Periapical Diseases

Front 1

Definition: Refers to a mass of chronically inflamed granulation tissue at the apex of a non-vital tooth

Back 1

Periapical granuloma

Front 2

Synonym: Chronic Apical Periodontitis

Back 2

Periapical granuloma

Front 3

Clinical Features:
1. Asymptomatic but pain with acute exacerbation.
2. Involved tooth shows no mobility or sensitivity to percussion.
3. Tooth is non-vital and thus does not respond to pulp testing.

Back 3

Periapical granuloma

Front 4

Radiographic Features:
1. Indistinguishable from a periapical cyst based on size and radiographic appearance.
2. Lesion may be either circumscribed or an ill-defined radiolucency of variable size.
3. There is loss of apical lamina dura
4. Root resorption may occur

Back 4

Periapical granuloma

Front 5

Treatment/Prognosis:
1. If tooth is restorable, one does root canal therapy.
2. Non-restorable teeth are extracted followed by curettage of all apical soft tissue, which is submitted for microscopic examination.
3. Lesions that do not resolve or that enlarge should be treated with periapical surgery, biopsy and retrofill.

Back 5

Periapical granuloma/periapical cyst

Front 6

Synonyms:
1. Radicular Cyst
2. Apical Periodontal Cyst

Back 6

Periapical cyst

Front 7

Definition:
Pathological cavity lined by epithelium (most commonly originating from rests of malassez)

Back 7

Periapical cyst

Front 8

Clinical Features:
1. Lesion is typically asymptomatic unless there is an acute exacerbation.
2. If large, the lesion may produce swelling and sensitivity.
3. Movement and mobility of adjacent teeth may occur as the ___ enlarges.
4. The associated tooth is non-vital (does not respond to pulp testing)
5. CANNOT BE distinguished from granuloma on radiograph

Back 8

Periapical cyst

Front 9

Definition: The accumulation of acute inflammatory cells at the apex of a non-vital tooth.

Back 9

Periapical abcess

Front 10

Clinical features:
1. Pain, sensitivity to percussion, extrusion of the involved tooth and swelling may occur.
2. Tooth does not respond to cold or electric pulp testing.
3. Patient may have a headache, chills, fever and malaise.
4. The apical periodontal ligament may appear thickened or an ill-defined radiolucency may occur or both over time.
5. No alteration may been seen on radiograph if not enough bone destruction has occurred.

Back 10

Symptomatic periapical abcess

Front 11

Treatment/Prognosis:
1. Requires adequate, timely treatment.
2. Establish drainage and by elimination of the focus of infection.
3. Endodontic therapy or extraction of non-restorable teeth removes the source of infection.
4. Analgesics and antibiotics are needed in severe cases.
5. May progress to an osteomyelitis, celluitis, or development of an intraoral or cutaneous sinus tract.
6. A parulis (gumboil) may develop at the opening of an intraoral sinus tract.

Back 11

Periapical abcess

Front 12

Which of the following are accompanied by SEVERE pain?
a. acute pulpitis
b. chronic pulpitis
c. reversible pulpitis
d. p.a. abcess
e. p.a. cyst
f. p.a. granuloma

Back 12

a and d

Front 13

Which of the following are accompanied by radiographic radiolucencies?
a. acute pulpitis
b. chronic pulpitis
c. reversible pulpitis
d. p.a. abcess
e. p.a. cyst
f. p.a. granuloma

Back 13

e and f

Front 14

Definition: Represents a mass of subacutely inflamed granulation tissue at the opening of the intraoral sinus tract and caused by inflammation arising from a periodontal or periapical abscess.
It appears as a red tumescence (or yellow if pus filled) which occurs more frequently on the buccal gingiva of children and young adults. It is often asymptomatic.

Back 14

Parulis

Front 15

Synonym: gum boil

Back 15

Parulis

Front 16

Treatment/Prognosis:
Treatment of the periodontal or periapical condition generally leads to the resolution of ____; occasionally surgical excision is required. Cyclic drainage occurs until the underlying condition is resolved.

Back 16

Parulis

Front 17

Definition: Diffuse inflammation of soft tissues, which is not circumscribed or confined to one area, but which in contradistinction to an abscess, tends to spread through tissue spaces and along fascial planes.

