Periradicular diseases

​ ​ ​Chronic pulpitis ​ ​ ​acute pulpal disease

​ ​Chronic apical periodontitis ​ ​Periapical abscess

​ ​ ​Periapical granuloma ​ ​ ​osteomyelitis

​ ​ ​periapical cyst ​ ​ ​ ​ ​
​ ​ ​ Chronic osteonyelitis ​ cellulitis garre’s
Osteomyelitis.

Classification of Periradicular pathologies

Grossman’s classification
1) Acute periradicular disease.
a) Acute alveolar abscess
b) Acute apical periodontitis
-Vital
-Non- vital
c) Phoenix abscess
2) Chronic periradicular disease with areas of rarefaction :-
a) chronic apical periodontitis
b) chronic alveolar abcess
c) granuloma
d) cyst
3) Condensing osteitis
4) External root resorption
5) Disease of periradicular tissue of non endodontic origin.
WHO classification
1) K 04.4 – Acute apical periodontitis
2) K 04.5 – chronic apical periodontitis
3) K04.6 – Periapical abscess with sinus
4) K04.60 – Periapical abscess with sinus to maxillary antrum
5) K04.61 - Periapical abscess with sinus to nasal cavity
6) K04.62 - Periapical abscess with sinus to oral cavity
7) K04.63 - Periapical abscess with sinus to skin
8) K04.7 - Periapical abscess without sinus
9) K04.8 – redicular cyst
10) K04.80 – apical and lateral cyst
11) K04.81- residual cyst
12) K04.82 – inflammatory paradental cyst
Acute apical periodontitis (AAP)
Definition: it is defined as painful inflammation of periodontium as a result of
trauma, irritation and infection through the root canal regardless of whether the
pulp is vital or non vital.
Etiology: In vital tooth- occlusal trauma, wedging
In nonvital tooth- sequelae to pulpal disease
Iatrogenic : over instrumentation of root canal, over extended obturation, root
perforation.
Symptoms: pain and tenderness of the tooth. It may slightly sore, sometimes only
When it is percurssed in certain direction or soreness may be severe, tooth may be
extruded making closure painful.

Diagnosis:
1) History
2) Recent endodontic treatment
3) Tender on percussion
4) Non tender on palpation
5) Radiograph: may show thickened PDL space or small area of rarefaction If pulp
less tooth is involved
if vital pulp then normal periradicular structure
Histopathology
Inflammatory reaction in apical PDL

Dilation of blood vessels

Presence of PMNLS and round cells

Serous exudates accumulation

Distension of PDL and extrusion of tooth

If continued irritation

Loss of alveolar bone

Treatment :
First determine the cause

Whether vital pulp ​ ​ ​ ​ ​pulp less tooth

Start endotherapy
If tooth is in hyperocclusion ​ ​relieve the occlusion

Acute Apical Abscess

It is localized collection of pus in the alveolar bone at the root apex of the tooth
following the death of pulp with extension of infection through the apical foramen
into periradicular tissue.
Etiology : bacterial invasion of dead pulp tissue can also occur because of trauma,
chemical and mechanical injury.
Symptoms :
1. First symptom is severe tenderness of the tooth.
2. Later – patient has severe, throbbing pain with attendant swelling of
overlying tissues.
3. As the infection progresses – swelling more pronounced and extends beyond
original site.
4. Tooth elongated and mobile.
5. If left untreated – may cause osteitis, periostitis, cellulitis, osteomyelitis.
6. Contained pus may form a sinus tract.
7. Systemic symptoms like fever, increased wbc count. Patient appear pale,
irritable, fever with chills, intestinal stasis can occur.
Diagnosis
• History.
• Clinical examination.
• Initially locating the tooth is difficult due to diffuse pain, location is easier
when there extension of tooth.
• Vitality test – negative
• Tenderness on percussion and palpation.
• Radiograph – may show a cavity or slight evidence of bone destruction at
root apex.
Differential diagnosis
From PD abscess and irreversible pulpitis
PD Abscess- it is associated with PD pocket and is manifested by swelling and
mild pain. On pressure, pus exudes from Gingival sulcus. Swelling at midsection
of root, whereas in PA abscess swelling at apex.
Treatment : Drainage as early as possible. This may include
1. Non surgical RCT
2. Incision and drainage
3. Extraction
Consider
• Prognosis of tooth
• Patient preference
• Strategic value of the tooth
• Economic status
If Localized infection – No systemic antibiotic.
• If systemic complications – antibiotic should be given
• Relive the tooth out of occlusion in hyper occlusion
 • NSAIDS

