SYMPTOMATIC APICAL PERIODONTITIS ET OLOGY / DIAGNOSIS AND TREATMENT

PERIAPICAL TISSUES
m Cementum
m Periodontal ligament (PDL)
m Alveolar bone (Alveolar process)
PERIODONTIUM
§ Periodontium: The tissues that surround and support teeth, attaching them to the alveolar bone; includes bone, connective tissue,
vascular and neuronal elements.
§ Gingiva, Cementum, Periodontal ligament (PDL), Alveolar bone
INFLAMMATION / INFECTION
§ Inflammation: The cellular and vascular response of tissues to injury.
§ Acute inflammation: A response that is abrupt in onset and short in duration, characterized by the exudation of fluid, serum proteins,
inflammatory m diators and cells, mainly PMN into the area of injury. may become chronic if the injurious agent persists.
§ Chronic inflammation: A response that is slow in onset and of long-standing duration, characterized by proliferation of fibroblasts and
vascular endothelium and an influx of lymphocytes, plasma cells, macrophages and inflammatory mediators. It may be primary or
preceded by acute inflammatory response.
§ Infection: Invasion and proliferation of pathogenic microorganisms in body tissues and the reaction of the tissues to their presence.
APICAL INFLAMMATION / APICAL INFECTION
§ Apical inflammation periapical tissue reaction to irritants emerging from the root canal system that manifests as vasodilation,
increased vascular permeability, and exudation.
§ In contrast apical infection is due to the physic presence of pathogenic microorganisms in the periapical tissues that subsequently
produce tissue damage.
§ In diseases caused by infection, bacteria are usually present in the involved tissues or organs.
§ Although apical periodontitis is primarily an infectious disease, bacteria are usually not present in the periapical tissues but in the root
canal system (except for extraradicular endodontic infection).
Pathological changes in the periapical region are defined as "periradicular / periapical diseases".

CLASSIFICATION OF PERIAPICAL DISEASES

§ Many attempts have been made to develop classifications of pulpal and periapical diseases over
the years.
§ However, studies have shown that it is difficult to make a correlation between clinical signs and
symptoms and the histopathology of a given case.
§ Therefore, clinical classifications have been developed to formulate treatment plan options.
CLINICAL CLASSIFICATION OF PERIAPICAL DISEASES
§ The current classification uses the terminology and classifications suggested by the American
Association of Endodontists (AAE 10th Ed., 2C120; Pathways of the Pulp 12th Ed., 2021).
§ In general terms, the subjective and objective findings are used to classify suspected pathosis. with the assigned definitions reflecting
only the presence of healthy. or diseased tissue.
CLINICAL CLASSIFICATION OF PERIAPICAL DISEASES
NORMAL APICAL TISSUES
(Standard classification against which all the other apical disease processes are compared)
§ The patient is asymptomatic.
§ The tooth responds normally and the periapical tissues are not sensitive to percussion and palpation testing.
§ The radiograph reveals that the lamina dura surrounding the root / roots is intact and the PDL space is uniform.
ENDODONTIC NOTE
Lamina dura
§ The layer of compact bone forming the wall of a tooth alveolus.
§ In radiographs, it is seen as a thin radiopaque line surrounding the roots of teeth lying adjacent to the periodontal
ligament.
§ Loss of continuity and changes in its width and radiopacity indicate pathosis.
§ The lamina dura (arrows) appears as a thin opaque layer of bone around
teeth (A) and around a recent extraction socket (B).
PERIODONTITIS
§ Inflammation of the periodontium
APICAL PERIODONTITIS
§ Inflammation of the apical periodontium, located in the periapical tissues
§ Apical Periodontitis is a general term used to describe (the periapical
inflammatory process» that occurs in response to the presence of micro-organisms and other irritants within the root canal system of
a tooth.
o SYMPTOMATIC APICAL PERIODONTITIS
o ASYMPTOMATIC APICAL PERIODONTITIS
SYMPTOMATIC APICAL PERIODONTITIS
§ The patient is symptomatic; frequently localised, spontaneous, throbbing pain
Clinical Findings
§ Painful response to biting / mastication or percussion
§ Painful response to palpation of the periapical area
§ No intraoral swelling
§ According to its etiology: the tooth may or may not respond to pulp sensibility tests.
Radiographic Findings
§ According to its etiology: the tooth will typically exhibit at least a widened PDL space and may or may not show an apical
radiolucency associated with one or all of the roots.
ETIOLOGY
§ Premature (abnormal) tooth contact / hyperocclusion
§ Occlusal trauma (chronic trauma)
§ Acute trauma
§ Extension of pulp inflammation / infection into the PDL / periapical tissues through the apical foramen
§ Iatrogenic problems during root canal treatment
§ Vertical root fractures
CONDITIONS MIMICKING SYMPTOMATIC APICAL PERIODONTITIS
§ Maxillary sinusitis
§ Periodontal disease
§ Various tumors or cysts
TEETH WITH VITAL PULPS
§ Premature (abnormal) tooth contact / hyperocclusion
o Recently made high fillings or crown restorations
TREATMENT
√ Removing the abnormal occlusal contacts, adjusting the occlusion