Back 17

Cellulitis

Front 18

Clinical features:
1. Swelling of floor of mouth, tongue and submandibular region.
2. Sublingual space involvement causes posterior enlargement , elevation and protrusion of the tongue (woody tongue).
3. Submandibular space involvement causes enlargement and tenderness of the neck about the hyoid bone (bull neck).
4. Initially it is unilateral but rapidly becomes bilateral.
5. Pain occurs in neck and/or floor of mouth.
6. Dysphagia, dysphonia, dysarthria, drooling, sore throat and restricted neck movement may occur.
7. Involvement of lateral pharyngeal space can cause respiratory obstruction.
8. Patient may manifest tachypnea, dyspnea, tachycardia, stridor and restlessness.
9. Fever, chills, leukocytosis and elevated SED rate is common.

Back 18

Ludwig Angina Cellulitis

Front 19

Treatment/Prognosis
1.Maintenance of the airway
2. Antibiotic therapy
3. Surgical drainage
4. The incidence of mortality is approximately 8 % with appropriate treatment.

Back 19

Ludwig Angina Cellulitis

Front 20

Clinical features:
1.Swelling around the eye with enlargement of the eyelids and conjunctiva.
2. Protrusion and fixation of the eyeball may occur.
3. Induration and swelling of forehead and nose is common.
4. Patients may develop lacrimation, photophobia, pupil dilation and loss of vision.
5. Pain over the eye and along the ophthalmic and maxillary branches of the trigeminal nerve occurs.
6. Fever, chills, sweating, tachycardia, nausea and vomiting can occur.
7. Signs of CNS involvement may occur and include tachycardia, tachypnea, irregular breathing, stiff neck, stupor and delirium.
8. Occasionally a patient will develop a brain abscess.

Back 20

Cavernous Sinus Thrombosis Cellulitis

Front 21

Treatment/Prognosis:
1. Extraction of the offending tooth, establishment of drainage, high dose antibiotics.
2. Corticosteroids may be given to decrease inflammation and prevent vascular collapse.
3. Some suggest the use of anticoagulants to prevent thrombosis and septic emboli while others indicate their usage increases vascular complications.

Back 21

Cavernous Sinus Thrombosis Cellulitis

Front 22

Definition: An acute or chronic inflammatory process in the medullary spaces or cortical surfaces of bone that extends away from the initial site of involvement. In the oral region, it is usually a bacterial infection. Predisposing factors thus include: alcohol and tobacco abuse, IV drug use, diabetes mellitus, malaria, anemia, malnutrition, malignancy and AIDS.

Back 22

Osteomyelitis

Front 23

Clinical features:
1. All ages can be affected with a male gender predominance. Most cases involve the mandible.
2. Fever, leukocytosis, lymphadenopathy, significant sensitivity, pain or paresthesia may occur. Soft-tissue swelling and redness may be present.
3. Radiographs may be unremarkable (especially early on) or may demonstrate an ill-defined radiolucency.
4. Fragments of necrotic bone may separate for vital bone and be exfoliated (sequestrum).
5. Less than a month since symptoms began.

Back 23

Acute Osteomyelitis

Front 24

Treatment/Prognosis:
If obvious abscess formation occurs, treatment of ____ consists of antibiotics and drainage. In most patients, sufficient and appropriate antibiotic regimen aborts the inflection and averts the need for surgical intervention.

Back 24

Acute Osteomyelitis

Front 25

Clinical features:
1. Acute osteomyelitis may become entrenched as ___ or it may arise de novo.
2. May occur at any age and is more common in males with the mandible being the favored jaw.
3. Swelling, pain, sinus formation, purulent discharge, sequestrum formation, tooth loss or pathologic fracture may occur.
4. During quiescent periods, the lesions may be asymptomatic or present minimal discomfort.
5. Radiographs reveal a patchy, ragged and ill-defined radiolucency often containing sclerotic foci. This is often referred to as a “moth-eaten” pattern.

Back 25

Chronic Osteomyelitis

Front 26

Treatment/Prognosis:
1. Difficult to manage medically. Antibiotics are used intravenously in high doses.
2. The extent of surgical intervention depends on the spread of the process with its goal of removal of all infected tissue.
3. Management of persistent cases often requires use of more sophisticated techniques such as: Scintigraphic techinques, hyperbaric oxygen, or direct delivery of antibiotics has been achieved via antibiotic-impregnated polymethyl-methacrylate beads.

