4. pulpal and periapical pathology and inflammatory lesions of the jaw

what are the seven main categories of pathologies discussed this lecture?

• periapical inflammatory disease

• pulpal inflammatory disease

• osteomyelitis

• osteoradionecrosis

• bisphosphonate related osteonecrosis 

• pericoronitis 

• soft tissue inflammation 

what are some terms relevant to inflammatory lesions?

• periapical inflammatory disease

  • rarefying and sclerosing osteitis

• periodontal disease

• pericoronitis

• osteomyelitis 

what is periapical inflammatory disease?

inflammatory response to pathogenic microorganisms and necrotic pulp (caries, trauma)

which is restricted to root apex?

periapical inflammatory disease

what inflammatory lesions are extension of inflammation into the bone from soft/gingival tissue?

periodontal disease, pericoronitis, osteomyelitis

which inflammatory lesion involves the supporting structures of the teeth?

periodontal disease

which inflammatory lesion involves crown of a partially erupted tooth?

pericoronitis

which inflammatory lesion involves extension of inflammation into bone marrow?

osteomyelitis

describe the flow of the following: caries and trauma, necrotic pulp. periapical inflammatory disease, osteomyelitis

inflammatory disease mechanism

apical vs periapical

apical: more tip itself vs periapical: broader term

radiographic signs:

• widened PDL space

• loss of lamina dura

apical periodontitis

lack of continuous lamina dura, initial sign 

apical periodontitis 

rarefaction

loss of bone mineral

osteitis

bone inflammation

rarefaction + osteitis = ?

increased radiolucency

loss of bone mineral + osteitis = increased radiolucency

rarefying osteitis

rarefying osteitis (LD gone and radiolucency)

• chronic inflam with a non-vital tooth 

• radiolucent due to removal of bone

• sequelae of acute episode 

• includes abscess, granuloma, or radicular cyst (these three have no distinction radiologically)

rarefying osteitis

rarefying osteitis

what are other terms for sclerosing osteitis?

focal sclerosing osteitis, condensing osteitis 

hardening of the bone; bone deposition increase in radiopacity of bone (plus widened PDL)

sclerosing osteitis 

sclerosing osteitis

describe how caries and trauma could lead to periapical abscess vs periapical granuloma

osteomyelitis and periapical cyst can arise from

periapical granuloma (chronic periapical inflammatory disease)

early periapical lesion

• widening of PDL space, thickening of LD

• in maxillary M lift floor of max sinus!

what is the location of periapical inflammatory disease?

apical to root apex, adjacent to accessory canal/root fracture. perforation 

bone deposition around area of rarefaction

sclerosing osteitis + radiolucency

what are the alterations in trabecular bone pattern and marrow spaces of periapical inflammatory diseases?

thicker trabeculae and increase in number 

what are some effects of periapical inflammatory disease on surrounding structures?

• bone deposition

• alteration in trabecular bone pattern and marrow spaces

• periosteal new bone formation

• perforation of bone border

halo sign

• elevation/displacement of floor f maxillary sinus

• maxillary posterior teeth 

periostitis/onion skin

periostitis, onion skin

periosteal bone formation in floor of maxillary sinus

periostitis and mucositis 

mucosal thickening 

mixture of rarefying and sclerosing osteitis

no pathology, submandibular gland fossa

dense bone island of vital tooth, no widening of PDL; inositiosis just extra bone w/in two plates of cortical bone

maxillary pneumatization 

mucus retention cyst

what are some potential results of periapical inflammation that all present identically radiographically?

• parulis aka gum boil

• periapical granuloma

• periapical cyst

• periapical abscess

• condensing osteitis

gum boil

parulis

which potential result of periapical inflammation?

• inflamed granulation tissue at intraoral opening of sinus tract

• classically dome-shaped yellow-pink papule; rarely hyperplastic soft tissue mass that may mimic pyogenic granuloma or other pathology ie exophytic hyperplastic perulis on adj tooth assocxiated w non-vital tooth

• usually on gingiva facial to non-vital tooth

• may or may not exhibit active suppuration

parulis

which potential result of periapical inflammation?

parulis

which potential result of periapical inflammation?

parulis; not easy to pulp test teeth that are equidistant to this sinus tract extrusion

what is the problem with the naming of periapical granuloma?

this is not a true granuloma

• granuloma: collection of immune cells around foreign body/infection

• granulation tissue: newly formed tissue around injury 

which potential result of periapical inflammation?

histopathological features: 

• granulation tissue surrounded by fibrous CT

  • tissue from apex of non-vital tooth socket

• lymphocytic infiltrate may be intermixed w neutrophils, plasma cells, histiocytes, and occasionally mast cells or eosinophils  

periapical granuloma

apical radicular cyst aka

periapical cyst

define a cyst

pathological cavity lined by epithelium 

which potential result of periapical inflammation?

