Periapical periodontitis

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Periapical periodontitis
Other namesApical periodontitis, periradicular periodontitis
Chronic apical periodontitis.jpg
Periapical dental radiograph showing chronic periapical periodontitis on the root of the left maxillary second premolar. Note large restoration present in the tooth, which will have undergone pulpal necrosis at some point before the development of this lesion.
Specialty Endodontics [1]
Complications Apical extrusion of pulpal debris, abscesses in the head and neck, Ludwig Angina [2]
CausesPulp infection [3]
Risk factors Dental caries, dental trauma, dental procedures [3] , professional misconduct [4]
Diagnostic method Apical Radiolucencies, Apical Radiopacities [5]
Treatment Root canal treatment [1] , periradicular surgery [6] , retrograde root canal treatment [7]
Medication Antibiotic in case of a sudden onset of symptoms in less than 24 hours. [8]

Periapical periodontitis or apical periodontitis [9] (AP) is an acute or chronic inflammatory lesion around the apex of a tooth root, most commonly caused by bacterial invasion of the pulp of the tooth. [10] It is a likely outcome of untreated dental caries (tooth decay), and in such cases it can be considered a sequela in the natural history of tooth decay, irreversible pulpitis and pulpal necrosis. Other causes can include occlusal trauma due to 'high spots' after restoration work, extrusion from the tooth of root filling material, or bacterial invasion and infection from the gums. Periapical periodontitis may develop into a periapical abscess, where a collection of pus forms at the end of the root, the consequence of spread of infection from the tooth pulp (odontogenic infection), or into a periapical cyst, where an epithelial lined, fluid-filled structure forms.

Contents

Etymologically, the name refers to inflammation (Latin, -itis) around (peri- ) the root tip or apex (-apical) of the tooth (-odont-). Periradicular periodontitis is an alternative term.

Diagnosis

The radiographic features of periapical inflammatory lesions vary depending on the time course of the lesion. Because very early lesions may not show any radiographic changes, diagnosis of these lesions relies solely on the clinical symptoms. More chronic lesions may show lytic (radiolucent) or sclerotic (radiopaque) changes, or both.

Classification

Classification of periapical periodontitis is usually based on whether the process is acute/symptomatic or chronic/asymptomatic.

(Note: alternative names for periapical periodontitis include 'apical periodontitis' and 'periradicular periodontitis'.)

Acute periapical periodontitis

Acute (or symptomatic) periapical periodontitis.... Malaise throbbing pain due to Inflammation within periodontal ligament

Chronic periapical periodontitis

Chronic (or asymptomatic) periapical periodontitis.

In addition to periapical abscesses, periapical periodontitis can give rise to various related lesions, including periapical granulomas and cysts. [11] A periapical granuloma (also referred to as an 'apical granuloma' or 'radicular granuloma') is a mass of chronically inflamed granulation tissue that forms at the apex of the root of a nonvital (dead) tooth. [12] (Although not a true granuloma, given the absence of granulomatous inflammation, the term 'periapical granuloma' is widely accepted.) [12]

Treatment

Treatment options may include antibiotic therapy (in the short term, augmented by chewing gum), root canal therapy, or extraction.[ citation needed ]

Epidemiology

Periapical periodontitis of some form is a very common condition. The prevalence of periapical periodontitis is generally reported to vary according to age group, e.g. 33% in those aged 20–30, 40% in 30- to 40-year-olds, 48% in 40- to 50-year-olds, 57% in 50- to 60-year-olds and 62% in those over the age of 60. [13] Most epidemiologic data has been generated in European countries, especially Scandinavia. While millions of root canal treatments are carried out in the United States alone each year, total numbers of such cases do not provide reliable indicators of frequency, even for symptomatic periapical periodontitis (given that root canal treatment is not always indicated or complied with, and may also be performed in the absence of periapacial periodontitis).

Related Research Articles

<span class="mw-page-title-main">Root canal</span> Hollow part of the root of a tooth

A root canal is the naturally occurring anatomic space within the root of a tooth. It consists of the pulp chamber, the main canal(s), and more intricate anatomical branches that may connect the root canals to each other or to the surface of the root.

<span class="mw-page-title-main">Endodontics</span> Field of dentistry which studies the interior tissue (pulp) of teeth

Endodontics is the dental specialty concerned with the study and treatment of the dental pulp.

<span class="mw-page-title-main">Toothache</span> Medical condition of the teeth

Toothache, also known as dental pain or tooth pain, is pain in the teeth or their supporting structures, caused by dental diseases or pain referred to the teeth by non-dental diseases. When severe it may impact sleep, eating, and other daily activities.

<span class="mw-page-title-main">Pulp (tooth)</span> Part in the center of a tooth made up of living connective tissue and cells called odontoblasts

The pulp is the connective tissue, nerves, blood vessels, and odontoblasts that comprise the innermost layer of a tooth. The pulp's activity and signalling processes regulate its behaviour.

A pulp polyp, also known as chronic hyperplastic pulpitis, is a "productive" inflammation of dental pulp in which the development of granulation tissue is seen in response to persistent, low-grade mechanical irritation and bacterial invasion of the pulp.

