Periapical Periodontitis

Dr. Rima Safadi

Periapical Periodontitis
Acute and chronic periapical periododntitis Dynamic process Rich periapical collateral circulation
Enhances ability of tissue to heal

Often accompanied by resorption of bone

Etiology/ Periapical Periodontitis

Pulpitis and pulp necrosis
Bacterial toxins Products of inflammation

Endodontic treatment:
Mechanical Chemical Bacterial

Trauma
Occlusal trauma Orthodontic treatment Biting on a hard body

Often acute, transient

Acute Periapical Periodontitis

Acute exudate Confined space Thermal stimuli and pain Localized pain
Proprioceptive nerve endings in PDL

Acute Periapical Periodontitis

Radiographically: normal
Or slight widening of PDL Less well defined lamina dura

Acute Periapical Periodontitis

Out comes:
Resolve if trauma is transient Chronic periapical periodontitis: if irritation persists Acute periapical abscess (massive exudate)
If severe irritation persists like tissue necrosis

Chronic periapical periodontitis

Persistent irritation Resorption of periapical alveolar bone
Replaced by inflamed granulation tissue Dense bundles of collagen fibers at periphery Capsule like Attached to root apex

Asymptomatic or mild tenderness to percussion

Chronic periapical periodontitis

Radiographically:
Widening of PDL Well circumscribed RL with or without cortication
Based on cellular activity of margin

Resorption of cementum or dentine

Periapical Granuloma
A localized mass of chronically inflamed granulation tissue that forms at the apex of a non-vital tooth root.

Periapical granuloma
Histologically
Granulation tissue: infiltrated mainly by lymphocytes, macrophages and plasma cells
Antigenic stimulation from the pulp

Cholesterol clefts formation Haemosidren deposits Multinucleated giant cells Foam cells-lipid laden macrophages Proliferation of epithelial rests of Malassez

Anastomosis of epithelial rests

Proliferation of epithelial cell rest of Malassez

Sequelae of Periapical Granuloma

1. Equilibrium with host immunlogic response: static for years 2. Acute exacerbation
Patient with acute symptoms

3. Suppuration:
Acute periapical abscess
Rapid onset of pain and swelling, tenderness to percussion

Chronic Abscess: little tendency to enlalrge or spread

4. Proliferation of epithelial cell rests of Malassez

Radicular cyst

Sequelae of Periapical Granuloma

5. Osteosclerosis: low grade irritation 6. Hypercementosis

Periapical Abscess
Radiographic Features
If abscess develops directly from pulp inflammation and necrosis, there may be no radiographic changes initially, except for slight widening of the PDL space. If the abscess develops through acute exacerbation in an area of previously existing chronic inflammation, a distinct radiolucent area is seen at the apex.

Acute periapical abscess and spread of inflammation

From acute PA periodontitis Or chronic PA granuloma Bacteriology: mixed infection mainly anaerobes

Acute periapical abscess and spread of inflammation

Routes of Spread: Through root canal PDL into gingival sulcus Through Cancellous bone and perforates cortex
Lingual plates are denser than buccal Origin of muscles guides spread of pus

Acute periapical abscess and spread of inflammation

Acute periapical abscess and spread of inflammation

Drain into oral cavity via a sinus
Small swelling may develop before opening A nodule of granulation tissue marks the opening of sinus

Acute periapical abscess and spread of inflammation

Palatal abscess Molar regions of both jaws:
Penetrate above or below buccinator muscle attachments:
Cellulitis Localized soft tissue abscess
Drain on skin

Acute periapical abscess and spread of inflammation

Anterior maxillary teeth:
Upper lip Perforate above attachment of lip muscles: infection passes to inner eye canthus, nasolabial fold, lower eyelid

Maxillary molars: discharge into the maxillary sinus

Acute periapical abscess and spread of inflammation

Mandibular premolar or molar: below attachment of MH muscle
Submandibular space, communicates with lateral pharyngeal spaces

Mandibular incisor: subcutaneous abscess

Cellulitis
Rapid spread of inflammation of the soft tissues associated with streptococcal infection Large amounts of streptokinase and hyaluronidase Mainly: Inflammatory edema Clinically Poorly localized Painful Malaise Elevated temperature

Complications: Cavernous sinus thrombosis due to involvement of veins at inner canthus of the eye

Ludwig`s angina
Severe cellulitis initially involving submandibular space Swelling in floor of the mouth, elevated tongue
edema of glottis may occur