Chronic apical

periodontitis
Clinical signs
Diagnostic methods
Katherina Kolb
 International Сlassification ICD-10
K 04.4 - Acute apical periodontitis
K 04.5 - Chronic apical periodontitis (apical granuloma)
K 04.6 - Periapical abscess with sinus
K 04.60 - Periapical abscess with sinus to maxillary
antrum
K 04.61 - Periapical abscess with sinus to nasal cavity
K 04.62 - Periapical abscess with sinus to oral cavity
K 04.63 - Periapical abscess with sinus to skin
K 04.7 - Periapical abscess without sinus
K 04.8 - Radicular cyst (periapical cyst)
K 04.80 - Apical and lateral cyst
K 04.81 - Residual cyst
K 04.82 - Inflammatory paradental cyst
PATHOGENESIS
“Apical periodontitis – a great battle”
…”our allies resisted the advance of the enemy!”
A consequence of the “battle outcome” –
chronic apical periodontitis
Chronic Apical Periodontitis
PATHOGENESIS
“Apical periodontitis – a great battle”
the human body builds a line of defence
Result - radicular cyst
PATHOGENESIS
“Apical periodontitis – a great battle”
source of epithelial cells in
the cyst - epithelial rests
of Malassez
 Radicular Cyst
bone
the contents of
the cyst
cyst membrane

root of the
tooth
CLINICAL PICTURE
Chronic apical periodontitis (K04.5)
• Mostly discovered on a routine radiographic
examination
• The earliest change in the periodontal ligament is
found to be thickening of ligament at the root apex
• The lesion may be well circumscribed or poorly
defined
• The size may vary from a small lesion to
large radiolucency exceeding
2 cm in diameter
• There has been reported
some amount of root resorption
CLINICAL PICTURE
Chronic apical periodontitis (K04.5)
CLINICAL PICTURE
Chronic apical periodontitis (K04.5)
CLINICAL PICTURE
Chronic apical periodontitis (K04.5)
CLINICAL PICTURE
Chronic apical periodontitis (K04.5)
CLINICAL PICTURE
Chronic apical periodontitis (K04.5)
CLINICAL PICTURE
Chronic apical periodontitis (K04.5)
CLINICAL PICTURE
Chronic apical periodontitis (K04.5)
CLINICAL PICTURE
Radicular cyst (periapical cyst) (K04.8)

The cyst is frequently asymptomatic and

sometimes it is discovered when periapical
radiographs of teeth with non-vital pulps are taken
• Incidence - Males are affected more often than
females
• Age - Peak incidence in third or fourth decades
• Site - Highest in anterior maxilla
• The involved tooth/teeth is/are usually non-vital,
discolored, fractured
CLINICAL PICTURE
Radicular cyst (periapical cyst) (K04.8)

• Slowly enlarging swelling sometimes attains a

large size
• As the cyst enlarges in size, the covering bone
becomes thin in size and exhibits springiness due
to fluctuation
• In maxilla, palatal expansion is mainly seen in
case of maxillary lateral incisor
CLINICAL PICTURE
Radicular cyst (periapical cyst) (K04.8)
Radicular cyst (periapical cyst) (K04.8) (maxilla)
CLINICAL PICTURE
Radicular cyst (periapical cyst) (K04.8) (mandibulla)
CLINICAL PICTURE
Radicular cyst (periapical cyst) (K04.8) (mandibulla)
CLINICAL PICTURE
Radicular cyst (periapical cyst) (K04.8) (mandibulla)
CLINICAL PICTURE
Radicular cyst (periapical cyst) (K04.8) (mandibulla)
Clinically, lesions of
endodontic origin may
be classified as follows:

•Acute apical periodontitis

•Acute alveolar abscess
•Chronic apical periodontitis
•Reactivation of chronic apical periodontitis

Arnaldo Castellucci, Endodontics, Vol. 1

 One must keep in mind that

all the lesions are of

endodontic origin with
somewhat variable
radiographic or clinical
presentations, but they
share the same etiology
and a similar pathogenesis

Arnaldo Castellucci, Endodontics, Vol. 1

•“geography” is of no
importance, since the
lesion may be periapical,
but can also be present at the radicular side or in
a bi- or trifurcation

•“histology” is of no significance, as modest

widening of the periodontal ligament,
granulomas, and cysts are different aspects of the
same process

THEY ALL ARE LESIONS OF ENDODONTIC ORIGIN

Arnaldo Castellucci, Endodontics, Vol. 1
THEY ALL ARE LESIONS OF ENDODONTIC ORIGIN
require the same etiologic therapy −
to remove the bacteria from the
root canal system
Clinically, lesions of
endodontic origin may
be classified as follows:

•Acute apical periodontitis

•Acute alveolar abscess
•Chronic apical periodontitis
•Reactivation of chronic apical periodontitis
 Temporary Seal of the
Permanent Canal Root Canal System
Obturation

Endodontic therapy or
root canal therapy

•Chronic apical periodontitis

INDICATIONS for the root canal
temporary obturation
•Intracanal medicament
•Apexification
•Exudation Control
•Periapical Lesions
•Root Resorption
•Temporary root filling
•Perforations
•Underdeveloped pulpless teeth
 Root Canal Temporary Obturation
The properties of an intracanal medicament:

• The antibacterial activity should be

greater than the cytotoxic effect
• The agent should be in contact with
the residual bacteria
• The agent must be present in
sufficient concentration
• Antibacterial intracanal
medicaments must have a wide
spectrum of activity
• The agent must have a sufficient
duration of action
The Material of Choice
Calcium hydroxide
•is antibacterial owing to its high pH
•can be easily inserted into the prepared root canal
•physically restricts bacterial recolonization
•effectively kills most of the pathogens found within
the confines of the root canal system
•aids dissolution of organic material remaining in the
root canal after preparation
•is easily removed from the root canal system prior to
obturation using EDTA and sodium hypochlorite
irrigants
•favors the formation of hard tissue at the apical end
of the root canal and at any cut lateral canals
The Material of Choice
Calcium hydroxide
Scheme for a routine procedure in root canal therapy
in case of apical periodontitis of the affected tooth

1. Assessing, diagnostic phase

2. Providing an aseptic field of operation including the use of
rubber dams
3. Accessing the preparation opening
4. Carrying out mechanical instrumentation of the canal interior
5. Irrigating the canal system to remove debris and provide
chemical disinfection
6. Placing an antimicrobial dressing until the next appointment
7. Closing the root canal system between appointments
8. Assessing the result of the initial treatment
9. Carrying out root canal filling
10. Recalling the patient in 6–12 months to assess long-term
outcome
The Material of Choice
Calcium Hydroxide
No more than
Treatment Algorithm 1 month
ProROOT MTA INDICATIONS
pulp
capping

root
pulpotomy
resorption

perforation at
the bifurcation
area
apexification
root
perforation

retrograde
apexogenesis
filling
IMPORTANT!
To exclude bacterial contamination in
endodontics, adequate temporary seals
between appointments are required