Acute exacerbation of chronic lesion

Pheonix abscess : This is defined as acute inflammatory reaction superimposed
on an existing chronic lesion such as cyst or granuloma.
Etiology : influx of necrotic products from diseased pulp or because of bacteria
and their toxins, they cause the dormant lesion to react.
Lowered body defences also trigger on acute inflammatory response.
Symptoms : some as acute apical abscess, tenderness, elevation in socket
Diagnosis :
➢ Associated with initiation of RCT most commonly
➢ History from patient
➢ -ve vitality
➢ Radiograph- it shows large area of radiolucency at the apex, created by
inflammatory connective tissue, which has replaced alveolar bone.
Histopathology : Shows area of liquefaction necrosis with PMNL, cellular debris
surrounded by macrophages, plasma cells and lymphocytes.
Treatment :
➢ Establishment of drainage
➢ Complete RCT

Chronic alveolar abscess (chronic

suppurative apical peridontitis)
It is a long standing, low grade infection of the periradicular alveolar bone. The
source of infection is in the root canal.
Etiology : Sequelae of necrosis of pulp
Symptoms :
1. Asymptomatic –
a. detected only during routine radiograph
b. Or because of sinus tract
Diagnosis :
➢ May be painless or mild pain
➢ History
➢ C/E – large carious exposure, a restoration of composite, acrylic, amalgam,
metal, discoloration of tooth.
➢ Presence of sinus tract
➢ Radiograph – shows diffuse area of rarefaction.
➢ Radiograph taken with GP cone in sinus tract often shows the involved
tooth.
Differential diagnosis : Granuloma, cyst and cementoma (which is associated
with vital tooth)
Treatment :
➢ Removal of irritant from the root canal and establishing drainage.
➢ Complete RCT.
➢ Sinus tract resolves following RCT.

Peri apical Granuloma

One of the most common sequelae of pulpitis. It is usually described as a mass of
chronically inflamed granulation tissue found at the apex of non-vital tooth.
Etiology : well known
Symptoms : Asymptomatic- except in rare case, when it breaks down and
undergoes suppuration
Diagnosis :
➢ Discovered on routine radiograph.
➢ Earliest change is thickening of PDL at root apex.
➢ Lesion may be well circumscribed or poorly defined.
➢ No tenderness on percussion.
➢ May or may not be tender on palpation.
➢ -ve vitality test.
Differential diagnosis :
➢ can not be differentiated from other periradicular disease unless examined
microscopically.
➢ From osteolytic stage of periapical osteofibroma (cementoma) in which
tooth in vital.
Histopathology :
• Inflamed granulation tissue that is surrounded by fibrous connective tissue
wall.
• Granulation consist of dense lymphocytic infiltrate – neutrophilis, plasma
cells, histocytes and eosinophils.
Treatment :
• In restorable tooth- RCT
• In non-restorable tooth – Extraction followed by curettage of apical soft
tissue.

