Acute apical periodontitis

Acute apical periodontitis is local inflammation that occurs in the area of the apical
periodontal ligament. The main cause of acute apical periodontitis is irritation that diffuses from
necrotic pulp to periapical tissues such as bacteria, bacterial toxins, disinfectant, and debris.
Additionally, physical irritation as restorations hyperpercussion, excessive instrumentation and
obturation discharge into the periapical tissues can also cause acute apical periodontitis.
(Ingel,2002)
Acute apical periodontitis also categorized as symptomatic apical periodontitis. In the case of
symptomatic, infection occurs in root canal that have reached the periapical tissues. Irritants
include inflammatory mediators from the pulp irreversibly inflamed or bacterial toxins from
necrotic pulp, chemicals (like irigan or disinfectant), restoration hyperocclusion, over
instrumentation and obturation material discharge into the periapical tissues. (Walton, 2008)
Acute apical periodontitis generally causing pain when biting. Sensitive to percussion is
an important sign of a diagnostic test. Palpation test can respond sensitively or no response. If the
apical periodontitis is an extension pulpitis, it will provide a response to vitality tests. If pulp
necrosis caused by then the tooth will not provide a response to vitality tests. Radiographically
visible thickening of the periodontal ligament. (Torabinejad,2009)
The radiographic of primary acute apical periodontitis, periodontal ligament space and
lamina dura looks normal, or there is a slight thickening of the ligament space and the loss of
some lamina dura around the apex of the tooth. (Abbott,2002)
Patients with secondary acute apical periodontitis can feel the same pain symptoms in
patients with primary acute apical periodontitis, but there are more signs of clinical and
radiographic diagnosis to determine because of an acute exacerbation of chronic apical
periondontitis. In radiography, lamina dura has been lost and there is usually a radiolucent on the
teeth concerned. Radiolucency size depends on how long the apialis chronic periodontitis has
occurred. (Abbott,2002)
Acute apical periodontitis associated with plasma exudation and migration of
inflammatory cells from blood vessels into the periapical tissues. This causes damage to the
periodontal ligament and alveolar bone resorption. (Ingel,2002)

Figure 2. Radiograph of acute periapical periodontitis

Source : Ingle J.I. Endodontics 5th ed. 2002.p.180.

Chronic apical periodontitis

Chronic apical periodontitis is a disease that develops after the occurrence of pulp
necrosis and infection due to caries, trauma, or iatrogenic procedures. Chronic apical
periodontitis have no symptoms or only mild discomfort and can be classified as asymptomatic
apical periodontitis. Teeth with chronic apical periodontitis not responding to stimuli electrically
or thermally. On examination of percussion there is little or no pain at all. Radiographically,
chronic apical periodontitis showed radiolucent periapical. Change begins with a thickening of
the periodontal ligament and resorption of lamina dura then periapical bone destruction. (Walton,
2008)

Figure 1. Radiograph of chronic periapical periodontitis

Source : Ingle J.I. Endodontics 5th ed. 2002.p.180.
Etiology of periodontal disease is very complex. The experts suggested that the etiology
of periodontal disease can be classified into two groups: local and systemic factors. Local and
systemic factors are closely related and act as the cause of periodontal tissue destruction.

Generally, the main cause of periodontal disease is local factors, this situation may be
exacerbated by systemic conditions that are less favorable and allow for progressive
circumstances. (Laskaris,2003)
Local factors are the factors that resulted directly to the periodontal tissue and can be
divided into two parts, namely local irritation and local functions. What is meant by local factors
as the main cause is bacterial. And other factors include the shape of the teeth is not good and the
location of irregular teeth, malocclusion, over hanging restoration and bruxism. Systemic factors
as periodontal disease include hormonal influences during puberty, pregnancy, menopause,
vitamin deficiency, diabetes melittus and others. In this case suggested that sex hormones play a
role in the pathogenesis of periodontal disease. (Laskaris,2003)
Types of facultative anaerobic bacteria found in chronic apical periodontitis (Pelcza et al.,
2008; Entjang,2003) :
1. Staphylococcus
2. Streptococcus
-

Streptococcus pneumoniae

Streptococcus pyogenes (sterptococci group A)

Streptococcus group D

Streptococcus viridans

The types of bacteria that are obligate anaerobes in chronic apical periodontitis, among others:
1. Obligate anaerobic Gram-positive rods. (Pelcza et al.,2008)
-

Actinomyeces

Lactobacillus

Bifidobacterium

Eubactrium

Propionibacterium

2. Obligate anaerobic Gram-negative rods

Obligate anaerobic bacteria Gram-negative rods were found in chronic apical
periodontitis is Fusobacterium. (Pelcza et al.,2008)

Walton RE, Torabinejad M. Prinsip & praktik ilmu endodonsia. Ed.3. Jakarta : EGC. 2008, hal.
47-51.
Abbott PV. The periapical space-a dynamic interface. Aust Endod J; 2002: 28(3) : 97-100.
Ingel J.I, Bakland LK. Endodontisc 5th ed. London: BC. Decker; 2002. p. 178-86.
Torabinejad M, Walton R.E. Principles and practice of endodontic 4th Ed. Philadelphia: Saunders
Company; 2009.p. 38-40, 58-63.
Laskaris, Scully. Periodontal manifestation of local and systemic disease. Berlin, Heidelberg:
Springer; 2003.p. 105-9.
Pelcza MJ. Chan ECS. Dasar-dasar mikrobiologi. Jakarta : UIP ; 2008.p.46-140.
Entjang I. Mikrobiologi dan parasitologi. Bandung: Citria Aditia Bakti; 2003. hal:99-103, 11722.