Chronic apical

periodontitis
( parodontitis apicalis
chronica )
Etiology, classification,
clinical features, dg.,

PERIAPICAL DISEASE
Classified as:
Acute Apical Periodonitis
Acute Apical Abscess
Chronic Apical Periodontitis
(Diffuse, Suppurative Apical Periodontitis with sinus
tract, Apical cyst)

Condensing Osteitis

Definition
The fundamental lesion of chronic
periapical inflammation is known as
chronic apical periodontitis
While this designation is the preferred
one, most dentists know it by the term
dental granuloma
The lesion is not a granuloma at all
because it is not composed of
granulomatous chronic inflammation.

Etiology
The etiology of apical periodontitis is an
infection of the tissues in the root canal
system and of the surrounding dentin, in
some cases also of tissues outside the
apical foramen or other portals of entry
Typically,the lesion is located at the root
apex, but communications may exist at
various levels along the root surface,and
lesions may develop at lateral and furcal
locations

 One or more of the clinical symptoms pain, swelling,

redness, increased temperature and impaired
functioncharacterize acute apical periodontitis.
Chronic apical periodontitis shows replacement of
adjacent tissue with an inflammatory cell infiltrate.
Due to the encasement of the root in bone and the
relatively greater resistance of the root to
resorption, the production of an inflammatory
infiltrate usually occurs at the expense of the
surrounding bone.
The changes in mineralization and structure of the
bone adjacent to the site of inflammation form the
basis of radiographic diagnostic procedures for the
detection and monitoring of chronic apical
periodontitis

 Apical periodontitis develops as a response to

infection and in the chronic form a granuloma is
formed with characteristics peculiar to the
location and anatomy.
In addition to the inflammatory cells, it typically
contains fibrous tissue and often cholesterol
crystals, as well as proliferating strands of
epithelium derived from the cells of Malassez. It
may or may not develop a cyst cavity, which is
lined in part or in full by epithelium. If the lumen
of this radicular cyst is continuous with the
infectious source at the pulpal entry, it may not
be self-sustained (a bay or pocket cyst) and will
heal following elimination of the infectious source.

 On the other hand, if the cyst is

completely encased by epithelium and
removed from the source of infection, it
may be self-sustained (atrue cyst) and
refractory to treatment except by surgical
excision.
The stages in development and also in
healing of chronic apical periodontitis,
granulomas and cyst are to a degree,
reflected by changes in the radiographic
appearance of the periapical area

 These changes are of decisive

importance in diagnosis and choice
of treatment.

Chronic apical periodontitis

The lesion is present over long time
of periode
Mild state of symptoms
Histologic picture of chronic
inflammation

Classification
1) Diffuse type:
- small, recurrent amount of tissue damage
- cellular infilltration with lymphocytes,
plasma cells, phagocytic mononuclear
cells, fibroblasts which produce
granulation tissues for repair of damaged
area
GRANULOMA: formation of large nodule of
granulation tissue that is slowly increase in size
Resorption of hard tissue, granulation tissue
around apex (outlined by capsule of fibrous
tissue)

 2) Chronic suppurative periodontitis

- central cavity which is accompanied
with fistula and stroma
- its known as chronic apical abscess
( chronic alveolar abscess)
3) Apical cyst
- true cyst: pathologic cavity which
contain fluid or semi-fluid substance
that is lined by epithelium and
surrounded by connective tissue
capsule

Clinical features
CAP is generally without symptoms that may
stay in the mouth with no-pain untill its
revealed by x-ray
The patient may rarely complain symptoms,
slight pain, some amount of swelling, a sinus
may be found in buccal sulcus or in skin
( fistula ) mucosa over swelling may be
bluish.
CAP is usually associated with long standing
restorations such as prosthetic crowns,
extensive bridge work, composite or
amalgam filling

Diagnosis

History
Vitality test no response of pulp
Percussion- slightly tender to percussion
X-ray diffuse or demarcated
radiolucency around the apex of the tooth,
root resorption, loss of bone, granuloma or
cyst with sclerotic margin to the bone
Diff. Dg.
Chronic Pulpitis

Case 1,fig.1a
21-years old woman-non
successful endodontic
treatment tooth
N.22,apical clear
radiolucency confirming
an established lesion
bigger than 3mm,it
shows features of lamina
dura disruption and bone
structural changes

Case 1,fig.1b
Measurement of the tooth canal length

Case 1,fig.1c
Final endodontic treatment
Foredent and gutapercha

Case 1,fig.1d
5 months after the endodontic
treatment without any surgical
procedure,intraoral x-ray shows
chronic apical periodontitis,
partial restitution of the
periapical region

Case 2,fig.2a
Orthopantogram image,unsuccessful endodontic treatment d.N.22,
Cystis radicularis D.N.22

Case 2,fig.2b
Intraoral image D.22-Cystis radicularis
processus alveolaris maxillae reg.frontalis
purulenta

Case 2,fig.2c
3months after the
therapy-Cystectomio
sec.PARTSCH II. et
resectio apicis dentis
N.22
Retrograde root
canal endodontic
therapy with amalgam
Egalisatio,suturae

Fig.B
Granuloma periapicalis
and infection
transmission paths

Chronic apical periodontitis. Extensive tissue

destruction in the periapical region of a mandibular
first molar occurred as a result of pulpal necrosis.
Lack of symptoms together with presence of a
radiographic lesion is diagnostic.

Periapical radiolucencies associated with

mandibular incisors. These teeth were
vital, and a diagnosis of cemental
dysplasia was made.

Periodontitis chronica
circumscripta d.41

Periodontitis
chronica
circumscripta
d.14