PERIRADICULAR LESIONS of pulpal origin

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PERIRADICULAR LESIONS of pulpal origin
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Definition

• Apical periodontitis is an inflammatory disorder
  of the periradicular tissue caused by a
  persistent microbial infection of the root canal
  system of the affected tooth

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In other words

• Apical periodontitis (AP) is a host response to
  infections by microbes and the subsequent
  inflammatory response

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• Apical periodontitis includes the infection and
  inflammation of the lateral and furcal locations.

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• The root canal and the pulp chamber are niche
  environments for the causative organism

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Biofilms

• Bacteria form biofilms and these pathological
  bacteria are embedded in the biofilms
• Biofilms protect the bacteria from antibiotic
  attack and make them a X 1000 more resistant to
  the effects.

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Infection portals

• Pulp becomes infected by
• Carious exposure
• Leaking restorations
• Dentinal tubules
• Fractures or cracks

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Inflammatory response

• The antigens and bacterial toxins percolate into
  the surrounding tissue

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• Most likely anaerobic bacteria invade that
  provoke an inflammatory response i.e.
• Chemotaxis
• Enzymatic breakdown with the subsequent release
  of antigens

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• The host mounts a immune response consisting of
  several classes intercellular messengers and
  antibodies.
• This response destroys much of the peripical
  tissue
• This results in the formation of various types of
  apical periodontal lesions.

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• The defence reaction minimises the spread of
  infection.
• It cannot eliminate the microbes entrenched in a
  necrotic root canal , and biofilm.

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• Treatment is required via surgical or non
  surgical endodontic therapy as biofilms protect
  the bacteria from the host defenses.

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Classification of AP

• Apical periodontitis is an inflammatory disease
  and classification is based on symptoms ,
  aetiology or histopathology.

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Nomenclature and Classification

• Numerous terms are used such as
• Apical granulomas
• Apical cysts
• Periapical lesions
• Periapical osteitis

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• Three main clinical groups
• symptomatic(acute) apical periodontitis
• asymptomatic(chronic) apical periodontitis
• apical abscess

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Symptomatic(acute) Apical Periodontitis

• The principal causes are irritants diffusing from
  an inflamed or necrotic pulp.
• Negative vitality test not always accurate
• Pain!!!(WHY?)

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Asymptomatic(chronic) Apical Periodontitis

• Preceded by an acute episode
• lesion frequently develops and enlarges without
  any subjective signs and symptoms
• Causes
• Inadequate endodontic procedure
• Low grade pathogenicity/ irritant
• Pathosis is a long-standing smoldering lesion

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Asymptomatic(chronic) Apical Periodontitis(Cont)

• Non vital respnse
• Radiographic evidence is the key
• Called a peri radicular granuloma or
  periradicular cyst.
• Periradicular Granuloma. Nobuhara and del
  Rio(JOE199319315) showed that 59.3 of the
  periradicular lesions were granulomas, 22 cysts,
  12 apical scars, and 6.7 other pathoses

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• Histologically, the periradicular granuloma
  consists predominantly of granulation
  inflammatory tissue with many small capillaries,
  fibroblasts, numerous connective tissue fibers,
  inflammatory infiltrate, and usually a connective
  tissue capsule

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Apical periodontitis (granuloma) with
containedepithelium. Epithelial cells of
periodontal ligament have proliferatedwithin new
inflammatory tissue. The epithelium tends to
ramify in areticular pattern (straight arrow)
toward receding bone. It also may,as in this
case, apply itself widely to the root surface
(curved arrow).Infiltration of epithelium by
round cells is everywhere apparent.Human tooth.
Reproduced with permission from Matsumiya
S.Atlasof oral pathology. Tokyo Tokyo Dental
College Press 1955.
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Periradicular Cyst.