<span class="mw-page-title-main">Condensing osteitis</span> Hardening of tooth roots due to infection

Condensing osteitis is a periapical inflammatory disease that results from a reaction to a dental related infection. This causes more bone production rather than bone destruction in the area, most commonly near the root apices of premolars and molars. The lesion appears as a radiopacity in the periapical area hence the sclerotic reaction. The sclerotic reaction results from good patient immunity and a low degree of virulence of the offending bacteria. The associated tooth may be carious or contains a large restoration, and is usually associated with a non-vital tooth. It was described by Dr. Carl Garré in 1893.

Dens invaginatus (DI), also known as tooth within a tooth, is a rare dental malformation and a developmental anomaly where there is an infolding of enamel into dentin. The prevalence of this condition is 0.3 - 10%, affecting males more frequently than females. The condition presents in two forms, coronal involving tooth crown and radicular involving tooth root, with the former being more common.

<span class="mw-page-title-main">Idiopathic osteosclerosis</span> Hardening of the teeth roots for an unknown reason

Idiopathic osteosclerosis, also known as enostosis or dense bone island, is a condition which may be found around the roots of a tooth, usually a premolar or molar. It is usually painless and found during routine radiographs as an amorphous radiopaque (light) area around a tooth. There is no sign of inflammation of the tooth, and if the island is associated with the root the periodontal ligament space is preserved.

<span class="mw-page-title-main">Periapical cyst</span> Sac growth at the root of a tooth

Commonly known as a dental cyst, the periapical cyst is the most common odontogenic cyst. It may develop rapidly from a periapical granuloma, as a consequence of untreated chronic periapical periodontitis.

<span class="mw-page-title-main">Dental abscess</span> Collection of pus in or around a tooth

A dental abscess is a localized collection of pus associated with a tooth. The most common type of dental abscess is a periapical abscess, and the second most common is a periodontal abscess. In a periapical abscess, usually the origin is a bacterial infection that has accumulated in the soft, often dead, pulp of the tooth. This can be caused by tooth decay, broken teeth or extensive periodontal disease. A failed root canal treatment may also create a similar abscess.

<span class="mw-page-title-main">Root canal treatment</span> Procedure to disinfect and fortify the interior of a tooth

Root canal treatment is a treatment sequence for the infected pulp of a tooth which is intended to result in the elimination of infection and the protection of the decontaminated tooth from future microbial invasion. Root canals, and their associated pulp chamber, are the physical hollows within a tooth that are naturally inhabited by nerve tissue, blood vessels and other cellular entities. Together, these items constitute the dental pulp.

Apical periodontitis is typically the body's defense response to the threat of microbial invasion from the root canal. Primary among the members of the host defense mechanism is the polymorphonuclear leukocyte, otherwise known as the neutrophil. The task of the neutrophil is to locate and destroy microbes that intrude into the body – anywhere in the body – and they represent the hallmark of acute inflammation.

<span class="mw-page-title-main">Tooth resorption</span> Breakdown of the tooth root to be absorbed by the blood

Resorption of the root of the tooth, or root resorption, is the progressive loss of dentin and cementum by the action of odontoclasts. Root resorption is a normal physiological process that occurs in the exfoliation of the primary dentition. However, pathological root resorption occurs in the permanent or secondary dentition and sometimes in the primary dentition.

<span class="mw-page-title-main">Periodontal abscess</span> Collection of pus within tissues surrounding a tooth

A periodontal abscess, is a localized collection of pus within the tissues of the periodontium. It is a type of dental abscess. A periodontal abscess occurs alongside a tooth, and is different from the more common periapical abscess, which represents the spread of infection from a dead tooth. To reflect this, sometimes the term "lateral (periodontal) abscess" is used. In contrast to a periapical abscess, periodontal abscesses are usually associated with a vital (living) tooth. Abscesses of the periodontium are acute bacterial infections classified primarily by location.

Combined periodontic-endodontic lesions are localized, circumscribed areas of bacterial infection originating from either dental pulp, periodontal tissues surrounding the involved tooth or teeth or both.

Pulp necrosis is a clinical diagnostic category indicating the death of cells and tissues in the pulp chamber of a tooth with or without bacterial invasion. It is often the result of many cases of dental trauma, caries and irreversible pulpitis.

A phoenix abscess is an acute exacerbation of a chronic periapical lesion. It is a dental abscess that can occur immediately following root canal treatment. Another cause is due to untreated necrotic pulp. It is also the result of inadequate debridement during the endodontic procedure. Risk of occurrence of a phoenix abscess is minimised by correct identification and instrumentation of the entire root canal, ensuring no missed anatomy.

<span class="mw-page-title-main">Regenerative endodontics</span> Dental specialty

Regenerative endodontic procedures is defined as biologically based procedures designed to replace damaged structures such as dentin, root structures, and cells of the pulp-dentin complex. This new treatment modality aims to promote normal function of the pulp. It has become an alternative to heal apical periodontitis. Regenerative endodontics is the extension of root canal therapy. Conventional root canal therapy cleans and fills the pulp chamber with biologically inert material after destruction of the pulp due to dental caries, congenital deformity or trauma. Regenerative endodontics instead seeks to replace live tissue in the pulp chamber. The ultimate goal of regenerative endodontic procedures is to regenerate the tissues and the normal function of the dentin-pulp complex.

