Disease of periapical tissue

The periapical area: It means the area which surrounds

the apical foramen of the dental root.
The Periapical Lesions: It means the Inflammation
surrounds the apical foramen of the dental root.
Etiology of the periapical lesions:
i. Pulpitis.
ii. Traumatic injury.
iii. Deep seated restorations.
iv. Infection through the gingival crevice as
periodontal diseases.
v. Use of unsterilized instruments during the root
canal treatment.
vi. Application of strong chemical antiseptic during the
root canal treatment.
 Types of the periapical lesions
1) Acute periapical periodontitis
2) Chronic periapical periodontitis (periapical or
apical granuloma)
3) Acute periapical abscess and spread of
inflammation
4) Osteomyelitis.
5) Periapical sclerosis.
 Periapical Periodontitis
It is inflammation of PDL around apical portion of
root
Types:
1) Acute periapical periodontitis
2) Chronic periapical periodontitis
 Acute periapical periodontitis

▪ It is painful inflammation of the

periodontium as a result of trauma , or
irritation or infection through the root
canal, regardless of whether the pulp is
vital or nonvital .
▪ Also referred to as symptomatic apical
periodontitis .
▪ Tooth is tender on percussion & pain
can be sever making closure of teeth
difficult .
Etiology
Clinical feature:
▪ Hot or cold substances do not cause pain in the tooth.
▪ Slight extrusion of tooth from socket.
▪ Cause tenderness on mastication due on inflammatory edema
collected in PDL .
▪ At this stage the gingiva over the root is red and tender, but
there is no swelling while inflammation is confined within the
bone.
▪ Exudate may penetrate overlying bone and periosteum a day or
so after the onset of pain, allowing relief of the pressure. Pain
quickly abates but exudate, if it cannot escape, distends the soft
tissues to form a swelling. When an upper canine is affected,
the swelling quickly spreads to the face and eyelid and may
close the eye on that side
▪ Due to external pressure , forcing of edema fluid against
already sensitized nerve ending results in sever pain
Edema due to acute apical periodontitis. An acute periapical infection of a
canine has perforated the buccal plate of bone causing oedema of the face;
this quickly subsided when the infection was treated.
Clinical diagnosis : preapical test (tender to percussion )
Radiographical feature:
▪ Widening of PDL space
Histopathological features:
▪ Acute apical periodontitis is a typical acute
inflammatory reaction with engorged blood vessels
and packing of the tissue with neutrophils .
▪ Inflammation is transient ,if caused by acute trauma .
▪ If irritant not removed , progress into surrounding
bone resorption .
▪ Abscess formation may occur if it is associated with
bacterial infection (acute preapical abscess \
alveolar abscess )
Treatment:
▪ selective grinding if inflammation due to occlusal trauma.
▪ Etraction & RCT be done to drain exudate.

Acute apical periodontitis. In this early acute lesion inflammatory cells,

mainly neutrophil polymorphonuclear leukocytes, are seen clustered
around the apex of a non-vital tooth. The inflammatory cells are
spreading around and into bone and there has not yet been time for
significant bone resorption to develop.
 ( Chronic periapical periodontitis
or periapical granuloma)

Periapical granuloma: It is a localized granulation tissue

mass which surrounds the apical foramen of the non
vital tooth .
▪ It is the most common periapical lesion
▪ It is resulting from death of the pulp and the diffusion
of bacterial toxins from the root canals into
surrounding periradcular tissue through the apical and
lateral canal.
▪ Presence of lateral or accessory root canal opening on
the lateral surface of the root give rise to lateral
granuloma
Etiology:
1) Death of the pulp
2) Irritation of the preapical tissue that stimulates a
productive cellular response
Clinical features
1)The tooth is non-vital.
2)May be slightly tender to percussion due to odema and
inflammation of the apical periodontal ligament.
3) The symptoms may be minimal.
4) Mild pain when biting or chewing on solid food.
5)The involved tooth is slightly extruded from its socket.
6)Sensetivity is due hyperemia ,edema, &inflammation of
PDL
7)In many cases asymptomatic
8)No perforation of bone & oral mucosa forming fistula
tract unless undergoes acute exacerbation
Radiographical features
▪ The area is usually about from 5 mm to1cm in
diameter in diameter and has well-defined margins.
▪ It appears as a rounded radiolucent area with regular
demarcated margin surrounding the apical foramen
of the dental root.
▪ Thin radiopaque line of sclerotic bone sometime seen
outlining lesion
▪ Long standing lesion may show varying degree of
root resorption .
Histopathological features:
▪ Hyperemia and edema of the PDL
▪ Granulation tissue containing fibers, fibroblasts
,endothelium cell, chronic inflammatory cell infiltration and
blood vessels.
▪ Granulation tissue is outlined by a capsule of fibrous tissue
which are firmly attached to the cementum ,so that during
extraction of the tooth is associated with this granuloma.
▪ Presence of foam cells which represent macrophages
containing lipid materials.
▪ Presence of cholestrole crystals as empty clefts due to the
processing of slides.
▪ Presence of epithelial islands (Epithelial rests of Malassez).
Treatment:
It requires apicectomy with root canal treatment.