• Periradicular cyst shows a central cavity lined
  by stratified squamous epithelium
• This lining is usually incomplete and ulcerated
• The lumen contains a pale eosinophilic fluid and
  occasionally some cellular debris

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Apical cyst with marked inflammatory overlay.
Roundcells permeate both the epithelium and the
connective tissue immediatelydeep to it. Spaces
indicate where crystalline cholesterol hasformed
within the cyst. Bone formation is evident
(arrow). Thismay reflect narrowing of the width
of the connective tissue zone, asoccurs in some
apical cysts. Human tooth. Reproduced with
permissionfrom Matsumiya S. Atlas of oral
pathology. Tokyo TokyoDental College Press
1955.
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Condensing Osteitis

• Inflammation of periradicular tissues of teeth
  usually stimulates concurrent osteoclastic and
  osteoblastic activities.
• Osteoclastic (resorptive) activities are usually
  more prominent than osteoblastic (formative)
• Condensing osteitis is associated with
  predominant osteoblastic activity

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Condensing Osteitis (CONT)

• attributable to a special balance between host
  tissues and the root canal irritants.
• Condensing osteitis, or chronic focal sclerosing
  osteomyelitis, is a radiographic variation of AAP
  and is characterized as a localized
  overproduction of apical bone.
• usually observed around the apices of mandibular
  posterior teeth with pulp necrosis or chronic
  pulpitis

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Condensing Osteitis (CONT)

• The tooth associated with condensing osteitis may
  be asymptomatic or sensitive to stimuli.

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Apical condensing osteitis that developed in
response tochronic pulpitis. Additional bony
trabeculae have been formed andmarrow spaces
have been reduced to a minimum. The periodontal
ligamentspace is visible, despite increased
radiopacity of nearby bone.
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APICAL ABSCESSES

• An abscess is a localized collection of pus in a
  cavity formed by the disintegration of tissue
• Apical abscesses can be divided into symptomatic
  or asymptomatic conditions

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APICAL ABSCESSES

• Symptomatic Apical Abscess A sudden egress of
  bacterial irritants into the periradicular
  tissues
• severe sequelae, acute osteitis and cellulitis.
• Accompanied by exudate formation within the
  lesion
• May occur without any obvious radiographic signs
• infection and rapid tissue destruction arising
  from within AAP( Phoenix abcess)

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APICAL ABSCESSES/clinical

• May or may not have swelling
• Swelling may be localized or diffuse
• Varying degrees of sensitivity to percussion and
  palpation
• No pulp reaction to cold, heat, or electrical
  stimuli as the involved tooth has a necrotic pulp
• Radiographic features of the SAA vary from a
  thickening of the periodontal ligament space to
  the presence of a frank periradicular lesion

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Radiographic features of symptomatic apical
abscess.The patient developed sudden symptoms of
pain and facialswelling. Radiographically, a
lesion is apparent apically to the maxillaryleft
lateral incisor, that did not respond to vitality
tests, confirmingpulpal diagnosis of necrosis.
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Asymptomatic Apical Abscess

• Asymptomatic apical abscess (AAA), also referred
  to as
• suppurative apical periodontitis, is associated
  with a
• gradual egress of irritants from the root canal
  system
• into the periradicular tissues and formation of
  an exudate.
• The quantity of irritants, their potency, and
  their
• host resistance are all important factors in
  determining
• the quantity of exudate formation and the
  clinical signs
• and symptoms of the lesion. Asymptomatic apical
• abscess is associated with either a continuously
  or
• intermittently draining sinus tract.

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• WHO uses a symptomatic classification based on
  clinical signs
• Acute apical periodontitis
• Chronic apical periodontitis
• Periapical abscess with sinus
• Periapical abscess without sinus
• Radicular cyst

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Histopathological classification(Nair PNR
Pathology of Apical Periodontitis)

• In order to understand the disease process a
  histopathological classification is used
• The distribution of pathological cells in the
  lesion
• Presence or absence of epithelial cells
• Transformation of a lesion into a cyst
• The relationship of the cyst cavity to the
  affected root

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Histopathological classification

• Acute apical periodontitis - an acute
  inflammation of endodontic origin . A distinct
  focus of neutrophils have to be present
• Primary or initial short lived inflammation in a
  healthy periodontium.
• secondary or exacerbating when an acute episode
  occurs on a preexisting chronic lesion also
  called a phoenix abcess

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Histopathological classification

• Established chronic apical periodontitis
• Long standing inflammation
• presence of granulomatous tissue
• Cells are lymphocytes , plasma cells and
  macrophages
• Lesion may be epithelialised or
  non-epithelialised

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Histopathological classification

• Periapical true cyst is an apical inflammatory
  cyst with a distinct pathological cavity
  completely enclosed in an epithelial lining so
  that NO communication to the root canal exists