• most common odontogenic cyst

• epithelium at apex of non-vital tooth may be stimulated to form cystic lining

  • usually derived from rests of Malassez

  • lateral variant may develop along lateral aspect of root at orifice of accessory canal (necrotic root)

    • mimics lateral periodontal cyst

  • may give rise to residual (BLANK)

periapical cyst

which is the most common odontogenic cyst?

periapical cyst

what are rests of Malassez?

clusters of epithelial cells in the periodontal ligament that are remnants of the Hertwig's epithelial root sheath left over from tooth development; maintain health of perio tissue health 

usually develop at apex but a lateral accessory canal could lead to lateral tooth root growth (necrotic root)

which potential result of periapical inflammation?

histopathological features: 

• lining of cyst composed of stratified squamous epithelium 

• wall of cysts consists of dense fibrous tissue w inflammatory infiltrate

periapical cyst

what is the only thing that can differentiate periapical cyst from periapical granuloma?

presence of epithelium 

which potential result of periapical inflammation shows acute symptoms?

periapical abscess unlike cyst and granuloma

which potential result of periapical inflammation?

• accumulation of acute inflammatory cells at the apex of non-vital tooth

• may arise as initial form of pathosis or fro acute exacerbation of chronic periapical inflammatory lesion (phoenix abscess)

phoenix abscess

a sudden, painful flare-up of a long-standing, often silent, dental infection. It occurs when a chronic periapical abscess, which may be asymptomatic, becomes acute, presenting with symptoms like severe pain, swelling, and pus

which potential result of periapical inflammation?

clinical features:

• non-specific symptoms may include headache, fever, malaise, chills

• tenderness of affected tooth

• abscess may spread through bone (osteomyelitis) or perforate cortex and spread through soft tissue (cellulitis)

periapical abscess

T or F: periapical abscesses are typically fluctuant, meaning you can displace with finger 

true

which potential result of periapical inflammation?

histopathological features: 

• acute inflammatory cells, cellular debris, necrotic material, and bacterial colonies

• phoenix may include soft tissue component

periapical abscess

which potential result of periapical inflammation?

treatment and prognosis: 

• drainage

• elimination of infection 

• antibiotics for medically compromised patients 

periapical abscess

which potential result of periapical inflammation?

• localized area of bone sclerosing

condensing osteitis

condensing osteitis

aka focal sclerosing osteitis (radiopaque)

which potential result of periapical inflammation?

periapical granuloma; granulation tissue w neutrophils, lymphocytes, plasma cells, vascular channels 

which potential result of periapical inflammation?

periapical granuloma; fibroblasts

which potential result of periapical inflammation?

periapical granuloma; lymphocytes

periapical cyst

periapical cyst

periapical cyst

what gives rise to lining of a cyst?

epithelial rests

periapical cyst

periapical abscess (sinus tract spread extraorally)

sclerotic bone = mineralized tissue vs granular tissue - less dense

condensing osteitis

condensing osteitis

which potential result of periapical inflammation?

treatment: 

• endodontic therapy or extraction of offending tooth

• 85% of cases will resolve or regress

  • bone scar may result following resolution of inflammation

condensing osteitis

what are treatment options and possible prognosis for non-vital teeth?

• root canal therapy

• non-restorable teeth treated w extraction and curettage of apical tissue

• periapical fibrous scar may form in area of defect, especially if cortical plates have been lost

• rare recurrences

• untreated cysts may give rise to squamous cell carcinoma

why choose root canal for treatment of non-vital teeth?

persistent lesions treated w periapical surgery and submission of tissue for microscopic examination

what is the rationale for treatment of all periapical pathology?

untreated cysts may give rise to squamous cell carcinoma

what is chronic hyperplastic pulpitis?

• pulp polyp 

• unique pattern of pulpitis sometimes seen in children and young adults w large pulp exposures (usually primary molars)

• hyperplastic granulation tissue extrudes from pulp chamber

• asymptomatic 

chronic hyperplastic pulpitis usually affects (primary) molars

true

chronic hyperplastic pulpitis is asymptomatic

true

treatment of chronic hyperplastic pulpitis?

endo or extraction

chronic hyperplastic pulpitis