Acute apical periodontitis
(parodontitis apicalis acuta)
(etiology, calssification, clinical
features, dg., diff. Dg. )
Definition of Periapical Disease
Periapical diseases are ´´an inflammatory conditions
occuring around the apex of a tooth caused by a necrotic
pulp´´
Inflammation around a root end is known as ´´apical
periodontitis´´
Structures around the apical foramen constitute the
´´periapical region´´
Structures surrounding the apex of tooth roots are known
collectively as the ´´periapical tissues´´, they consist of
the periodontal ligament and the alveolar bone.
Lesions produced by periapical infection are in close
proximity to the apices of the teeth.
Periapical lesions are recognized by their radiographic
appearance and the symptoms they produce.
Etiology of Periapical Disease
Most periapical diseases are caused by
dead pulps.
Most, but not all, pulpal disease is caused
by bacterial invasion from dental caries or,
less commonly, cracked teeth.
The remainder are caused by non-bacterial
pulpal deaths caused, for example trauma.
The products of bacterial invasion and pulp
necrosis initiate most periapical diseases.
Clinical Features of Periapical Disease
The signs and symptoms of periapical
disease are related to inflammation
Being inflammatory in origin, periapical
diseases manifest with the signs and
symptoms of acute or chronic inflammation.
However, there is no consistent relationship
between patient´s symptoms and histologic
findings.
Radiographic Features of Periapical
Disease
Most periapical lesions manifest as
sharply-defined radiolucencies.
Most, but not all, periapical lesions destroy
bone around the tooth apex resulting in
radiolucent defects on radiographic
examination of the area.
Because it takes several days for enough
bone destruction to produce a radiolucent
lesion, the earliest periapical lesions may
not be detected in a radiograph.
The more long-lived ones will cause
enough bone destruction to produce a
radiolucency that can be easily detected in
a radiograph.
As will be seen, most periapical lesion are
small and well- circumscribed.
It is uncommon for these lesions to
become large, to spread, or to break
through the surrounding cortical bony
plates
Acute Apical Periodontitis
Acute Inflammatory Periapical Diseases
A common condition accompanied by
excruciating pain, a necrotic pulp, and
radiographic thickening of the apical
periodontal ligament space, treatment
requires pulp extirpation or tooth
extraction.
Acute inflammation may extend into the
periapical tissues
Excruciating is associated with acute
pulpitis, it is also associated with extension
of the acute inflammatory process into the
periapical tissues creating acute apical
periodontitis
While bacterial infection and necrotic pulp
are responsible for the onset of most
cases of AAP, it may also be a
complication of initial endodontic therapy.
In these cases, machanical cleansing of
the root cannals forces irritating debris into
the periapical tissues initiating an acute
inflammatory response there .
Pain is the presenting symptom, it may be
provoked by percussion.
The patient may also sense that the
affected tooth is higher than nearby ones.
Often the pain is so diffuse that the patient
cannot localize it.
The dentist can usually locate the
offending tooth by the crude but effective
technique of tapping (percussion) on one
tooth after another until the patient
experiances pain.
Extension of the acute inflammatory
response into the periodontal ligament
explains both tooth elevation and tappinginduced pain
Usually there are very few radiographic
features accompanying acute apical
periodontitis
AAP arises so quickly, probably within an
hour or two, that bone destruction and its
resulting radiographic changes may not be
evident.
Sometimes, however, widened periodontal
ligament around the apex may produce a
radiolucent thickening there.
Microscopic features include a localized
acute inflammatory exudate with dilated
capillaries, and neutrophils
The pulp will die making extirpation or
extraction necessary
Since the source of AAP is a necrotic pulp,
it follows that pulp extirpation or extraction
is the appropriate therapy for it.
If the lesion resulted from endodontic
therapy, the endodontist will usually reopen the canal to allow drainage or, if the
canal filling has been completed, enter the
periapical area surgically to debride the
region
APICAL PERIODNTITIS
Inflammation of periapical region
Causes: 1, Trauma-direct blow to the
tooth
2, Chemicals- Passage of
chemical irritants through
the apical foramen during the use
of drugs in treatment of deep cavities, and
pulp lesions
3, Bacterial toxins, bacterial
infections-in dental caries, pulp lesions.
The response to apical irritans can be
acute or chronic1. Most commonly balance between body
resistance and noxious agent–granuloma
formation.
2.  noxious stimuli or ↓ body resistance–
suppurative apical periodontitis
3. chronic lesion may develop apical cyst.
Acute Apical Periodontitis
Aetiology:
Pulp disease (deep caries), bacterial
toxins, bacterial irritations-passage of
instruments beyond the canal which
may push some irritants as necrotic,
pulp tissue, bacteria, or dentine
fragments into periodontal ligament.
Stages
1. Periodontal stage hyperemia of
blood vessels and oedema in
periodontium
2. Endosseus stage the bone is
envolved first by hyperemia of vessels
then by leukocytic infiltration and
finally by pus formation
3. Subperiostal stage pus beneath the
periosteum-subperiostal abscess
4. Submucous stage pus in soft tissuesubmucous abscess
Clinical features
Generally- Rapid onset, acute pain, tooth
sensitive to touch, massive swelling.
Periodontal stage- the tooth is painful to
touch by eating, bite slightfeeling of
elevated tooth in the socket
Endosseous stage- intensive pain,
constant, throbbing, pressing pain.