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Histopathological classification

• A periapical pocket cyst is an apical
  inflammatory cyst containing a saclike epithelium
  lined cavity that is open and continuous with the
  root canal

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Histopathologically the lesions of AP can be
classified as acute, chronic ,or cystic .AAP may
be (A.) primary or secondary(B) and is
characterized by a focus of PMN, (C) major
component are lymphocytes plasma cells and
macrophages, (D) true cysts enclosing the lumina
and pocket cysts (E)cavity is open to the root
canal. Arrows indicate the direction of in which
the lesion can change.
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Important points

• Bacteria are anaerobes
• Bacteria have to be present
• There has to be a portal for infection to occur
  i.e.
• Caries
• Clinical procedures
• Fractures
• Dentinal tubules

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To treat or not to treat?

• Anatomic considerations
• Root shapes?
• Can you remove infected hard and soft tissue
• Give disinfecting agents access to the apical
  canal space
• Create space for the delivery of medicaments and
  subsequent obturation
• Retain the integrity of the radicular structures

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To treat or not to treat?

• Is the tooth restorable?
• Is there an adequate ferule, the amount of
  remaining tooth structure
• Is root decay present
• Vertical fractures
• Post preparations in teeth
• Anatomical positions of the tooth
• Occlusal forces on the tooth

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To treat or not to treat?

• Restorative requirements of the tooth
• Aesthetic requirements
• Sclerotic canals

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Surgical

• Posterior part of mandible
• Inferior dental nerve
• Thickness of mandible
• Mental foramen
• Facial artery
• PDL
• Consider alternative

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Surgical

• Posterior part of Maxilla
• Sinus perforation with infected root fragments
• Palatal access
• Anterior maxilla / mandible
• Long roots
• Inclinations (mandible) and mental protuberance

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• Prepared teeth are anatomically more difficult to
  treat

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Endodontic and periodontal relationships

• Vascular connections exist between the pulp and
  periodontal ligament.
• Pulp and periodontal problems are responsible for
  more than 50 of tooth mortality.
• There is no doubt that an interrelationship
  exists in diseases that affect both the pulp and
  periodontium

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• When the pulp necroses for whatever reason
  products from pulp degeneration reach the
  supporting periodontium. This is characterised by
  bone loss, tooth mobility , and sometimes sinus
  tract formation.
• Apically if this occurs , a periradicular lesion
  forms which can extend crestally (Reverse pocket
  is formed)

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• Periodontal disease may have a gradual , atrophic
  effect on the pulp.
• Periodontal treatments such as deep root planing
  or curettage, or localized irritants e.g. acids
  may cause pulpal irritation.is

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• Apical foramina have been shown to be the most
  direct root of communication to the periodontium.
• In addition lateral or accessory canals with 28
  at the furcation.

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Periradicular periodontitis

• Acute, painful to biting or percussion, the
  vitality may or may not be positive. No
  periradicular radiolucency and widened PDL,
  Apical 1/3 of root
• Chronic , no clinical symptoms, negative vitality
  test , periapical radiolucency , altered patient
  sensation

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Periradicular abcess

• Acute, sensitive to pressure and palpation,
  negative vitality test , increased mobility ,
  increased pdl space, associated temperature
• Chronic, no clinical symptoms, no vitality
  response periradicular radiolucency on
  radiograph, suppurative lesion(pus drainage )

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• Periodontal considerations
• Channels exist between pulp and periodontal
  tissue
• These include neural pathways, lateral canals
  dentinal tubules, palato-gingival grooves
  periodontal ligament alveolar bone , apical
  foramina and vascular and lymphatic pathways

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Endodontic / Periodontic Relationships

• Primary endodontic -lesions lateral aspects of
  the root sinus tract along the root
  gutta-percha trace
• Primary endodontic with secondary periodontal
  involvement accumulation of plaque / calculus
  apical migration of tissue

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Endodontic / Periodontic Relationships

• Primary periodontal lesions -deposit in sulcus
  migrates apically. Vital pulp got to distinguish
  this from previous both look the same.
• Primary periodontal secondary endodontic
  involvement-accentuated pain from lesion. Hard to
  separate from endo perio

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Endodontic / Periodontic Relationships

• True combined lesion- damage to pulp and
  periodontium at the same time that may coalesce
  classic J- lesion
• Treatment can include the resection of roots
  (multirooted) , but lesions associated with
  cracked roots , older patients and posts.
  Regeneration procedures.