An apical granuloma showing

neutrophils, lymphocytes and plasma cells in loose oedematous
fibrous tissue.
Complication of the periapical granuloma:
▪ Painless due to infected periapical granuloma.
▪ Periapical cysts develops due to proliferation of the epithelial
rests of Malassez presenting in the histological structure of
periapical granuloma.

Cholesterol clefts with associated foreign-body giant cells.

Histological section of root and attached periapical granuloma from
Note the more heavily inflamed central area of the periapical
granuloma (blue/purple stained), compared to the less inflamed,
more collagenous peripheral zone.
 Periapical abscess
(Dento -alveolar abscess ,alveolar abscess)
▪ It is an acute or chronic suppurative process of the
periapical area of the dental root.
▪ Developed from acute periodontitis \ preapical
granuloma .
Etiology:
▪ Traumatic injury
▪ Pulp necrosis
▪ Irritation from preapical tissues .
Abscess related to maxillary canine
pointing buccally.
Clinical Features:
▪ The involved tooth is extremely painful.
▪ The involved tooth is extremely sensitive to percussion
due to odema and inflammation of the apical periodontal
ligament.
▪ The involved tooth is slightly extruded from its socket.
▪ systemic manifestations like lymphadenitis ,pain,
swelling, fever and redness of overlying skin.
▪ The periapical abscess may be intraorlly (buccally or
lingually) or extraorally.
▪ Rapid extension to adjacent bone marrow spaces produce
acute osteomyelitis or dentoalveolar abscess
Histopathological Features
▪ A periapical abscess appears as a zone of liquefaction
composed of proteinaceous exudate, necrotic tissue,
and viable and dead neutrophils (pus). Adjacent tissue
containing dilated vessels and a neutrophilic infiltrate
surrounds the area of liquefaction necrosis.
▪ With chronicity, an abscess develops into a granuloma,
which is composed of granulation tissue and fibrous
tissue infiltrated by variable numbers of neutrophils,
lymphocytes, plasma cells, and macrophages.
▪ The surrounding bone shows resorption and
degeneration of osteocytes.
Radiographical features:
It appears as an amorphous radiolucent area with an
irregular faintly margin in the periapical area of the
dental root
Complications of untreated periapical abscess:
▪ Osteomyelitis.
▪ Cellulitis.
▪ Bacteremia.
▪ Maxillary sinusitis.
Treatment:
▪ It requires administration of antibiotic, analgesic
▪ Draing of abcess by opening the pulp chamber is
performed, apicectomy or extraction .
▪ As infection erodes through bone , it can express itself in variety of places
depending on thickness of overlying bone and relationship of muscle
attachment to site of perforation . This illustration notes six possible
locations :
1. Vestibular abscess
2. Buccal space
3. Sublingual space
4. Submandibular space
5. Maxillary sinus.
A Palatal abscess related to lateral
incisor.
Localized extraoral spread of abscess related to a
mandibular molar.
 Cellulitis
It is a diffuse inflammation of soft tissues which is not
circumscribed of confined to one area , but which in contrary
to the abscess ,tend to spread through tissue spaces and long
fascial spaces.

