Lecture 6 Periapical Periodontitis (Slide)

8/3/2019 Lecture 6 Periapical Periodontitis (Slide)

1/25

Periapical PeriodontitisPeriapical Periodontitis

Dr. Rima SafadiDr. Rima Safadi


2/25

Periapical PeriodontitisPeriapical Periodontitis

Acute and chronic periapical periododntitisAcute and chronic periapical periododntitis

Dynamic processDynamic process

Rich periapical collateral circulationRich periapical collateral circulation Enhances ability of tissue to healEnhances ability of tissue to heal

Often accompanied by resorption of boneOften accompanied by resorption of bone


3/25

Etiology/ Periapical PeriodontitisEtiology/ Periapical Periodontitis

Pulpitis and pulpPulpitis and pulp

necrosisnecrosis

Bacterial toxinsBacterial toxins

Products ofProducts ofinflammationinflammation

TraumaTrauma

Occlusal traumaOcclusal trauma

Orthodontic treatmentOrthodontic treatment

Biting on a hard bodyBiting on a hard body

Often acute, transientOften acute, transient

Endodontic treatmentEndodontic treatment::

MechanicalMechanical

ChemicalChemical

BacterialBacterial


4/25

Acute Periapical PeriodontitisAcute Periapical Periodontitis

Acute exudateAcute exudate

Confined spaceConfined space

Thermal stimuli and painThermal stimuli and painLocalized painLocalized pain

Proprioceptive nerve endings in PDLProprioceptive nerve endings in PDL


5/25


Radiographically:Radiographically:

normalnormal

Or slight widening ofOr slight widening of

PDLPDL Less well definedLess well defined

lamina duralamina dura


6/25


Out comes:Out comes:

Resolve if trauma is transientResolve if trauma is transient

Chronic periapical periodontitis: if irritationChronic periapical periodontitis: if irritation

persistspersists

Acute periapical abscess (massive exudate)Acute periapical abscess (massive exudate)

If severe irritation persists like tissue necrosisIf severe irritation persists like tissue necrosis


7/25

Chronic periapical periodontitisChronic periapical periodontitis

Persistent irritationPersistent irritation

Resorption of periapicalResorption of periapical

alveolar bonealveolar bone

Replaced by inflamedReplaced by inflamed

granulation tissuegranulation tissue

Dense bundles of collagenDense bundles of collagen

fibers at peripheryfibers at periphery

Capsule likeCapsule like

Attached to root apeAttached to root apexx

Asymptomatic or mildAsymptomatic or mild

tenderness to percussiontenderness to percussion


8/25

Chronic periapical periodontitisChronic periapical periodontitis

Radiographically:Radiographically:

Widening of PDLWidening of PDL

Well circumscribed RLWell circumscribed RL

with or withoutwith or withoutcorticationcortication

Based on cellularBased on cellular

activity of marginactivity of margin

Resorption ofResorption of

cementum or dentinecementum or dentine


9/25

Periapical GranulomaPeriapical Granuloma

A localized mass of chronically inflamedA localized mass of chronically inflamed

granulation tissue that forms at the apex of agranulation tissue that forms at the apex of a

non-vital tooth root.non-vital tooth root.


10/25

Periapical granulomaPeriapical granuloma

HistologicallyHistologicallyGranulation tissue: infiltratedGranulation tissue: infiltratedmainly by lymphocytes,mainly by lymphocytes,macrophages and plasmamacrophages and plasmacellscells

Antigenic stimulation from theAntigenic stimulation from thepulppulp

Cholesterol clefts formationCholesterol clefts formation

Haemosidren depositsHaemosidren deposits

Multinucleated giant cellsMultinucleated giant cells

Foam cells-lipid ladenFoam cells-lipid ladenmacrophagesmacrophages

Proliferation of epithelial restsProliferation of epithelial restsof Malassezof Malassez


11/25


12/25

Proliferation of epithelial cell rest ofProliferation of epithelial cell rest of

MalassezMalassez


13/25

Sequelae of Periapical GranulomaSequelae of Periapical Granuloma

1. Equilibrium with host immunlogic response:1. Equilibrium with host immunlogic response:static for yearsstatic for years

2. Acute exacerbation2. Acute exacerbation

Patient with acute symptomsPatient with acute symptoms3. Suppuration:3. Suppuration:

AcuteAcute periapical abscessperiapical abscessRapid onset of pain and swelling, tenderness to percussionRapid onset of pain and swelling, tenderness to percussion

