APICAL PERIODONTITIS
 Prof. MUDr. M. Kukletová
Periodontitis
 Painful pulpoperiapical pathoses
 (acute apical periodontitis)
 Inflammatory response - to pulpal irritants
 exogenous forces become hyperactive
 great increase in intraperiapical pressure
 algogenic mediators released by the
injured cells
Acute apical periodontitis
 mild symptomatic (exudative) response
 contaminants from the pulp, vasodilatation, fluid
exudation,
 white cells infiltration
 periodontal phase - abscess in the periodontal space
 enosseal phase - localized ostitis
 periosteal phase - severely symptomatic
 pain - throbbing character, radiating
 submucous phase - periosteal inflammation - relief
Acute periapical abscess
 Advanced exudative, severely symptomatic
 steadily increasing amount of inflammatory
exudate, leucocytic infiltration
 suppuration
 Etiology
 infection
 injury (acute, chronic)
 chemical irritation (dressings)
Recrudescent abscess
(phoenix abscess)
 previously - chronic (granulomatous lesions)
 contaminated (infected)
 decrease in immunity
 Symptoms: acute symptoms + periapical radiolucency
 Subacute periapical abscess
 chronic periapical abscess cycle
 drainage through the stoma = the sinus tract (fistula)
 parulis (gumboil) on the mucosa = swelling (gingiva, oral
mucosa)
Acute periodontitis - symptoms
1. Phase
(periodont)
hyperemia in the apical periodontium
increase in pressure - elevates slightly
the tooth nerve endings are stimulated slight
pressure - mild pain
2. phase
(enosseal)
as the process advances - the tooth becomes
increasingly tender, lymph nodes sensitive, alteration
of the patient, starts pus formation, pain more
intense and steady soft vestibular tissue - painful to
palpation, patient may be febrile
Acute periodontitis - symptoms
3. phase
(periost)
the most intense pain - throbbing, steady
radiating - pus penetrates the outer plate of the bone
- raises the periosteum
swelling in the apical region
great mobility
face asymmetry, swelling
the symptoms greater in horizontal position
patient - febrile
4. phase
(submucous)
periosteum and mucosa - ruptured
RELIEF
pain subsides - but swelling
fluctuation
great asymmetry
Non painful pulpoperiodontal pathoses
 inflammatory response to pulpal irritant proliferative
components
 (granulomatous)
 Pain is absent
Pulpoperiapical osteosclerosis
 (condensing osteitis, sclerosing osteitis)
 increase in the density of the periapical bone
 osteoblastic hyperactivity - bony trabeculae thicker
 in young persons - mandibular teeth
 (carious lesion, chronically inflammed pulp)
 After root canal therapy - return to normal
Incipient chronic apical periodontitis
 slightly widened apical periodontal space
 dilated blood vessels, mild inflammatory
response
 -chronic inflammatory cells (plasma cells,
lymphocyte)
Periapical granuloma
 more advanced form
 granulation tissue + chronic inflammatory
cells
 (granulomatous tissue)
 peripheral collagenous fiber capsule
Chronic periapical abscess
 (suppurative apical periodontitis)
 formation of parulis - sinus tract
 mild painful symptoms - when stoma is
blocked
Periapical cyst
 chronic inflammatory response - from the
chronic lesion
 -central cavity filled with fluid + crystals of
cholesterol
 (cellular fatty degeneration)
 lined with epithelium (rest of Malassez)
 surrounded by granulomatous tissue
 peripheral fibrous encapsulation
X-ray examination
radiolucency
chronic diffuse area of bone rarefaction
granuloma, cyst - opaque hyperostotic
border
Classifications
 diffusa
 circumscripta
 granulomatosa progressive
According to Hirsch
periapical granuloma
 granulomatous tissue, endothelial cells swollen
 macrophages, cholesterol may be present
 epithelial granuloma
 the same pattern + solid strands of epithelium
radicular cyst
 without inflammation
 strong inflammation (abscess)
 cavity surrounded by epithelim, mostly stratified
 peripheral fibrous capsule
Recrudescent chronic periodontitis (phoenix abscess, periodontitis
chronica acutae exacerbans)