Classification of periradicular pathosis:

1. Acute apical periodontitis.

 Last lecture we talk about 1/2/3
2. Chronic apical periodontitis.
3. Condensing otitis.  Today we will talk about 4/5
4. Acute apical abscess.
5. Chronic apical abscess( suppurative apical periodontitis) .

4- Acute apical abscess

AAA is a localized or liquefaction lesion that destroys periradicular
tissues & is a severe inflammatory response to microbial & non
bacterial irritants from necrotic pulp.

Symptoms of AAA
 Moderate to severe discomfort or swelling.
 Occasionally systemic manifestations: ( high temp, malaise &
leukocytosis).
 No response to vitality tests.
 Pain on percusion or palpation.

X-ray: Depending on the degree of hard tissue destruction, ranges from thickening of PDL
space to resorptive lesion..

Histologic features of AAA:

1. Localized destructive lesion of liquefaction necrosis containing numerous
disintegrating PMN leukocytes, debris, cell remnants & accumulation of
purulent exudate.
2. Surrounding the abscess is granulomatous tissue ( the lesion is best categorized as an
abscess within a granuloma.
Treatment of AAA
 Removal of the underlying cause.
 Release of pressure (drainage if possible). (insert file in swelling to evacuate pus)
 Routine RCT resolution in most cases.

5- Chronic apical abscess (suppurative apical periodontitis)

 It is the result of a long standing lesion that has resulted in an abscess that is draining to
a surface.
 Etiology similar to AAA.
  It also results from pulp necrosis.
 Usually associated with chronic apical perodiontitis that has formed an abscess.
 The abscess has penetrated through bone & soft tissue to form a sinus tract on the oral
mucosa or sometimes onto the skin of the face.
 It may also drain through periodontium into the sulcus & may mimic a periodontal
abscess or pocket.so it is always misdiagnosed as pocket

Signs & symptoms

 Because drainage exists, it is usually asymptomatic except when there is occasional
closure of the sinus pathway which can cause pain.
 Clinical, X-ray & histology are similar to those described for CAP.
 An additional feature is the sinus tract which may be lined partially or totally by
epithelium surrounded by inflamed C.T.
Healing of per radicular lesions either regeneration or repair
 Regeneration is a process by which altered per radicular tissues are completely replaced
by native tissues to their original architecture or function.
 Repair is a process by which altered tissues are not completely restored to their original
structures.
 Inflammation & healing are not two separate entities & in fact constitute part of one
process in response to tissue injury.
Extent of healing

 It is proportional to the degree & extent of tissue injury & the nature of tissue destruction.
 Per radicular repair ranges from a relatively simple resolution of an inflammatory infiltrate
in the PDL to considerable reorganization & repair of varities of tissues.

Nonendodontic periradicular pathosis

ODONTOGENIC CYST 4 Types of cyst
1- Dentigerous cyst or circumferential dental cyst
 Derived histogenetically from the reduced enamel epithelium of an
impacted or embedded tooth.
Radio graphically, the lesion is usually less than 1 cm in diameter and may or
may not have a surrounding rim of dense bone.
 It resembles the lateral radicular cyst, which is an endodontic
inflammatory lesion related to a necrotic pulp.
 Differentiation is made on the basis of pulp vitality
In case of dentigirous cyst the pulp is vital
testing.
&teeth act normally in case of lateral
radicular cyst the teeth is non vital
2- LATERAL PERIODONTAL CYST

 Uncommon cyst arises at the lateral surface of a tooth,

usually in the mandibular premolar-canine area
 Pulp of the involved tooth is vital.
 Resembles the lateral radicular cyst, which is an
endodontic inflammatory lesion related to a necrotic pulp. Here the teeth is vital but
 Differentiation is made on the basis of pulp vitality testing.
in lateral radicular cyst the
3- ODONTOGENIC KERATOCYST teeth is non vital

 Arise from remnants of dental lamina.

 Pain, soft tissue swelling or expansion of bone.
 Unilocular or multilocular.
 Marked tendency to recur following surgical removal,
indicating that the keratinized epithelium has a greater growth
potential than does ordinary cyst epithelium.

BONE PATHOLOGY:

Periradicular cemental dysplasia (osteofibrosis) initial stage:

 Etiology unknown.
 Affecting middle aged african women.
 Normaly bone to bone resorption & fibrosis.

Initial stage : Osteolytic stage. 3 stages initial &intermediate &final

A.The initial stage (osteolytic stage)

 is characterized histologically by a proliferation of fibroblasts and

collagen fibers in the apical region of the periodontal ligament
 New growth is free of inflammation.
Here the teeth is vital
 Furthermore, nerves and vessels are unimpeded as they make
their passage to and from the root canal.

B.Periradicular cemental dysplasia (intermediate stage)

In time Cementoblasts differentiate within the soft tissues & a central

focus of calcification appears

Here teeth still vital

C.Periradicular cemental dysplasia (mature stage)

 Reossification is characterized radio graphically by increasing radio-opacity

 An intact lamina dura is usually visible around the apices by careful
looking
 Clinically, the lesions are always asymptomatic, and the adjacent teeth respond to vitality
testing.
 Radiographically, an intact lamina dura is usually (but not
always) visible around the apices if carefully looking
“through” the radiolucency.