ChronicChronic Abscess: little tendency to enlalrge or spreadAbscess: little tendency to enlalrge or spread4. Proliferation of epithelial cell rests of Malassez4. Proliferation of epithelial cell rests of Malassez

Radicular cystRadicular cyst


14/25

Sequelae of Periapical GranulomaSequelae of Periapical Granuloma

5. Osteosclerosis: low5. Osteosclerosis: low

grade irritationgrade irritation

6. Hypercementosis6. Hypercementosis


15/25

Periapical AbscessPeriapical AbscessRadiographic FeaturesRadiographic Features

If abscess develops directlyIf abscess develops directlyfrom pulp inflammation andfrom pulp inflammation andnecrosis, there may be nonecrosis, there may be noradiographic changes initially,radiographic changes initially,

except forexcept forslight widening ofslight widening ofthe PDL space.the PDL space.

If the abscess developsIf the abscess develops

through acute exacerbation inthrough acute exacerbation inan area of previously existingan area of previously existingchronic inflammation, achronic inflammation, a distinctdistinctradiolucent area is seen at theradiolucent area is seen at theapex.apex.


16/25

Acute periapical abscess andAcute periapical abscess and

spread of inflammationspread of inflammation

From acute PAFrom acute PA

periodontitisperiodontitis

Or chronic PAOr chronic PA

granulomagranulomaBacteriology: mixedBacteriology: mixed

infection mainlyinfection mainly

anaerobesanaerobes


17/25



Routes of Spread:Routes of Spread:

Through root canalThrough root canal

PDL into gingival sulcusPDL into gingival sulcusThrough Cancellous bone and perforatesThrough Cancellous bone and perforates

cortexcortex

Lingual plates are denser than buccalLingual plates are denser than buccal Origin of muscles guides spread of pusOrigin of muscles guides spread of pus


18/25




19/25



Drain into oral cavity via a sinusDrain into oral cavity via a sinus

Small swelling may develop before openingSmall swelling may develop before opening

A nodule of granulation tissue marks theA nodule of granulation tissue marks the

opening of sinusopening of sinus


20/25



Palatal abscessPalatal abscess

Molar regions of bothMolar regions of both

jaws:jaws:

Penetrate above orPenetrate above orbelow buccinatorbelow buccinator

muscle attachments:muscle attachments:

CellulitisCellulitis

Localized soft tissueLocalized soft tissueabscessabscess

Drain on skinDrain on skin


21/25



Anterior maxillary teeth:Anterior maxillary teeth:

Upper lipUpper lip

Perforate abovePerforate above

attachment of lip muscles:attachment of lip muscles:

infection passes to innerinfection passes to innereye canthus, nasolabialeye canthus, nasolabial

fold, lower eyelidfold, lower eyelid

Maxillary molars:Maxillary molars:

discharge into thedischarge into the

maxillary sinusmaxillary sinus


22/25



Mandibular premolarMandibular premolaror molar: belowor molar: belowattachment of MHattachment of MHmusclemuscle Submandibular space,Submandibular space,

communicates withcommunicates withlateral pharyngeallateral pharyngealspacesspaces

Mandibular incisor:Mandibular incisor:subcutaneoussubcutaneousabscessabscess


23/25

CellulitisCellulitis

Rapid spread of inflammationRapid spread of inflammationof the soft tissues associatedof the soft tissues associatedwith streptococcal infectionwith streptococcal infection

Large amounts ofLarge amounts ofstreptokinase andstreptokinase and

hyaluronidasehyaluronidase Mainly: InflammatoryMainly: Inflammatory

edemaedema

ClinicallyClinically

Poorly localizedPoorly localized PainfulPainful

MalaiseMalaise

Elevated temperatureElevated temperature


24/25

Complications: Cavernous sinusComplications: Cavernous sinus

thrombosis due to involvement of veins atthrombosis due to involvement of veins at

inner canthus of the eyeinner canthus of the eye


25/25

Ludwig`s anginaLudwig`s angina

Severe cellulitis initially involvingSevere cellulitis initially involving

submandibular spacesubmandibular space

SwellingSwelling inin floor of the mouth, elevatedfloor of the mouth, elevated

tonguetongue

edema of glottis may occuredema of glottis may occur

Lecture 6 Periapical Periodontitis (Slide)

Documents

Transcript of Lecture 6 Periapical Periodontitis (Slide)