Patient wants to extract the tooth, strong
feeling of elevated tooth
Subperiosteal stage- throbbing pain
increasing in intensity, the tooth is
extremly sensitive to touch, swelling
area is sensitive
Submucous stage- decrease of painful
symptoms
Diagnosis:
History (painful symptoms) sensitivity to
touch, tooth in supraocclusion, face
asymetry due to swelling, lymph node
involvement, tenderness to percussion,
pyrexia
X-ray: vary from widen periodontal space
to a large alveolar radiolucency.
Differential diagnosis
Acute serous and purulent pulpitis,
abscess
Apical Abscess
Acute pulpal-periapical inflammation may
enlarge into an abscess
Pain associated with AAP is sufficient to
require the patient to seek dental care.
It is also usually the case that the patients
defenses are capable of localizing the
infection to the periapical region
The acute inflammatory reaction may
enlarge forming an abscess (apical
abscess, dento-alveolar abscess)
Abscesses are caused by virulent organisms
and decreased immunologic rsponses
Apical abscesses are caused by necrotic
pulps.
Abscess formation suggests that the
microorganism responsible is virulent or
the patients immunologic defenses are
impaired
Apical abscesses are painful
Fever, leukocytosis, and neutrophilia are
commonly present.
As the lesion enlarges, it may penetrate the
buccal or lingual cortical plates and expand into
the surrounding soft tissues.
Such extension may include the floor of the
mouth, the palate, the face, and the neck.
Soft tissue extension will show the usual
features of acute inflammation:
redness,
swelling and warmth
Unless a dentist intervenes, the abscess will drain
spontaneously exuding a purulent exudate.
A tooth abscess is normally not
seeable, except as a lump - sometimes
- as the tooth abscess exists under the
skin and can only be seen, as such, by
X-rays. Sometimes you may see a
picture of a face with part of it swollen,
again you are seeing the swelling
under the skin, not actually seeing the
tooth abscess as such - some of the
swellings can be through the lymph
glands trying to take the infection
caused by the tooth abscess. On X-ray,
the tooth abscess can be seen by a
trained eye. Most pictures of a tooth
abscess simply show a drawing of a
tooth, a cavity leading into the soft
pulp, and a colored area denoting the
infection
Acute tooth abscess: Characterized
by rapid, painful onset. Sleep and
overall function may be disturbed
due to symptoms involved. Swelling
of gum tissue and surrounding
areas my be present. It can be very
difficult to find relief during the
painful peak of a tooth abscess.
Daily activities are often interrupted
during this time
Any abscessed tooth has the
potential to become a life threatening
situation. Infection of a tooth in the
lower jaw can cause swelling of the
check and under the jaw bone. If the
swelling under the jaw becomes too
advanced, swallowing and breathing
can become critically impaired
(Ludwig's Angina).
An infection of a top tooth may produce swelling in the check, side of the
temple or under the eye. The gradual closing of the eye due to swelling
and infection represents a dire situation (Cavernous Sinus Thrombosis).
Abscesses may not be detected with
radiographs, they are composed of acute
inflammation
An apical abscess, like AAP, arises suddenly so
there is little radiographic change.
If the lesion has been present long enough,
however, a faint, diffuse radiolucency may be
evident.
Abscesses are composed of an intense acute
inflammatory reaction.
In addition to the usual features of acute
inflammation, immature neutrophils (band cells)
are likely to be seen, dead and dying neutrophils
and necrotic debris (suppuration) are also
prominent.
Establishing drainage and proper
antimicrobial therapy will cure most
abscesses
In the absence of significant radiographic
changes, the dentist must rely on clinical
features to arrive at a proper diagnosis (pain,
systemic features, suppuration)
Once the presence of an apical abscess is
suspected , vigorous treatment must be
pursued.
First, the source of the acute inflammatory
response must be identified and eliminated.
Second, a bacterial culture of exudate must be
obtained and submitted to a laboratory for the
purpose of identifying the offending
microorganism and determine the antibiotic most
effective in killing it (culture and sensitivity test)
Finnaly, the dentist should prescribe an ATB.
If the abscess has spread into the surrounding
soft tissues, an incision and hrainage should be
performed.
This procedure provides a source of exudate for
culture and sensitivity testing, and, allows for the
removal of suppuration so that repair will follow.
Acute Osteomyelitis
The main reason for treating apical
abscesses with vigor is to prevent spread
along the bone marrow spaces causing a
condition known as osteomyelitis.
Ost. Is a very serious condition that can
cause destruction of large sections of jaw
and be difficult to cure.
Ost. May be the inevitable result of
untreated pulpal or periapical infection.
Almost always, bacterial infection is
involved.
Ost. More commonly affects the mandible
than the maxilla. Probably the maxillas
excellent blood supply is the difference.
There is usually malaise (discomfort),
pain, fever, and leukocytosis.
There may be swelling of the mandible
and suppurative drainage into the oral
cavity
Because the Ost. Takes longer to develop
than other acute inflammatory lesions,
usually there are significant and specific
radiographic changes.
These include involvement of bone away from
the periapical region, indistinct outline (diffuse
growth pattern) and combination of
radiolucencies and radiopacities (mottled
radiographic apperarance)
Microscopically shows bone destruction
(osteoclasts) and bone deposition (osteoblasts)
proceeding side by side.
So, it is in bone:
Inflammation induced bone resorption and bone
repair may proceed simultaneously.
It is this reaction that produces the mottled
radiographic features of Ost.