Periodontal And Periapical Diseases

Periodontal Disease

Usefulness of Radiographs
• • • • • Amount of bone present Condition of alveolar crest Bone loss in furcation areas Width of periodontal ligament Local factors: calculus, overhanging restorations • Crown/root ratio

Limitations of Radiographs
• No indication of morphology of bony defects • No indication of successful management • No indication of hard/soft tissue relationship, i.e., depth of pockets

0-1.Normal Alveolar Crest • 1.5 mm apical to cemento-enamel junction • Parallel to line joining the CEJ of adjoining teeth • Smooth • Continuation of lamina dura. has the same radiopacity .

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anterior teeth • Loss of sharp angle between lamina dura and crest • Widening of PDL near crest .Evidence of Early Periodontitis • Localized erosion of crest of bone • Blunting of crest.

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Local Factors • Calculus • Overhanging restorations • Poor restoration contours .

Calculus .

Overhanging Restoration .

Buccal VS Lingual Bone Loss .

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Direction Of Bone Loss Horizontal Bone Loss: Crest of bone is parallel to CEJ line between adjoining teeth. The remaining bone is still horizontal but may be positioned apically. .

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Direction Of Bone Loss Vertical bone loss Crest of remaining bone is not parallel to the CEJ line between adjoining teeth (displays an oblique angulation to the CEJ line ) .

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Bone Loss In Bifurcation/trifurcation Areas .

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Bitewing Radiographs Most Reliable For Crestal Bone Evaluation .

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Generalized Periodontal Disease .

Rapidly Progressing Periodontitis) Juvenile Periodontitis • Occurs in healthy individuals between puberty and age 25 • Amount of bone loss is not consistent with local factors and oral Hygiene habits.(Early-onset Periodontitis. Rate of bone loss is 3-4 times faster than in typical periodontitis .

Juvenile Periodontitis(cont. . • Bone loss is progressive and frequently bilaterally symmetrical. • Host neutrophil dysfunction has been demonstrated by several investigators.) • Typically affects crestal bone of first molars and incisors. Eventually affects greater # of teeth. Many teeth show vertical bone loss.

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Papillon-Lefevre Syndrome • Autosomal recessive trait • Hyperkeratosis of palms and soles • Occasional keratosis of other skin surfaces • Calcification in falx cerebri • Severe destruction of alveolar bone involving all deciduous and perm. teeth • Exfoliation of teeth .

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Langerhans’ Cell Histiocytosis (Histiocytosis X)
• Complex of three diseases: • Eosinophilic granuloma (usually solitary) • Hand-Schuller-Christian disease (chronic) • Letterer-Siwe disease (acute) • Due to abnormal proliferation of Langerhans’ cells or their precursors

Eosinophilic Granuloma of Bone • Most common in children and young adults • Usually single radiolucency • Skull. vertebra and long bones commonly involved • Painful. mandible. mobile teeth and gingival lesions .

Hand-Schuller-Christian Disease • Most cases reported in children under 10 years. Has been reported in older individuals • Skeletal and soft tissues may be involved • Classic triad of symptoms: – “punched out” destructive bone lesions – unilateral or bilateral exophthalmos – diabetes insipidus • Complete triad occurs in 25% of patients .

Hand-Schuller-Christian (Cont. jaws and other bones .) • Oral manifestations include: – – – – loose teeth exfoliated teeth gingivitis loss of alveolar bone / advanced periodontitis • Sharply outlined multiple radiolucent lesions in skull.

disseminated form of disease • Usually occurs before age 3. lymphadenopathy common • Destructive radiolucencies in jaws • Loosening and premature loss of teeth . enlargement of liver and spleen. Most patients die • Involves several bones and organs • Skin rash • Intermittent fever.Letterer-Siwe Disease • Acute.

Hand-Schuller-Christian Disease .

Hand-Schuller-Christian Disease .

Skull lesions of Histiocytosis X .

Other Diseases Influencing Course Of Periodontal Disease • Diabetes mellitus • Leukemia .

Leukemia .

Leukemia .

Periapical Inflammatory Lesions • Bone destruction around apex of tooth. • Bacterial invasion of pulp produces toxic metabolites which escape to the periapical bone through apical foramen and cause inflammation. . mostly secondary to pulp exposure due to caries or trauma.

