2.

3 Acute Apical Periodontitis

Acute apical periodontitis would be better described as symptomatic apical periodontitis.
The first extension of pulpal inflammation into the periradicular tissues is called acute apical
periodontitis (AAP).It can be defined as inflammation of all the supporting structures of the teeth
in the area surrounding the apex of the tooth. Periapical inflammation is usually due to tooth
infection which characteristically causes pain of tooth in its socket. It is often accompanied by
destruction of bone and occasionally, the root apex of tooth. However the periapical tissue has
the ability to heal if the cause of inflammation is removed.

Figure 2.3.1 : Apical Periodontitis

(source: American Family Physician 2003)

2.3.1 Causes of apical periodontitis

1. Infection by far the most common cause, bacteria causes decay of tooth which leads to
pulp inflammation (pulpitis) and death of the pulp (the soft inner part of the tooth). If
pulpitis is not treated; bacteria, bacterial toxins or products of inflammation can extent
down the root canal and cause periodontitis.
2. Trauma any direct blow to the tooth can sometimes cause the pulp of the tooth to die
and it may become infected by bacteria from the gum margins, leading to apical
periodontitis. A sudden bite on a hard object, undue pressure during orthodontic
treatment or a filling that is high can sometimes cause acute periodontitis though usually
short-lived.
3. Root canal treatment mechanical instrumentation through the tooth root during
treatment or chemical irritation from root-filling materials may result in inflammation of
the periapical region.
2.3.2 Signs and Symptoms

1. The affected tooth is often having a large decay area, a filling or may be discolored due to
a dead pulp in the tooth.
2. The gum over the root of the affected tooth is red and sore.
3. May be associated with swelling of the face for infection can penetrate the overlying
bone or soft tissues.
4. Sometimes connected with fever or body discomfort.
5. Radiologically there is usually widening of the periodontal ligament space.

6. Pain associated with the disease:

1)

Is spontaneous in onset with a moderate to severe intensity in pain and usually

persists for long periods of time (hours).

2)

Is more intense and throbbing if inflammation becomes more severe and pus starts to
form.

3)

Can be pinpointed to the affected tooth.

4)

Is aggravated by biting of teeth. In some cases, the tooth feels high or like it is
coming out and is very sensitive to touch.

5)

Has often been followed by pain in the pulp and usually associated with a dead tooth.

6)

Hot or cold substances do not cause pain unless in multirooted teeth whereby some
pulp tissue remains healthy.

2.3.3 Treatment
1. Root canal treatment is required. The root canals must be completely cleaned, shaped and
dressed. The tooth may need to be stabilized whilst cutting the access cavity, as the vibration
when cutting can be uncomfortable.
2. Sodium hypochlorite is used as an irrigant, and calcium hydroxide as the medicament after
complete cleaning.
3. The occlusion is adjusted to relieve any discomfort on biting.
4. Antibiotics are ineffective for the treatment of acute apical periodontitis if root canal
treatment is not carried out.

5. Therefore the practice of prescribing antibiotics instead of undertaking root canal treatment is
not recommended, as pain will be prolonged.
6. Analgesics may be required, and a combination of paracetamol (500 mg six times daily) and
ibuprofen (200 mg six times daily) should be sufficient.
Reference:
intelligent dental. (n.d.). Retrieved from intelligent dental:
www.intelligentdental.com/2009/12/14/apical-periodontitis-symptoms-and-treatment/