Chronic apical Chronic apical periodontitisperiodontitis

( parodontitis apicalis ( parodontitis apicalis chronica )chronica )

Etiology, classification, Etiology, classification, clinical features, dg., clinical features, dg.,

diff. Dg.diff. Dg.

PERIAPICAL DISEASEPERIAPICAL DISEASEClassified as:Classified as:

– Acute Apical PeriodonitisAcute Apical Periodonitis

– Acute Apical AbscessAcute Apical Abscess

– Chronic Apical PeriodontitisChronic Apical Periodontitis((Diffuse, Diffuse, Suppurative Apical Periodontitis with Suppurative Apical Periodontitis with

sinus tractsinus tract, Apical cyst, Apical cyst))

– Condensing OsteitisCondensing Osteitis

DefinitionDefinition• The fundamental lesion of chronic The fundamental lesion of chronic

periapical inflammation is known asperiapical inflammation is known as ´´´´chronic apicalchronic apical periodontitis´´periodontitis´´

• While this designation is the preferred one, While this designation is the preferred one, most dentists know it by the termmost dentists know it by the term ´´dental granuloma´´´´dental granuloma´´

• The lesion is not a granuloma at all The lesion is not a granuloma at all because it is not composed of because it is not composed of granulomatous chronic inflammation.granulomatous chronic inflammation.

EtiologyEtiology

• The etiology of apical periodontitis is an The etiology of apical periodontitis is an infection of the tissues in the root canal infection of the tissues in the root canal system and of the surrounding dentin, in system and of the surrounding dentin, in some cases also of tissues outside the some cases also of tissues outside the apical foramen or other portals of entryapical foramen or other portals of entry

• Typically,the lesion is located at the root Typically,the lesion is located at the root apex, but communications may exist at apex, but communications may exist at various levels along the root surface,and various levels along the root surface,and lesions may develop at lateral and furcal lesions may develop at lateral and furcal locationslocations

• One or more of the clinical symptoms pain, swelling, One or more of the clinical symptoms pain, swelling, redness, increased temperature and impaired redness, increased temperature and impaired function»characterizefunction»characterize acute apical periodontitis.acute apical periodontitis.

• Chronic apical periodontitisChronic apical periodontitis shows replacement shows replacement

of adjacent tissue with an inflammatory cell of adjacent tissue with an inflammatory cell infiltrate. Due to the encasement of the root in bone infiltrate. Due to the encasement of the root in bone and the relatively greater resistance of the root to and the relatively greater resistance of the root to resorption, the production of an inflammatory resorption, the production of an inflammatory infiltrate usually occurs at the expense of the infiltrate usually occurs at the expense of the surrounding bone. surrounding bone.

• The changes in mineralization and structure of the The changes in mineralization and structure of the bone adjacent to the site of inflammation form the bone adjacent to the site of inflammation form the basis of radiographic diagnostic procedures for the basis of radiographic diagnostic procedures for the detection and monitoring of chronic apical detection and monitoring of chronic apical periodontitisperiodontitis

• Apical periodontitis develops as a response to Apical periodontitis develops as a response to infection and in the chronic form a infection and in the chronic form a granulomagranuloma is is formed with characteristics peculiar to the formed with characteristics peculiar to the location and anatomy.location and anatomy.

• In addition to the inflammatory cells, it typically In addition to the inflammatory cells, it typically contains fibrous tissue and often cholesterol contains fibrous tissue and often cholesterol crystals, as well as proliferating strands of crystals, as well as proliferating strands of epithelium derived from the cells of Malassez. It epithelium derived from the cells of Malassez. It may or may not develop a cyst cavity, which is may or may not develop a cyst cavity, which is lined in part or in full by epithelium. If the lumen lined in part or in full by epithelium. If the lumen of this of this radicular cystradicular cyst is continuous with the is continuous with the infectious source at the pulpal entry, it may not infectious source at the pulpal entry, it may not be self-sustained (a ‘bay’ or ‘pocket’ cyst) and be self-sustained (a ‘bay’ or ‘pocket’ cyst) and will heal following elimination of the infectious will heal following elimination of the infectious source. source.

• On the other hand, if the cyst is On the other hand, if the cyst is completely encased by epithelium and completely encased by epithelium and removed from the source of infection, it removed from the source of infection, it may be self-sustained (a‘true’ cyst) and may be self-sustained (a‘true’ cyst) and refractory to treatment except by surgical refractory to treatment except by surgical excision. excision.

• The stages in development and also in The stages in development and also in healing of chronic apical periodontitis, healing of chronic apical periodontitis, granulomas and cyst are to a degree, granulomas and cyst are to a degree, reflected by changes in the radiographic reflected by changes in the radiographic appearance of the periapical areaappearance of the periapical area

• These changes are of decisive These changes are of decisive importance in diagnosis and choice importance in diagnosis and choice of treatment.of treatment.

