PERIAPICAL DISEASE

Ria Puspita Sari, drg, Sp.KG

Overview of Periapical Disease
Terminology

As a consequence of pulpal necrosis, pathologic changes can occur in the

periradicular tissues. Depending on the severity of irritation, its
duration, and the host response, periradicular pathoses may range from
slight inflammation to extensive tissue destruction (walton)

Pulpal disease is only one of the several possible causes of diseases of the
periradicular tissues. Because of the inter-relationship between the pulp
and the periradicular tissues, pulpa inflammation causes inflammatory
changes in the periodontal ligament even before the pulp becomes
totally necrotic. Bacteria and their toxins, immunologic agents, tissue
debris, and products of tissue necrosis from the pulp reach the
periradicular area through the various foramina of the root canals and give
rise to inflammatory and immunologic reactions. (Grossman)
Etiology

Most periapical diseases are caused by dead pulps.

Pulpal disease is caused by bacterial invasion from
dental caries or, less commonly, cracked teeth.

Pulpal death can caused by non-bacterial, for example

trauma.

The products of bacterial invasion and pulp necrosis

initiate most periapical diseases.
Pathophysiology
Pathophysiology
Apical Diagnoses (AAE)

Normal Apical Tissues

Symptomatic Apical Periodontitis

Asymptomatic Apical Periodontitis

Chronic Apical Abscess

Acute Apical Abscess

Condensing Osteitis
Normal Apical Tissues
are not sensitive to percussion or palpation testing and
radiographically, the lamina dura surrounding the root is intact
and the periodontal ligament space is uniform. As with pulp
testing, comparative testing for percussion and palpation should
always begin with normal teeth as a baseline for the patient.

No pain

Not abnormally sensitive to palpation and percution

Ro : Normal intact lamina dura, Normal periodontal ligament

Symptomatic Apical Periodontitis
represents painfull inflammation, usually of the apical
periodontium, producing clinical symptoms involving a painful
response to biting and/or percussion or palpation. This may or
may not be accompanied by radiographic changes (i.e. depending
upon the stage of the disease, there may be normal width of the
periodontal ligament or there may be a periapical radiolucency).
Severe pain to percussion and/or palpation is highly indicative of
a degenerating pulp and root canal treatment is needed.

Regardless of whether tooth is vital or non-vital.

In vital tooth is associated with occlusal trauma, high points in

restoration, over hanging

In non vital tooth is associated with sequele of pulpal infection

Symptomatic Apical Periodontitis

Dull throbing constant pain

Pain on biting or percussion
Negative or delayed vitality test reponse
Not associated with apical radiolucency
Widening PDL space
Cold may relieve pain
Heat exacerbate pain
Asymptomatic Apical Periodontitis

is inflammation and destruction of the

apical periodontium that is of pulpal
origin. It appears as an apical
radiolucency and does not present
clinical symptoms (no pain on
percussion or palpation)
Asymptomatic Apical Periodontitis

Does not respond to vitality test

Percussion no pain
Slight sensitivity to palpation
Radiographically interruption in lamina dura
Destruction of periapical tissue
Acute Apical Abscess

is an inflammatory reaction to pulpal infection

and necrosis characterized by rapid onset,
spontaneous pain, extreme tenderness of the
tooth to pressure, pus formation and swelling of
associated tissues. There may be no radiographic
signs of destruction and the patient often
experiences malaise, fever and lymphadenopathy
Acute Apical Abscess

Rapid onset
Spontaneous pain
Moderate to severe discomfort woth swelling
No response to vitality test
Pain on percution and palpation
Ro : widening of PDL to periapical lession
Chronic Apical Abscess

is an inflammatory reaction to pulpal infection

and necrosis characterized by gradual onset,
little or no discomfort and an intermittent
discharge of pus through an associated sinus
tract. Radiographically, there are typically signs
of osseous destruction such as a radiolucency.
To identify the source of a draining sinus tract
when present, a guttapercha cone is carefully
placed through the stoma or opening until it
stops and a radiograph is taken.
 Chronic Apical Abscess

Asymptomatic
Discomnfort
Presence of sinus tract
Condensing Osteitis

is a diffuse radiopaque lesion

representing a localized bone reaction
to a low-grade inflammatory stimulus
usually seen at the apex of the tooth.
Condensing Osteitis

Asymptomatic or associated with pain

Not respond to electric or thermal stimuli
May or may not be sensitive percussion
Ro : Radiopacity around root of tooth
Diagnostic Methods - Clinical Examination