. plasma cells.Periapical Inflammatory Lesions • Periapical granuloma: Localized mass of chronic granulation tissue containing PMN’s. lymphocytes.

widening of PDL or variable size of periapical radiolucency may be present .Periapical Granuloma • Radiographically.

Periapical Granuloma .

Periapical Granuloma .

appears identical to granuloma. Radiographically.Periapical Abscess • Periapical abscess: When pus forms in the area. It may develop directly as an acute process or develop in a preexisting granuloma. .

Periapical Granuloma Or Abscess • Can one differentiate between the two on the basis of radiographs alone? .

• Radicular cyst is the ONLY cyst related to non-vital pulp.Periapical Inflammatory Lesions • Radicular cyst (periapical cyst): Cell rests of Mallasez (remnants of epithelial root sheath of Hertwig) proliferate due to inflammatory stimulus of a granuloma or an abscess and provide the epithelial lining. . • A cyst is an epithelium lined cavity which is filled with fluid or semi-solid material.

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Periapical Inflammatory Lesions • Can you definitively differentiate between a periapical granuloma. abscess or radicular cyst on the basis of radiograph alone? .

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more sclerotic bone is formed (radiopaque mass). • Usually occurs in children or young adults when the resistance is high. Occasionally. • Most common location is mandibular 1st molar. .. i.Periapical Inflammatory Lesions • Sclerosing osteitis (chronic sclerosing osteomyelitis).e. the reaction to periapical inflammation is predominantly osteoblastic.

Sclerosing Osteitis .

(Idiopathic) Osteosclerosis .

Patient is symptomatic. No treatment is necessary. Endodontic treatment or extraction is indicated. • Sclerosing osteitis is secondary to pulp exposure. There are no clinical signs or symptoms.Osteosclerosis • How do you differentiate between osteosclerosis and condensing osteitis? • In osteosclerosis. the pulp is vital. .

Calcific Degeneration (Calcific Metamorphosis) Secondary to Trauma to the Tooth .

Calcific Degeneration .

Calcific Degeneration .

Radiographic Evidence Of Non-vital Teeth • Widening of apical PDL or periapical radiolucency ( associated with indication of pulp exposure) • Discontinuity of lamina dura • Displacement of lamina dura • Sclerosing osteitis • Calcific degeneration (metamorphosis) • Radiographic indication of pulp exposure .

• No treatment is required. . There are no clinical signs.Periapical Cemental Dysplasia • Also called Cementoma. Patient is asymptomatic. • Mean age is 39 years. Localized alteration in periapical area. • Pulp is vital. cementum-like material. Osseous structure is replaced by fibrous tissue. abnormal bone or combination of these.

• Well-defined radiolucency. opacity or mixed. • 3 times more common in African-americans. • Most commonly seen in mandibular anterior areas. . • May be multiple.Periapical Cemental Dysplasia • 85% patients are females. • May be bilateral.

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Periapical Cemental Dysplasia • Stage I ( Osteolytic stage ) • Stage II ( Osteo or cementoblastic stage) • Stage III ( mature stage ) .

Stage II .

Stage III .

Multiple .

normal mineralization and remodeling fails to occur. • Patient is asymptomatic and no treatment is required. Normally surgical site fills with blood clot which organizes and eventually mineralizes and remodels like surrounding bone. .Apical Scar (Fibrous Scar ) • Variation in healing process. • Occasionally.

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Apical Scar (Fibrous Scar ) .

Apical Scar (Fibrous Scar ) .

Apical Scar (Fibrous Scar ) .

Periapical Lesions (Bhaskar) • • • • • • • Periapical granuloma 48% Radicular cyst 43% Periapical abscess 1.7% Rare lesions 1.1% Residual cyst 3.0% Periapical cemental dysplasia 1.0% .5% Apical scar 3.

Rare Periapical Lesions (Bhaskar) • Central giant cell granuloma • Traumatic (simple) bone cyst • Hyperparathyroidism .

0% 8.8% 3.Periapical Lesions (LaLonde and Leubke) • • • • Periapical granuloma Radicular cyst Periapical abscess Other periapical lesions 45.0% .2% 43.

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