Chronic apical periodontitisChronic apical periodontitis

• The lesion is present over long time The lesion is present over long time of periodeof periode

• Mild state of symptomsMild state of symptoms

• Histologic picture of chronic Histologic picture of chronic inflammationinflammation

ClassificationClassification• 1) 1) Diffuse type:Diffuse type: - - small, recurrent amount of tissue damagesmall, recurrent amount of tissue damage - cellular infilltration with lymphocytes, - cellular infilltration with lymphocytes, plasma cells, phagocytic mononuclear plasma cells, phagocytic mononuclear cells, fibroblasts which produce cells, fibroblasts which produce granulation tissues for repair of damaged granulation tissues for repair of damaged areaarea GRANULOMAGRANULOMA: formation of large nodule of: formation of large nodule of granulation tissue that is slowly increase in sizegranulation tissue that is slowly increase in size Resorption of hard tissue, granulation tissue Resorption of hard tissue, granulation tissue around apex (outlined by capsule of fibrousaround apex (outlined by capsule of fibrous tissue) tissue)

• 2)2) Chronic suppurative periodontitisChronic suppurative periodontitis -- central cavity which is accompanied central cavity which is accompanied with fistula and stromawith fistula and stroma - its known as chronic apical abscess- its known as chronic apical abscess ( chronic alveolar abscess)( chronic alveolar abscess)• 3) Apical cyst3) Apical cyst - - true cyst: pathologic cavity which true cyst: pathologic cavity which contain fluid or semi-fluid substance contain fluid or semi-fluid substance that is lined by epithelium and that is lined by epithelium and surrounded by connective tissuesurrounded by connective tissue capsulecapsule

Clinical featuresClinical features• CAP is generally without symptoms that may CAP is generally without symptoms that may

stay in the mouth with no-pain untill its stay in the mouth with no-pain untill its revealed by x-rayrevealed by x-ray

• The patient may rarely complain symptoms, The patient may rarely complain symptoms, slight pain, some amount of swelling, a sinus slight pain, some amount of swelling, a sinus may be found in buccal sulcus or in skin may be found in buccal sulcus or in skin

( fistula ) mucosa over swelling may be ( fistula ) mucosa over swelling may be bluish.bluish.

• CAP is usually associated with long standing CAP is usually associated with long standing restorations such as prosthetic crowns, restorations such as prosthetic crowns, extensive bridge work, composite or extensive bridge work, composite or amalgam fillingamalgam filling

DiagnosisDiagnosis

• HistoryHistory• VitalityVitality testtest – – no response of pulpno response of pulp• PercussionPercussion- - slightly tender to percussionslightly tender to percussion• X-rayX-ray – – diffuse or demarcated diffuse or demarcated

radiolucency around the apex of the tooth, radiolucency around the apex of the tooth, root resorption, loss of bone, granuloma or root resorption, loss of bone, granuloma or cyst→ with sclerotic margin to the bonecyst→ with sclerotic margin to the bone

Diff. Dg.Diff. Dg.• Chronic Pulpitis Chronic Pulpitis

Case 1,fig.1a21-years old woman-non

successful endodontic treatment tooth

N.22,apical clear radiolucency confirming

an established lesion bigger than 3mm,it

shows features of lamina dura disruption and bone

structural changes

Case 1,fig.1bMeasurement of the tooth canal length

Case 1,fig.1cFinal endodontic treatment Foredent and gutapercha

Case 1,fig.1d5 months after the endodontic

treatment without any surgical procedure,intraoral x-ray shows

chronic apical periodontitis, partial restitution of the

periapical region

Case 2,fig.2aOrthopantogram image,unsuccessful endodontic treatment d.N.22,

Cystis radicularis D.N.22

Case 2,fig.2bIntraoral image D.22-Cystis radicularis processus alveolaris maxillae reg.frontalis purulenta

Case 2,fig.2c3months after the

therapy-Cystectomio sec.PARTSCH II. et

resectio apicis dentis N.22

Retrograde root canal endodontic

therapy with amalgam

Egalisatio,suturae

Fig.BGranuloma periapicalis

and infection transmission paths

Chronic apical periodontitisChronic apical periodontitis. . Extensive tissue Extensive tissue destruction in the periapical region of a mandibular destruction in the periapical region of a mandibular first molar occurred as a result of pulpal necrosis. first molar occurred as a result of pulpal necrosis. Lack of symptoms together with presence of a Lack of symptoms together with presence of a radiographic lesion is diagnosticradiographic lesion is diagnostic..

Periapical radiolucencies associated with Periapical radiolucencies associated with mandibular incisors. These teeth were mandibular incisors. These teeth were vital, and a diagnosis of cemental vital, and a diagnosis of cemental dysplasia was made.dysplasia was made.

Periodontitis chronica circumscripta d.14

Periodontitis chronica circumscripta d.41