Diagnosis cannot be made from a single isolated piece of information. Taking the medical and dental history, especially if there is
a chief complaint, then clinical and radiographic examinations in combination with a thorough periodontal evaluation and
clinical testing (pulp and periapical tests) are then used to confirm the preliminary diagnosis.
Diagnostic Methods - Radiograph Techniques

periapicals techniques : bisection and parallel

bitewing

Cone beam-computed tomography

Treatment and Management
Initial Treatment Option

Incision and drainage

Emergency Endodontic
Endodontic Treatment Option

Conventional Endodontic
Treatment

Endodontic Surgery
 Evaluation and Follow-Up
• Period for evaluation implementation: 6 months – 2 years
• Treatment usually begins to show radiographic results after 1 year
• Factors influencing success:

• Presence of periapical disease before treatment lowers

success probability

• Quality of obturation affects long-term treatment success

• Tooth type and location,

• Intracanal medication,

• Intracanal bacterial status before treatment,

• Demographic factors (age, gender) - minor influence

Evaluation period: 6 months – 4 years.

Treatment usually begins to show results radiograph after 1

year. However, keep in mind success after the first year is
notlasting success because failure is still possible at any time.
Clinical Evaluation

No pain

No swelling

No sinus tract

Normal tissue

No periodontium damage

Normal function
 Radiograph Evaluation

• Success : lession gone or getting smaller, no new lession appear

after treatment

Doubtful : nothing changes

Fail : The radiolucent lesion enlarge

HEALING PROCESS
• Occurs from the edge to the center of the lesion

• Based on the removal of infected area in the root canal

stimulating proliferative activity of healing cells to the
infected area

• After infected tissue is removed, this condition encourages

the formation of new connective tissue. Resulting from
pulp extirpation, bleeding provides the origin of the fibrin
clot at the apex.
• Elimination of irritation and causative factors

• Decrease in response & signs of inflammation

• Increase in regenerative cells (capillaries, fibroblasts)

• New capillaries surrounded by mesenchymal tissue

• Tissue organization & maturation

• Replaced resorbed bone with new bone, Repaired resorbed cementum and dentin
by cellular cementum

• PDL, being the first affected tissue, is the last to be restored to normal architecture
• Histological Picture of Healing

• Cementum deposition, Increased vascular activity,

Increased fibroblastic and osteoblastic activities
• Factors Affecting Healing

• Local

• Infection, Bleeding, Tissue damage, Blood supply, Foreign

bodies, Operator actions

• Systemic

• Age, Nutrition, Chronic diseases, Hormones, Vitamins,

Dehydration, Stress
Local factor

• Infection :

In infections caused by microorganisms which produce the

effects of suppuration, pain and the swelling is very intense.
Endo treatment can fail if the pus is not evacuated (because the
growth of granulation tissue is inhibited). To aid repair,
reduction of microorganisms by cleansing of necrotic/inflamed
pulp tissue or with antibacterial agents is necessary
• Bleeding/Hemorraghe

bleeding and blood clot is important for healing process, but excessive
bleeding and blood pooling in the periodontium tissue can disrupt repair.

• If bleeding is minimal, blood clotting quickly closes ruptured blood

vessels (during pulp extirpation and root canal instrumentation). If
bleeding is excessive, it can cause pericementitis, due to pressure on the
tissue and inflammatory changes.

• Excessive reaming and filling at the apex causes blood accumulation in

the periapical tissue → delaying healing, because the blood must be
resorbed first before complete repair
• Tissue Damage

The extent of tissue damage and the type of tissue affected influence the
potential for healing (odontoblast cells are more difficult to heal compared to
fibroblasts).

• It takes a long time for damaged tissue to be repaired → dead and damaged
cells must be phagocytosed and removed from the area before complete repair.

• Within 24 hours, PMNs (polymorphonuclear leukocytes) can be observed in

the periodontal ligament and in the alveolar bone marrow.

• Fibroblast proliferation in the healing process can isolate the extension of

tissue damage.
• Blood Supply

Adequate blood supply to the inflamed area aids in the

resorption of damaged tissue, allowing new tissue to form
more quickly.
• Foreign Object

Foreign objects pushed during treatment (filling material debris,

PSA/root canal sterilization materials) are irritants that disrupt the
organization of tissue cells during healing.

• When repair occurs, foreign objects will be encapsulated by fibrous

tissue. Macrophages in granulation tissue find it difficult to remove
excess gutta-percha, especially silver cones, leading to frequent root
resorption
• Operator

Lack of carefulness or absence of in-depth knowledge can lead

to treatment failure.

• Operator errors (iatrogenic causes), for example: Excessive

of cavity preparation, Use of irritating disinfectant drugs,
etc
Systemic factors
Age

It has an influence on susceptibility to infection (infections are more severe in the

very old/very young compared to adolescents/adults) and the smoothness of
blood flow.

