygomandibular, superficial and deep temporal,
lateral and retropharyngeal and prevertebral.

28. • Canine space infection: infection from maxillary canine leading to swelling of cheek, upper lip and
oedema of lower eyelid.
• Buccal space infection: infection form maxillary premolars and molars, causing dome shaped
swelling from the inferior border of the mandible to zygomatic arch.
• Submandibular space infection: second and third mandibular molars infected and can cause
swelling extending from lower border of mandible to the level of hyoid bone. Infection can also
spread from adjacent sublingual and submental spaces.

29. • Submental space infection: infection starts from lower incisors. Swelling is confined to the region
of the chin.
• Sublingual space infection: mandibular premolars and molars when infected spread to the
sublingual space infection. Space is seen below the mucosa of the floor of the mouth.
Ludwig’s angina is a severe diffuse cellulitis that involves submandibular, submental and sublingual
spaces simultaneously. It occurs as a complication of extraction of a problematic tooth.

30. • Pterygomandibular space infection: infection spreads from mandibular 3rd
molar(pericoronitis).Extraoral swelling not very obvious, but intraoral swelling of anterior tonsillar
pillar and deviation of uvula seen. Patient has severe trismus and dysphagia.
• Submasseteric space infection: pericoronitis of mandibular 3rd molar is the cause. Swelling is seen
extraorally over the angle of the mandible. Trismus and throbbing pain is present.
• Temporal space infection: severe pain and trismus present. Swelling more obvious in superficial
temporal space infection than deep space infection. When temporal SI associated with buccal SI ,
dumbbell shaped swelling seen( restricted by zygomatic arch)

32. Thankyou!