CLASSIFICATION

WHO:
Acute apical periodontitis.
Chronic apical periodontitis (Apical granuloma)
Grossman:
Acute- vital; non vital
Chronic
Ingle:
Acute apical periodontitis
Chronic apical periodontitis- periradicular granuloma, radicular
cyst, condensing osteitis.

Apical (periapical) disease:

Normal apical tissues
Symptomatic apical periodontitis
Asymptomatic apical periodontitis
Acute apical abscess
Chronic apical abscess

ETIOLOGY
Directly due to non treated pulpal disease

(spread of infection via foramen, accessory canals)

Trauma (hyperocclusion , high filling)
Irrigants (irritate the periapical tissues)
Instrumentation or extruding obturation material.

NORMAL PERIAPICAL TISSUE

This is the standard against which all other apical

disease processes are compared.

The patient is asymptomatic, tooth responds normally
to percussion and palpation testing. The radiograph
reveals an intact lamina dura and periodontal ligament
space around all the root apices.

SYMPTOMATIC APICAL
PERIODONTITIS
an acutely painful response to biting pressure or percussion.
This tooth may or may not respond to pulp vitality tests
radiograph will generally exhibit at least a widened periodontal

ligament space and may or may not have an apical radiolucency

associated with one or all of the roots.

ASYMPTOMATIC APICAL PERIODONTITIS

A tooth with asymptomatic apical periodontitis generally presents with

no clinical symptoms.
This tooth does not respond to pulp vitality tests
the radiograph or image will exhibit an apical radiolucency.
This tooth is generally not sensitive to biting pressure but may feel
different to the patient on percussion.

ACUTE APICAL ABSCESS

tooth will be acutely painful to biting pressure, percussion, and

palpation.
not respond to any pulp vitality tests and will exhibit varying degrees of
mobility.
The radiograph can exhibit anything from a widened periodontal
ligament space to an apical radiolucency.
Swelling will be present intraorally and the facial tissues adjacent to the
tooth will almost always present with some degree of swelling.
the cervical and submandibular lymph nodes may exhibit tenderness
to palpation.

CHRONIC APICAL ABSCESS

tooth will not generally present with clinical symptoms.
This tooth will not respond to pulp vitality tests
radiograph will exhibit an apical radiolucency.
The tooth is generally not sensitive to biting pressure but

can feel different to the patient on percussion.

This is distinguished from asymptomatic apical
periodontitis because it will exhibit intermittent drainage
through an associated sinus tract.

DIAGNOSIS
CORRELATION BW CLINICAL SIGNS/SYMP AND HISTOLOGICAL
FINDINGS
Clinical diagnosis of inflammatory periapical disease is mainly based on
clinical signs and/or symptoms, duration of disease, pulp tests, percussion,
palpation, and radiographic findings. A histologic diagnosis is a
morphologic and biologic description of cells and extracellular matrix of
diseased tissues.
Like pulpitis, apical periodontitis is not always symptomatic or painful.
Although many inflammatory mediators (histamine, bradykinin,
prostaglandins) and proinflammatory cytokines (IL-1, IL-6, nerve growth
factor [NGF]), are capable of sensitizing and activating nociceptive sensory
nerve fibers, other mediators such as endogenous opioids and somatostatin
released by inflammatory cells during inflammation are able to inhibit
firing of sensory nerve fibers. Thus, there is no good correlation between
clinical symptoms and histopathologic findings of apical periodontitis.
many teeth with apical periodontitis are free of symptoms.

SYMPTOMATIC APICAL PERIODONTITIS

Definition:
Painful inflammation of the periodontium due to
trauma, irritation or infection through the root canals
regardless of whether the pulp is vital or non vital.
Inflammation around the apex of the tooth.

SYMPTOMATIC APICAL PERIODONTITIS

Symptomatic apical periodontitis

EtiOlogy:
Vital teeth- occlusal trauma, high restorations,
wedging objects bw teeth
Non vital teeth- consequence of pulpal disease
Iatrogenic: overinstumentation, overextending
obturations, perforation

Symptomatic apical periodontitis

CLINICAL FEATURES
Moderate-severe discomfort, spontaneous and pain on biting or

percussion
Pain usually dull, throbbing
Pain occurs over a short period of time
If its an extension of pulpitis there will be abnormal response to
thermal, electric tests.
If pulp is necrotic- no response to pulp tests.
Radiographically:
Usually it is not associated with apical radiolucent area, thickening of
PDL space may be a sign, usually pdl space and lamina dura are normal.