4. Cementoblastoma

 Radiographically, the lesion is characteristically associated and continuous with the

roots of the teeth, usually a mandibular first molar.
 Tumor mass is often surrounded by a thin radiolucent zone that is continuous with the
periodontal ligament space. By observe the radiolucent
zone which surrounds the
Differentiation between cementoblastoma and condensing osteitis:
lesion
Condensing osteitis is diffuse, shows no well-defined borders, and is
associated with chronic pulpal disease. (CAP)
The lamina dura and normal periodontal ligament space may remain intact in
condensing osteitis.
But cementoblastoma the lesion is a fairly well-defined
radiopaque mass surrounded by a thin radiolucent line.
It has also replaced the apical portions of the distal root of the first molar.
Fibroosseous lesions: 1 type

1.Ossifying fibroma

 Originates from elements of PDL

 Occur in younger patients.
 Mandibular premolar or molar region.
 Attain a large size, often with visible
expansion of the overlying cortex.
ODONTOGENIC TUMOUR
1.Ameloblastoma

 Usually painless and grows slowly.

 The lesion expands & can cause displacement and increased mobility of teeth in the
young age
 Multilocular but may appear as a solitary lesion, frequently associated with the apices of
teeth, particularly in the mandibular posterior region. Often there is associated root
resorption.
 May cause expansion of the jaws or erode the cortical bone and invade adjacent soft
tissue.
 It is then visible and detectable on palpation.

2.CENTRAL GIANT CELL GRANULOMA

 A relatively smooth radiolucent lesion in the anterior region of the

mandible.
 No resorption or displacement of teeth is noted.
 The teeth responded to vitality tests.
 Unknown etiology,
 The central giant cell granuloma is an expansile destructive lesion of the bone.
 It most commonly occurs in children and young adult females and appears
radiographically as a unilocular or multilocu-lar radiolucency in the anterior-premolar
region of the mandible.

Clinically, the lesion is usually asymptomatic, but the involved region may be painful and show
bony expansion

Radiographically, it often surrounds apices

 Significantly and diagnostically, the pulps are usually vital, although the teeth are
occasionally non responsive, apparently because of sensory nerve damage.
 Because the pulps of adjacent teeth often have their blood supply interrupted during
curettage of the lesion, root canal treatment is often necessary before or after surgical
removal.
3.Nasopalatine duct system

 Arises from remnants of the embryologic nasopalatine duct and so

is considered a developmental cyst.
 Asymptomatic but may show swelling
 If secondarily infected, discharge of pus in the incisive papilla
region.

Radiographically:

 Well-defined radiolucent area is seen interradicularly or apically to the maxillary central

incisors.
 It is often heart shaped owing to superimposition of the anterior nasal spine.
 Growth of the cyst may cause divergence of roots.
 A radiolucency associated with vital teeth indicates a nasopalatine duct cyst.
 Exposing radiographs from different horizontal angles can help in differentiation.
 If the radiolucency is caused by a necrotic pulp, it will not be separated from the apex by
the change in angles.
 However, if the radiolucency is caused by a large normal or a cystic nasopalatine duct, it
will be moved from the apices with different horizontal angles of the cone.
I use the angulation of vertical plane to detect the
horizontal fracture
4.Simple bone cyst

 Simple bone cysts usually present a well-defined radiolucency but may

also manifest radiopacities.
 They may have characteristically scalloped superficial borders as the
lesions extend between the roots of the teeth.
 Superimposed over the root apices, they closely resemble periradicular
lesions
 The differentiation is not easily made on radiographs alone.
 In the case of the traumatic bone cyst, the lamina dura often remains intact, and the
associated teeth respond to pulp testing.
 An empty or fluid-filled cavity with a scanty granulation tissue lining is encountered at
surgery.
Treatment
 Consists of establishing hemorrhage into the defect.
 These lesions should not be curetted in their entirety because this may sever=cut the blood supply to
the pulps in the overlying teeth and result in pulp necrosis.
5.Enostosis. Also known as Sclerotic bone.

Radio graphically

 Radiopaque mass probably represents an outgrowth of cortical

bone on the endosteal surface.
 Associated with neither pulpal nor periradicular
pathosis
 Differentiated radiographically from condensing
osteitis by its well-defined borders and homogeneous
opacity.
Here in enostosis we have well
defined borders not like
condensing ostitis which have
irregular borders (trabeculae)

6.Globulomaxillary cyst

 Although having every appearance of a true

apical cyst, this lesion is associated with
anterior teeth. This may be a true
globulomaxillary cyst
 Necrotic pulp in the lateral incisor with dens in
dente.
 The resultant lesion simulates a
globulomaxillary cyst and is a frequent
occurrence with anomalous incisors.