§ Occlusal trauma (chronic trauma)

o Occlusion disorders / Traumatic occlusion
TREAMENT
√ Treatment of occlusal trauma

à Occlusal Trauma with thickening of the lamina dura, widening of the periodontal space and increased diffuse periodontal bone density
(red arrow), with vertical bone loss (green arrows)

§ Acute trauma
o Mostly extrusion and lateral luxation cases
§ Extension of irreversible pulpitis in the late stage into the PDL / periapical tissues through the apical foramen
TREATMENT
√ Root canal treatment
Iatrogenic problems during root canal treatment
MECHANICAL, CHEMICAL AND PHYSICAL IRRITATION OF THE PERIAPICAL TISSUES
§ Inaccurate determination of the root canal working length
§ Disruption/widening of the apical construction during instrumentation
§ Exiting the periapical tissues with canal instruments (over instrumentation)
§ During the root canal treatment of irreversible pulpitis
§ Exiting the periapical tissues with canal instruments (over instrumentation); since the patient is under anesthesia, he/she does not
feel pain and does not react. The bleeding continues.
§ Because the periapical tissues are intact, when the root canal instrument comes out of the apex; mechanical irritation immediately
causes symptomatic apical periodontitis.
§ Patient's complaint: I have a lot of pain, I feel like my tooth has elevated, when I close my mouth, it feels like that tooth touches the
first, I can't even speak...
EXTRUSION OF MICROORGANISM OR TOXINS INTO THE PERIAPICAL TISSUES
§ Disruption/widening of the apical construction during instrumentation
§ Exiting the periapical tissues with canal instruments (over instrumentation)
§ Overextension of the microorganisms or their toxins within the root canal into the intact periapical tissues causes symptomatic apical
periodontitis.
MECHANICAL, CHEMICAL AND PHYSICAL IRRITATION OF THE PERIAPICAL TISSUES
§ In cases with intact periapical tissues;
o Overextension of root canal filling materials, sealer and/or gutta-percha cause chemical and phycical damage.
o Extrusion of root canal irrigation solutions (eg. NaOCl) or intracanal medicaments (eg. Ca(OH)2) cause chemical damage and
symptomatic apical periodontitis develops.
(a) Preoperative periapical radiograph, (b) clinical view after curettage of periapical lesion (c) clinical view showing root
capping with mineral trioxide aggregate (MTA) (Ins shows the resected overfilled g a-percha portion) d) Immediate post-
operative periapical radiograph following MTA retrograde filling

TEETH WITH NONVITAL PULPS

§ Vertical root fractures
TREATMENT
√ Extraction of the tooth
A. Radiograph of a nonvital mandibular second molar with a minimal restoration.
B. After the tooth was sectioned, a fracture was seen extending into the pulp (arrows).

CONDITIONS MIMICKING SYMPTOMATIC APICAL PERIODONTITIS

§ Maxillary sinusitis
§ Periodontal disease
§ Various tumors or cysts
• EVALUATION THE FINDINGS OF THE CLINICAL AND RADIOGRAPHIC EXAMINATION
o Finding the source of the pain
• Tooth
• Surrounding tissues
• Unrelated
ENDODONTIC DIAGNOSIS AND TREATMENT PLANNING
§ What is main complaint of the patient?
§ Why is that complaint?
§ The Source of the Complaint?
§ Treatment options?
§ which treatment method?
WHAT? WHY? WHERE? HOW? WHICH?