Back 26

Chronic Osteomyelitis

Front 27

Definition: A group of presentations that are characterized by pain, inflammation and varying degrees of gnathic periosteal hyperplasia, sclerosis and lucency.
Term should be used only in cases where the infectious process is DIRECTLY (not secondarily) responsible for the bony sclerosis.
The pathoses can be discussed under three categories: 1. diffuse sclerosing osteomyelitis 2. chronic tendoperiostitis 3. SAPHO syndrome.

Back 27

Diffuse Sclerosing Osteomyelitis

Front 28

Clinical features:
1. Condition occurs almost exclusively in adults and there is no gender predilection. It occurs primarily in the mandible.
2. Increased radiodensity develops around sites of chronic infection and it may be either multifocal or fill in an entire quadrant.
3. Pain and swelling are not common features.

Back 28

Diffuse Sclerosing Osteomyelitis

Front 29

Treatment/Prognosis:
1. This condition is best treated by removal of the source of infection; with this being accomplished the sclerosis remodels in some patients but it remains in others.
2. Of great importance, the patient and dentist should work together to prevent future processes which would cause an inflammatory response

Back 29

Diffuse Sclerosing Osteomyelitis

Front 30

Definition: May represent a reactive hyperplasia of bone caused by chronic overuse of the muscles of mastication.
Several studies have associated _____ with parafunctional muscle habits such as bruxism, clenching and nail-biting.

Back 30

Chronic Tendoperiostitis

Front 31

Clinical features:
1. This condition may affect patients of any age but the mean age is around 40 yrs. 2. There does not seem to be a gender predilection.
3. Recurrent pain, swelling of the cheek and trismus are classic symptoms.
4. Evidence of infection is lacking, e.g. no suppuration and negative microbiological cultures.
5. Some cases have spontaneously resolved.
6. Areas of radiolucency are observed in areas of radiodensity.
7. The sclerosis is usually limited to one quadrant and often centers around the anterior region of the mandibular angle and posterior region of the body of the mandible; erosion of the inferior border of the mandible just anterior to the angle often occurs

Back 31

Chronic Tendoperiostitis

Front 32

Treatment/Prognosis:
1. Treatment results are often unsatisfactory. Antibiotics, exploration, intraoral decortication, hyperbaric oxygen and corticosteroid therapy often fail.
2. Treatment must center on resolving muscle overuse; thus muscle relaxation techniques, exercises, splints, myofeedback and drugs have been useful in some patients.

Back 32

Chronic Tendoperiostitis

Front 33

Definition: synovitis, acne, pustulosis, hyperostosis and osteitis.

Back 33

SAPHO Syndrome

Front 34

Clinical features:
1. Most patients are under the age of 60 years and suffer from chronic multifocal osteomyelitis, which yields negative microbiological cultures and is unresponsive to antibiotic therapy.
2. The cause is unknown, however some theorize that there is an abnormal immune response to microorganisms that cross-reacts with normal bone or joint structures leading to the variety of clinical manifestations.
3. In some cases, the bone lesions are present without the associated skin involvement. 4. The sternum, clavicles and ribs are the most commonly involved bones.
5. The jaw lesions, when they occur, often show diffuse areas of osteolysis with some bony sclerosis. Early periosteal new bone formation is prominent but later this diminishes making the bone smaller.
6. On occasions, the skin lesions do not develop for as long as 20 years after the bony manifestations.

Back 34

SAPHO Syndrome

Front 35

Treatment/Prognosis:
1. Most treatments that attempt to eliminate infection are, as would be suspected, unsuccessful. Steroids and non-steroidal anti-inflammatory drugs are most helpful in relieving symptoms.
2. Even with significant medical and surgical interventions, there is typically incomplete resolution.

Back 35

SAPHO Syndrome

Front 36

Definition: Characterized as localized areas of bone sclerosis associated with the apices of teeth with pulpitis or pulpal necrosis in vital or non-vital teeth.