In the dental specialty of endodontics, periradicular surgery is surgery to the external root surface. Examples of periradicular surgery include apicoectomy, root resection, repair of root perforation or resorption defects, removal of broken fragments of the tooth or a filling material, and exploratory surgery to look for root fractures.

Periapical granuloma, also sometimes referred to as a radicular granuloma or apical granuloma, is an inflammation at the tip of a dead (nonvital) tooth. It is a lesion or mass that typically starts out as an epithelial lined cyst, and undergoes an inward curvature that results in inflammation of granulation tissue at the root tips of a dead tooth. This is usually due to dental caries or a bacterial infection of the dental pulp. Periapical granuloma is an infrequent disorder that has an occurrence rate between 9.3 to 87.1 percent. Periapical granuloma is not a true granuloma due to the fact that it does not contain granulomatous inflammation; however, periapical granuloma is a common term used.

References

  1. 1 2 Blake, Ahren; Tuttle, Travis; McKinney, Reed (2024). "Apical Periodontitis". StatPearls. Treasure Island (FL): StatPearls Publishing. PMID   36943974. Further management is indicated when a periapical radiolucency remains unchanged after one year of root canal treatment, when it has increased in size, or if it appears in an endodontic-treated tooth without a prior apical disease.
  2. Blake, Ahren; Tuttle, Travis; McKinney, Reed (2024). "Apical Periodontitis". StatPearls. Treasure Island (FL): StatPearls Publishing. PMID   36943974.
  3. 1 2 Blake, Ahren; Tuttle, Travis; McKinney, Reed (2024). "Apical Periodontitis". StatPearls. Treasure Island (FL): StatPearls Publishing. PMID   36943974. It may occur due to the advancement of dental caries, trauma, or operative dental procedures. The infected pulp is the main cause of apical periodontitis.
  4. Blake, Ahren; Tuttle, Travis; McKinney, Reed (2024). "Apical Periodontitis". StatPearls. Treasure Island (FL): StatPearls Publishing. PMID   36943974. A periapical radiolucency often persists when the root canal treatment cannot control the infection because some clinical steps were not adequately followed, such as insufficient aseptic control, poor instrumentation, inadequate access cavity design, unreached canals, and restoration leakage.
  5. Blake, Ahren; Tuttle, Travis; McKinney, Reed (2024). "Apical Periodontitis". StatPearls. Treasure Island (FL): StatPearls Publishing. PMID   36943974. Apical radiopacities are likely not associated with endodontic infection directly but are commonly found on routine radiographic evaluation. Radiopacities are generally benign.
  6. Blake, Ahren; Tuttle, Travis; McKinney, Reed (2024). "Apical Periodontitis". StatPearls. Treasure Island (FL): StatPearls Publishing. PMID   36943974. non-surgical endodontic retreatment or periradicular surgery are treatment alternatives to save the tooth.
  7. Kvist, Thomas; Jonasson, Peter (2021). Retrograde Root Canal Treatment. Cham: Springer International Publishing. doi:10.1007/978-3-030-78666-3. ISBN   978-3-030-78666-3.
  8. Blake, Ahren; Tuttle, Travis; McKinney, Reed (2024). "Apical Periodontitis". StatPearls. Treasure Island (FL): StatPearls Publishing. PMID   36943974. Antibiotic use is generally contraindicated, except in cases with rapid onset or systemic involvement.
  9. Nair PN (April 2006). "On the causes of persistent apical periodontitis: a review". International Endodontic Journal. 39 (4): 249–81. doi: 10.1111/j.1365-2591.2006.01099.x . PMID   16584489.
  10. Segura-Egea JJ, Castellanos-Cosano L, Machuca G, López-López J, Martín-González J, Velasco-Ortega E, et al. (March 2012). "Diabetes mellitus, periapical inflammation and endodontic treatment outcome". Medicina Oral, Patologia Oral y Cirugia Bucal. 17 (2): e356-61. doi:10.4317/medoral.17452. PMC   3448330 . PMID   22143698.
  11. Graunaite I, Lodiene G, Maciulskiene V (January 2012). "Pathogenesis of apical periodontitis: a literature review". Journal of Oral & Maxillofacial Research. 2 (4): e1. doi:10.5037/jomr.2011.2401. PMC   3886078 . PMID   24421998.
  12. 1 2 Neville BW, Damm DD, Allen CA, Bouquot JE (2002). Oral & maxillofacial pathology (2nd ed.). Philadelphia: W.B. Saunders. pp.  113–124. ISBN   978-0721690032.
  13. Hargreaves KM, Cohen S, Berman LH, eds. (2010). Cohen's pathways of the pulp (10th ed.). St. Louis, Mo.: Mosby Elsevier. pp. 529–555. ISBN   978-0-323-06489-7.