Radicular cyst
Cyst : It is a closed cavity or sac internally lined by epithelium, the centre of which
is filled with fluid or semi-solid material.
• The radicular cyst is an inflammatory cyst which results because of extension
of infection from pulp into surrounding periapical tissue.
Etiology : caries, irritating effect of restorating material, trauma, pulpal death due
to development defects.
Symptoms :
• Asymptomatic
• Discovered on routine radiograph
• If large – then swelling
• Presence of cyst may cause movement of the affected tooth.
Diagnosis :
• Vitality test : -ve
• Other clinical test : -ve
Radiograph : appear as round pear or ovoid shape radiolucency, outlined by
narrow radio opaque margine.
D/D :
➢ periapical granuloma – cyst is usually larger may cause the root of adjacent
teeth to spread apart because of continuous pressure.
➢ Differentiate forms a normal bone cavity like incisive foramen. Cyst remain
attached to apex, even when taken at different angles, whereas foramen will
move away from apex.
➢ Globulo maxillary cyst between maxillary lateral and cuspid teeth (fissural
cyst). Here tooth will be vital.
➢ Traumatic bone cyst.
Histopathology: The lesion is granuloma with a cavity lined with stratified
squamous epithelium. The cyst is surrounded by connective tissue that is infiltrated
by lymphocytes, plasma cells, PMNL. Cystic cavity contains debris eosinophilic
material.
Source of epithelium – Epithelium rests of malassez which is stimulated because of
products of inflammation.
Cyst formation occurs as a result of epithelial proliferation.
When it occur in the body of granuloma it plugs the apical foramen. Epithelial
lining doesn’t communicate with root canal. This is true periapical cyst.
When epithilial lining communicates with root canal then it is called pocket or bay
test (periapical pocket cyst).
 A- True cyst
B- Bay cyst
C- Grunoloma

Theories of cyst growth:

1. Nutritional deficient theory – as the epithelium grows into mass of cells, the
center losses the nutrition and necrosis occur in the center and the cavity is formed
lined by st. sq. epithelium.
2.Abscess theory – abscess cavity is formed in connective tissue and is then
surrounded by proliferative epithelial tissue, thereby producing a cyst.
Other causes of cyst growth
1. Shedding of epithelial cells into cyst cavity increases osmotic pressure.
Which cause filtration of edema and tissue fluids into cystic cavity.
2. Granulation tissue may proliferate and exert pressure.
3. Epithelium may invade connective tissue and may cause cyst to grow.
Treatment :
❖ Endotherapy
❖ Apicoectomy
❖ Extraction
❖ Enucleation with primary closure
❖ Marsupialization
Condensing osteitis – it is the response to the low grade chronic
inflammation of the periradicular area as a result of mild irritation through the root
cannal. It appears as a radiopacity in the periapical area which is termed as
sclerotic reaction. Sclerotic reaction results from good patient immunity and a low
grade virulence of offending bacteria.
Symptoms
Asymptomatic

Diagnosis : from routine radiograph, localized ares of radiopaticity.

Treatment : Endotreatment
External root resorption
It is a lytic process occurring in cementum or cementum and dentin of roots of
teeths.
Etiology : Periradicular inflammation due to trauma, excessive forces, granuloma,
cyst, central jaw tumor, replantation of teeth, bleaching, impaction, systemic
disease, idiopathic
Symptoms :
❖ asymptomatic
❖ when root is completely resorbed – mobility
❖ if extended into crown – it gives pink tooth appearance
❖ if replacement resorption/ankylosis occurs - immobile, infraocclusion and.

with high percussion sound

Diagnosis :
Radiograph – concave or ragged areas on root surface or blunting of apex.
Loss of laminadura.
Area of replacement resorption – no PDL space
D/D – internal resorption
Treatment – if caused by extension of pulpal disease – endotreatment
If by ortho treatment- reduce the forces
Due to reimplantation – preparation of root canal followed by calcium hydroxide
paste.

Diseases of perioradicular tissue of non endodontic

origin.

1. Benign lesion
❖ Early stage – Periradicular cemental dysplasia
❖ Early stage – Monostatic fibrous dysplasia
❖ Ossifying fibroma
❖ Primordial cyst
❖ Lateral PD cyst
❖ Dentigerous cyst
❖ Traumatic bone cyst
❖ Central giant cell granuloma
❖ Central hemangiomas
❖ Hyperparathyroidism
❖ Myxoma
❖ Ameloblastoma
2. Malignant lesion
❖ Squamous cell carcinoma
❖ Osteogenic sarcoma
❖ Chondro sarcoma
❖ Multiple myeloma