Periapical diseases. Markéta Hermanová Periapical periodontitis - aetiology nPulpitis and pulp necrosis nTrauma nEndodontic treatment n n Periapical periodontitis nAcute periapical priodontitis n nChronic periapical periodontitis n (periapical or apical granuloma) n nAcute periapical abscess and spread of inflammation n Periapical periodontitis nDynamic process; inflammation can vary with time nOutcome reflects the balance between the nature, duration, and severity of the irritant and the effectiveness of the host defences nBacterial infection of the root canals is the major cause of clinically significant periodontitis nCan follow acute traumatic injury to periapical tissues without pulp necrosis nEndodontic treatment, instrumentation of infected root canal Acute periapical periodontitis nAcute inflammatory exudate in the periodontal ligament (between root apex and alveolar bone) nPain elicited by external pressure (pulpitis well located) nHot or cold stimulation does not induce pain, as it would in pulpitis nRadiography usually normal; no bone resorption yet nAcute periapical or alveolar abscess can develop directly n Periapical abscess big_root_canal Periapical_abscess 500038-fx4 Chronic periapical periodontitis (periapical or apical granuloma) nPersistant irritation, bacteria (anaerobes predominate) in the pulp chamber and root canals results in chronic periapical periodontitis nResorption of periapical alveolar bone, replacement by granulation tissue, periapical granuloma nRoot with attached periapical granuloma Apical and periapical granulomas nAsymptomatic (may remain quiscent for long periods) or symptomatic nChronically inflammed granulation tissue around apex of a non-vital tooth nInfection and antigenic chalange from endodontic flora nStimulation of proliferation of rests of Malassez within the lesion (=radicular cysts) n Periapical granuloma P7040055 P7040056 Radiological findings in apical and periapical granulomas. nMargins reflects the dynamics of the lesion nWidening of periodontal ligament space at the beginning nActive bone resorption = margins ill defined nStatic lesions = bone aposition and the formation of a zone of sclerosis (=osteosclerosis) n n a1198_8 Sequelae of chronic periapical periodontitis nAntigenic chalange and host´s immunological response in balance = quiescent granuloma nThe balance disturbed = enlargement of the granuloma, bone resorption nBacteria invading the granuloma from the root canal = acute exacerbation = acute symptoms = enlargement of granuloma = abscess formation nSuppuration in the granuloma nDevelopment of radicular cyst nOsteosclerosis (=bone apposition) nHypercementosis (=apposition of cementum) Radicular cysts nApical, residual periapical, or lateral sub-types nApical most common nAssociated with non-vital tooth nApical radiolucency indistinguishable from a periapical granuloma nMay be symptomless nEnlargement of cyst leads to bone resorption Radicular cyst apikální laterální reziduální Radicular cyst radicular_cyst Radicular cyst-histology nArise from proliferation of the rests of Malassez within chronic periapical granulomas nLined by non-keratinizing squamous epithelium nSupported by a chronically inflammed capsule nCapsule may contain collections of cholesterols nHypertonic content: breakdown products, serum proteins, water and electrolytes, cholesterol crystals Expansion of radicular cyst nHydrostatic pressure of the cyst fluid increased due to hypertonic content nWater drawn into the cyst cavity along this osmotic gradient nCyst expansion nBone resorption Aetiology and microbiology Frequently detected bacterial species in periapical abscesses Microaerophilic streptococci S. Milleri group e. g. S. anginosus Anaerobic streptococci Peptostreptococcus species, e. g. P. anaerobius Gram-positive anaerobic rods Actinomyces species, e. g. A. israelii Eubacterium species, e. g. E. lentum Gram-negative anaerobic rods Porphyromonas species, e. g. P. gingivalis Prevotella species, e. g. P. intermedia Bacteroides species Campylobacter species Fusobacterium species, e. g. F. nucleatum Routes of spread nIncrease in hydrostatic pressure causes pus to track along lines of least resistence nPus directly into oral cavity through a sinus following penetration of periostium and mucosa nPalatal mucoperiostium resistent = palatal absces nAbscesses in molar region penetrate the bucal cortical plate spreading into soft tissues = cellulitis nAbscesses at anterior maxillar teeth = perforation of the labial bone = spreading to inner canthus of the eye and lower eyelid, obliteration of nasolabial fold, into upper lip nAbscesses at maxillary molars and premolars = into the maxillary sinus nAbscesses at mandibular premolars and molars = involvement of submandibular, sublingual and lateral pharyngeal spaces, and anteroposteriorly under the skin surface nAbscesses at mandibular incissors and canine = labially, perforate the bone, subcutaneous abscess in the midline between attachments of mentalis muscles n n n Cellulitis nRapidly spreading inflammation of the soft tissues nUsually associated with streptococcal infections (related to the release „spreading enzymes, e. g. hyaluronidase, stroptokinase) ndiffuse, tense, painful swelling of soft tissues; malaise, elevated temperature nRisk: cavernous sinus thrombosis; extension into submandibular and cervical tissues = respiratory embarrassment; pain, trismus Ludwig´s angina nSevere cellulitis involving the submandibular, sublingual, and submental spaces nMay involve the pharynx and larynx nOedema of the glottis; risk of death by suffocation Ludwig´s angina Ludwig_angina3 Thank you for your attention …