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NONENDODONTIC PERIRADICULAR LESIONS

• Got to differentiate between pulpal pathology and
  non-endodontic origins of alterations in bone
  morphology.
• 38 radiolucent lesions and other abnormalities
  of the jaws.Three of these lesions, dental
  granuloma, radicular cyst, and abscess, are
  categorized as being related to necrotic pulps.
  In addition,16 radiopaque lesions of the jaws, 3
  of which, condensing osteitis, sclerosing
  osteomyelitis, and Garrés osteomyelitis, are
  also related to pulpal pathosis
• Never assume a radiolucency is pulpal pathology.

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NONENDODONTIC PERIRADICULAR LESIONS

• Lesions of the jaws categorized as odontogenic or
  nonodontogenic in origin
• Odontogenic lesions arise from remnants of
  odontogenesis (or the tooth-forming organ),
  either mesenchymal or ectodermal in origin.
• Nonodontogenic lesions trace their origins to a
  variety of precursors and therefore are not as
  easily classified.

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• Differentiating between lesions of endodontic and
  nonendodontic origin is usually not difficult.
  Pulp vitality testing, when done with accuracy,
  is the primary method of determination nearly
  all nonendodontic lesions are in the region of
  vital teeth, whereas endodontic lesions are
  usually associated with pulp necrosis, giving
  negative vitality responses. Except by
  coincidence, nonendodontic lesions are rarely
  associated with pulpless teeth.

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Odontogenic Cysts

• Dentigerous Cyst
• Lateral Periodontal Cyst
• Odontogenic Keratocyst
• Residual Apical Cyst.

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Lateral periodontal cyst.Well-circumscribed
radiolucentarea in apposition to the lateral
surfaces of the lower premolars(black arrows
demarcate the extent of lesions). No clinical
signs orsymptoms were noted. Pulps tested vital.
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Bone Pathology Fibro-osseous Lesions

• Periradicular Cemental Dysplasia
• Osteoblastoma and Cementoblastoma
• Cementifying and Ossifying Fibroma.

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A, Periradicular cemental dysplasia
(osteofibrosis), initial stage. Pulps in both
teeth are vital. B, Transition to the second
stage is developing. C, Biopsy of periradicular
osteofibrosis, initial stage. Fibrous
connective tissue lesion has replaced cancellous
bone.
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Cementoblastoma. The lesion is a fairly
well-definedradiopaque mass surrounded by a thin
radiolucent line. It has alsoreplaced the apical
portions of the distal root of the first molar
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Ossifying fibroma. The patient presented with
pain.The pulp was vital, indicating that this
was not an endodonticpathosis. Root canal
treatment was followed by root end removaland
excision of the lesion. Biopsy confirmed the
diagnosis
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Odontogenic Tumors

• Ameloblastoma.

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Two examples of ameloblastoma. A, Surgical
specimenof infiltrating ameloblastoma of
mandible. B, Unicystic ameloblastoma.This
solitary lesion has displaced teeth much as an
apical cystwould do. The teeth are vital.
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Nonodontogenic Lesions

• Central Giant Cell Granuloma.
• Nasopalatine Duct Cyst
• Simple Bone Cyst.
• Globulomaxillary Cyst
• Enostosis.

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Malignancies

• Carcinomas or sarcomas of various types are found
  in the jaws, rarely as primary but usually as
  metastatic lesions
• Carcinoma. Generally found in older patients,
  involvement of the jaws (usually the mandible) is
  by metastasis from a primary lesion elsewhere
• Carcinoma lesions of the jaw may also manifest
  pain and swelling, loosening of teeth, or
  paresthesia, similar to endodontic pathosis
• Radiolucent jaw malignancies have been mistaken
  for periradicular lesions.

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• Radicular cyst 
• Residual cyst 
• Paradental and mandibular infected buccal cysts
• Mandibular Infected Buccal Cyst   
• Lateral periodontal cyst
• Glandular odontogenic cyst
• Odontogenic keratocyst
• Gorlin syndrome