• Healing is faster in young adults (fibroplasia starts earlier). Endodontic treatment

usually fails in patients aged 31-60 years, but is not contraindicated.

• With increasing age, arteriosclerotic changes in blood vessels increase, making

repair more difficult.
Nutrition

Protein is necessary for growth, function, healing, and replication of cell life.

• Protein combined with nucleic acid forms nucleoprotein, which contains genes.
Protein also plays a role in forming antibodies in immunological reactions, so if
protein is deficient, the patient will be more susceptible to infection.

• Insufficient protein synthesis results in systemic abnormalities, as proteins can form

the enzyme system in the body. Additionally, low serum protein can delay fibroplasia.

• Bone matrix consists of fibrous protein, and disturbances in protein metabolism affect
bone regeneration
Chronic Illness

TBC (Tuberculosis): Respiratory disorders suffered will inhibit the exchange of O2 in the
blood through the lungs, causing tissue cells to lack O2 (hypoxia). If it persists for a long
time, cells are damaged/die due to lack of O2 (anoxia).

• Diabetes: Impediments to healing are marked by persistent inflammation after endodontic

treatment. Patients unable to control sugar intake are prone to bacterial infection,
arteriosclerotic changes appear, and blood flow is limited → leading to anoxia. It's
important to administer antibiotics (premedication) and anesthesia (avoiding epinephrine).

• Blood dyscrasias (anemia, hemophilia, leukemia, thrombocytopenia, platelet disorder):

inadequate blood supply to injured periapical tissue → nutrients are not delivered to the
damaged area → repair is hindered
 Liver Disease: The liver has functions of secretion, metabolism and nutrition,
blood formation and coagulation, blood purification, regulation of blood
volume, mineral metabolism, and regulation of acid-base balance. If there are
abnormalities, then the body's metabolism will be disturbed.

• Heart Disease:

• If there is a history of rheumatic heart fever, there is a concern of bacteremia

during treatment, necessitating the use of antibiotics and chemotherapy.

• The use of pacemakers in heart disease patients, which emit EMI

(electromagnetic interference) and electrostatic interference, can be affected
by dental medical equipment such as electric pulp testers, root canal meters,
etc
Hormon

Function: aids in life processes, such as the replacement of old/damaged cells.

• Prolonged administration of cortisone hormone inhibits the formation of plasma cells in

immune reactions, and its excess can disrupt connective tissue formation even though it
can halt the continuation of the inflammatory process.

• Estrogen hormone → increases tissue fluid volume, thereby reducing the spread of
particles in the skin.

• Enzymes → depolymerize the base substance and also increase the spread of infection.
Some pathogenic bacteria (staphylococcus chains, pneumococci, hemolytic streptococci)
produce hyaluronidase, which increases invasive power and thus virulence
Vitamin

• A: necessary for the formation of new epithelial tissue; if deficient, wound

healing is impaired.

• C: important in the formation of collagen matrix and fibrous tissue structure,

so its deficiency can prevent connective tissue development.

• B complex: if deficient, will show edema due to carbohydrate metabolism

disturbance.

• K: needed for blood coagulation; a deficiency can disrupt the process of

granulation tissue formation by inhibiting the production of prothrombin in
the blood clotting process
Dehydration

• Cell death due to dehydration, caused by increased blood

viscosity leading to reduced circulation to the periphery.

Stress

• Body metabolism is disrupted, preventing cells from

functioning normally
 Emergency Endodontic
To relieve pain and control any inflammation or infection that may be present
Endodontic Emergencies Classification

!
!
Flare Up
Flare ups is described as the occurrence of severe pain swelling or the combination of
these during the course of root canal therapy which result in unscheduled visit by patient
Flare ups is described as the occurrence of severe pain swelling or the combination of these during the course of root canal therapy which result in unscheduled visit by patient

Vital Pulp :

Complete debridement : analgetic

Incomplete debridement : NaOCl irigation, intracanal medicament

Non vital pulp :

No swelling : instrumentation, irigation sequences, intracanal medicament

Swelling : incision, instrumentation, irigation sequences, intracanal medicament

• Pharmocological
• Localized infection = drainage without AB

• Systemic complication = Drainage with AB.

• Antibiotics in cases of diffuse cellulitis with rapid onset

• Postoperative pain control = NSAID,

• Combination of non steroids wioth opioids for severe pain

•
• Relieve the tooth out of occlusion in hyper occlusion cases

• RCT : isolation, irigation with NaOCl, shaping and

cleaning, temporary dressing