Symptomatic apical periodontitis

TREATMENT
Remove irritant, diseased pulp
Endodontic therapy should be performed asap.
If tooth is in hyperocclusion, relieve the occlusion

Symptomatic apical periodontitis

OUTCOMES:
Depending on the interaction between host defenses and microbial
insults, acute apical periodontitis can result in
(1) reconstruction of normal periapical tissues if irritants are immediately
eliminated by root canal therapy;
(2) abscess formation if massive invasion of periapical tissues by bacteria
occurs;
(3) organization by scarring if extensive destruction of periapical tissues
results;
(4) progression to chronic apical inflammation if irritants continue to
persist.

ASYMPTOMATIC APICAL
PERIODONTITIS
Apical Granuloma
Chronic apical periodontitis
Asymptomatic apical periodontitis with cyst

formation:
o Radicular cyst
o chronic apical periodontitis with cyst formation
Asymptomatic apical periodontitis with reactive bone
formation- condensing osteitis.

Asymptomatic Apical periodontitis (AAP)

ETIOLOGY:
Results from pulp necrosis and is usually a sequel to symptomatic AP

(SAP)
If pathogens in the root canal are not eliminated, the symptomatic
apical periodontitis may progress to become an asymptomatic apical
periodontitis. Asymptomatic apical periodontitis is characterized by
the persistence of inflammatory stimuli, adaptation of the host's
response to stimuli, presence of adaptive immune responses, and
initiation of the repair process.

Asymptomatic apical periodontitis

Asymptomatic Apical periodontitis (AAP)

Definition:
Clinical asymptomatic condition associated of pulpal origin
associated with inflammation and destruction of periapical
tissues.
Clinical signs/symptoms
Pulp is necrotic- no response to vitality tests
Percussion produces little or no pain
Radiographic features: range from interruption of lamaina
dura to extensive destruction of periapica tissues.

Asymptomatic apical periodontitis

Asymptomatic Apical periodontitis (AAP)

HISTOLOGY:
Histologically AAP lesions are classified as either cysts or granulomas.
A periapical granuloma consists of granulomatous tissue infiltrated with
mast cells, macrophages, PMN leukocytes, plasma cells, lymphocytes.
A periapical cyst (radicular cyst) has a central cavity filled with fluid or a
semisolid substance and is lined with startified squamous epithelium
(from hertwigs epithelial sheath). This is surrounded by connective tissue
containing cellular elements found in granuloma.

Asymptomatic Apical periodontitis (AAP)

TREATMENT:
RCT results in resolution of granuloma or cyst
Outcomes
Asymptomatic apical periodontitis may result in (1) regeneration or repair
of the periapical tissues after root canal therapy; (2) severe periapical
tissue destruction; (3) acute exacerbation; (4) development of an abscess
with an intraoral or extraoral draining sinus tract; or (5) development of a
serious cellulitis.

CONDENSING OSTEITIS
Definition:

Varient of Asymp AP.; Increase in trabecular bone formation due to

persistent irritation. Irritant diffusing from RC to periradicular areas is
the main cause.
Signs/symptoms:
Depending on the cause pulpitis/ pulp necrosis it can be symptomatic
or asymptomaic.
May or may not respond to vitality tests and may or may not be
sensitive to percussion/palpation
Radigraphically: radio-opacity around apex of the tooth.
Treatment: Remove the cause: RCT

ACUTE APICAL ABSCESS

Its a localized or diffuse liquefaction lesion of pulpal origin that

destroys periradicular tissues due to a severe inflammatory response

from microbial and nonbacterial irritants from a necrotic pulp.
Signs/symptoms:
Rapid onset, spontaneous pain
May be swelling, usually not if confined to bone
may have systematic signs of infection: fever, malaise
Usually TTP
Radiographic: thickening of pdl space - obvious radiolucency.

ACUTE APICAL ABSCESS

HISTOLOGICALLY:
Lesion of liquifaction necrosis containing PMN leukocytes, exudate
TREATMENT:
Removal of the underlying cause, drainage where possible and routine
root canal treatment can lead to resolution in most cases.

CHRONIC APICAL ABCESS

Inflammatory lesion of pulpal origin that is characterized by presence of
long standing lesion that has resulted in an abcess draining through a
sinus tract on the mucosa or skin surface.
ETIOLOGY:
Similar to acute apical abcess.
Usually associated with chronic apical periodontitis thats has formed
an abscess. Abscess had gone through bone and soft tissue to form a
sinus tract: intraoral, extraoral. It can drain through the periodontium
into the sulcus and can mimic abscess and pocket.
Sinus tract has two advantages: relieves pain, track the cause.

CHRONIC APICAL ABCESS

CHRONIC APICAL ABCESS

Signs/symptoms:
Drainage exists, sinus tract is present, no pain.
Other clinical radiographic feathures are similar to
acute.
Siuns tract may be lined partially or completely with
epithelium.
Treatment:
Remove the cause.