Cellulitis associated with spread of inflammation from

abscess related to a maxillary molar.
Etiology :
▪ It occurs as result of infection by microorganism that
produce significant amount of streptokinase
,hyaluronidase and fibrinolysins which acts to breakdown
or dissolve hyaluronic acid , the universal intercellular
cement substance , and fibrin .
▪ Microorganisms streptococci , prevotella &
porphyromonas.
▪ Dental infection
▪ Sequela of periapical abscess or osteomyelitis
▪ Pericoronitis
▪ Tooth extraction or injection with infected needles
Ludwig angina
It is a rapidly swelling cellulitis of the sublingual and submandibular and
sub mental spaces, often arising from infection of the tooth roots (molars
and pre-molars) that extends below the mylohyoid line of the mandible.
bilateral involvement
Clinical Features:
▪ Brawny induration: It is characterized by brawny indurations. Tissues
are board-like and do not pit on pressure. No fluctuation is present
▪ Three facial spaces are involved bilaterally, i.e. submandibular,
submental and sublingual
▪ Open mouth and respiratory obstruction
▪ woody tongue
▪ Bull neck

Treatment
▪ maintenance of the airway
▪ Antibiotic high dose IV (Pen+ Metronidazole)
▪ Corticosteroid
Cavernous Sinus Thrombosis
Etiology and pathogenesis
▪ Infection of maxillary premolar and molar teeth
▪ Infection from maxillary anterior teeth
Symptoms: There is high spiking fever
Signs: Signs of meningeal irritation including severe
▪ headache, stiffness of neck, ocular palsy and facial
weakness
Eye: Proptosis or protrusion of eye is seen as a result of
▪ decreased venous drainage, chemosis and edema of eyelid,
▪ which is secondary to venous stasis
 Osteomyelitis
It is s an inflammatory process in the medullary spaces
or cortical surfaces of bone, that extends away from the
initial site of involvement.
Etiology:
▪ Most common cause : dental infection
▪ Infection due to fracture of jaw , gun shot wounds
▪ Hematogenous spread
Predisposing factors :
▪ Radiation damage
▪ Paget’s disease
▪ Osteoporosis
▪ Systemic disease (malnutrition , acute leukemia,
uncontrolled diabetes ,sickle cell anemia ,chronic
alcoholism )
Acute osteomyelitis:
Serious sequela of preapical infection that often results in
diffuse spread of infection throughout the medullary spaces ,
with subsequent necrosis of variable aureus , s. Albus ,
porphyromonas , prevotella , Bacteroides
Radiographical features
1) A lesion must have resorbed or demineralized
approximately 60% of the bone. Therefore unless the
inflammatory process has been present for some time,
radiographic evidence of acute osteomyelitis is usually not
present. With time, diffuse radiolucent changes begin to
appear as more bone is resorbed and replaced by infection.
2) It appears as ill-defined radiolucency.
In adult:
▪Sever pain
▪Swelling with external swelling due to inflammatory edema. Later,
distension of the periosteum with pus and, finally, subperiosteal bone
formation cause the swelling to become firm. The overlying gingiva and
mucosa is red, swollen and tender.
▪Trismus(Muscle edema causes difficulty in opening the mouth and
swallowing)
▪Paresthesia of low lip in cases of mandibular involvement.
▪Elevation of temperature
▪Regional lymphadenopathy
▪Loosening of teeth and exudation of pus from gingiva
 Pathology

Acute inflammation of marrow tissue

Spread of exudate along the marrow spaces

Thrombosis of vessels due to compression

Necrosis of bone

Necrotic tissues ,dead and drying cell , pus from bacteria

Fill the bone marrow

Involves cortical bone

Lifting of periosteum causing further necrosis

Finally osteoclastic activity

Histological features:
▪ A purulent exudate occupies the marrow spaces in acute osteomyelitis. Bony
trabeculae show reduced osteoblastic activity and increased osteoclastic
resorption with a loss of osteocytes.
▪ If an area of bone necrosis occurs (sequestrum), osteocytes are lost and the
marrow undergoes liquefaction.
▪ bacterial colonization, and acute inflammatory cell infiltration ( neutrophils).

Showing non-vital bone (the osteocyte lacunae are empty) and eroded outline with
superficial lacunae, produced by osteoclastic resorption, and a dense surface growth
of bacteria.
 Chronic osteomyelitis

▪ It is an inflammatory process of bone may develops

from acute osteomyelitis , or may arise spontaneously
without a previous acute episode.
▪ The most common site is the posterior area of the
mandible.
▪ Low-grade pain
▪ Bad taste from pus draining to the mouth through
sinuses. In more active phases there is swelling,
increased pain and discharge, and increased tooth
mobility.
Radiographical features:
It appears as a patchy, and ill-defined
radiolucency, that often contains central radiopaque
sequestra.
Histopathological features:
It consists of chronically inflamed
fibrous connective tissue filling the intertrabecular
area of the bone with scattered sequestra.