Back 36

Condensing Osteitis

Front 37

Synonym:
Focal Sclerosing Osteomyelitis

Back 37

Condensing Osteitis

Front 38

Clinical features:
1. Can occur at any age but is more common in children and young adults.
2. It occurs most commonly in the mandibular premolar/molar region.
3. The dental pulp of the associated tooth demonstrates pulpitis or necrosis.
4. In diagnosing, clinical expansion of the jaw should not occur.
5. Localized, uniform zone of increased radiodensity adjacent to the apex of a tooth that exhibits a thickened PDL or apical inflammatory lesion.
6. Early lesions may appear radiolucent towards the apex with a radiodensity to the periphery.
7. Lesions do not exhibit a radiolucent border as periapical cemento-osseous dysplasia does and they are not separated from the apex of the tooth as would be the case with idiopathic osteosclerosis.

Back 38

Condensing Osteitis

Front 39

Treatment/Prognosis:
1. Treatment consists of resolution of the odontogenic focus of infection via endodontic therapy or extraction.
2. The literature tells us that 85 % of these lesions partially or completely regress following treatment.
3. A residual area that remains after resolution of the inflammatory focus is termed a bone scar.

Back 39

Condensing Osteitis

Front 40

Synonyms:
Periostitis Ossificans
Garrè’s Osteomyelitis

Back 40

Osteomyelitis with Proliferative Periostitis

Front 41

Definition: This condition represents a periosteal reaction to the presence of inflammation.
The source of infection is typically a carious tooth.
The affected periosteum forms several rows of reactive, vital bone that parallel each other and expand the bone.

Back 41

Osteomyelitis with Proliferative Periostitis

Front 42

Clinical features:
1. The most frequent cause is dental caries.
2. The mean age of the condition is approximately 13 years and there is no gender predilection.
3. Most cases are unifocal and the site predilection is the mandibular premolar/molar region with involvement of the inferior border of the mandible.
4. Appropriate radiographs reveal radiopaque laminations of bone that roughly parallel each other and the underlying cortical surface.
5. Beware: if bony destruction is seen in association with the cortical surface or new periosteal bone, then one should consider the possibility of a neoplastic process, e.g. Ewing sarcoma.

Back 42

Osteomyelitis with Proliferative Periostitis

Front 43

Treatment/Prognosis:
1. Treatment consists of the elimination of the source of infection via either endodontic therapy or extraction.
2. Resolution typically occurs in 6-12 months following successful treatment of the infection with the inferior border of the mandible returning to its normal contour.

Back 43

Osteomyelitis with Proliferative Periostitis

Front 44

Synonyms:
Dry Socket
Fibrinolytic Alveolitis

Back 44

Alveolar Osteitis

Front 45

Definition: Develops as a result of destruction of the blood clot which naturally occurs following tooth extraction. This prevents normal healing.
Local trauma, estrogens and bacterial pyrogens are known to stimulate fibrinolysins which can destroy the clot.

Back 45

Alveolar Osteitis

Front 46

Clinical features:
1. Occurs more commonly in the posterior portion of the mandible.
2. If the use of oral contraceptives is taken into account, there is no gender predilection.
3. Occurs in approximately 25-30% of the impacted mandibular third molar extractions and in approximately 1-3 % of all extractions overall.
4. The likelihood of developing a dry socket is highest in the 40-45 yr. old age group.
5. The clot is lost leaving a bare bony (dry) socket.
6. Severe pain and foul odor are common, while swelling and lymphadenopathy occur less commonly.
7. A dry socket usually develops 3-4 days after extraction and the condition may last from 10-40 days.
8. Probing of the socket reveals exposed, extremely sensitive bone.

Back 46

Alveolar Osteitis

Front 47

Treatment/Prognosis:
1. Radiographs should be taken to rule out a retained root tip or foreign body.
2. Once the clinical diagnosis is made, the socket should be irrigated and then packed with an obtundent and an antiseptic dressing such as iodoform gauze with eugenol.
3. It is suggested that the dressing should be changed every 24 hrs. for the first 3 days and then every 2-3 days thereafter until granulation tissue covers the exposed bone.
4. Studies have shown that preventive measures may be helpful.
5. Patients using oral contraceptives should be scheduled for extractions on days without estrogen supplementation.
6. Intraoperative irrigation, topical and systemic antibiotics, systemic and topical antifibrinolytics and antimicrobial rinses have been used in “high risk” patients with some success.
7. High risk patients include those who are taking oral contraceptives, patients who smoke, and those that have existing signs of a pericoronitis, have a history of alveolar osteitis or those with more complicated (thus traumatic) extractions.

Back 47

Alveolar Osteitis