S. R. Prabhu - Handbook of Oral Pathology and Oral Medicine

Apical periodontitis:Identify and eliminate the cause: endodontic therapy is effectiveExtraction of the tooth if exudate is to be drained (apical abscess)Usually, antibiotics are not required for simple (non‐suppurative) cases of periodontitisPain management with analgesics

Periapical granuloma:Endodontic treatmentExtraction of the tooth if tooth cannot be restored

An odontogenic infection characterized by localization of pus in the structures that surround the teeth

Shows a wide range of variation

Common in children: accounts for 47% of all dental‐related attendances at paediatric emergency rooms in the United States

Secondary to dental caries, trauma, or failed root canal treatment

Bacteria and their toxic products enter the periapical tissues via the apical foramen and induce acute inflammation and pus formation

Polymicrobial odontogenic infection:Anaerobic cocci, Prevotella speciesFusobacterium speciesViridans group streptococci

Non‐vital tooth in most cases

Involved tooth is tender to percussion

Lower molars commonly involved

In the initial stages there is no swelling, only intense, throbbing pain

Gingiva related to the tooth is red and tender

In established abscess buccal or labial painful gingival swellings ( Figure 3.3a)

Palatal swelling for maxillary molars is common

Trismus due to pain and swelling

Cervical lymphadenopathy is common

Early dental abscesses, within the first 10 days, may not show any radiographical features

Mild thickening of apical PDL, loss of lamina dura and loss of trabecular bone become evident as abscess advances ( Figure 3.3b)

Discharge of pus may occur in established abscess; pain subsides after the discharge of pus

Complications include cellulitis/Ludwig's angina or osteomyelitis

Life‐threatening complications include thrombophlebitis and septicaemia

Complete blood count for leucocytosis

Acute periodontitis

Infected radicular cyst

Focal sclerosing osteomyelitis

Periapical granuloma Figure 3.3 Apical abscess. (a) Presenting as a fluctuant gingival swelling; a decayed, broken down tooth with pulpal necrosis has caused this apical (periapical) abscess. Note draining pus via an intraoral sinus(source: Damdent, https://commons.wikimedia.org/wiki/File:Abces_parulique.jpg. Licensed Under CC BY‐SA 3.0.(b) Radiographical appearance of an established periapical abscess. Note the loss of periodontal ligament, lamina dura, and trabecular bone.

History

Clinical examination

Radiography (periapical and panoramic views)

Needle aspirate for aerobic and anaerobic cultures

Blood culture studies

Most dental abscesses respond to incision and drainage, root canal, or extraction. These procedures eliminate the source of infection

Antibiotics are usually not recommended for localized abscesses

If drainage is not possible or if the patient shows signs of systemic involvement, or is immunocompromised, antibiotics are required for a period of seven days

Condensing osteitis refers to focal areas of bone sclerosis associated with apices of teeth with pulpitis or pulpal necrosis

Also known as focal sclerosing osteitis and focal sclerosing osteomyelitis

Occurs in 4–7% of population

Low‐grade inflammatory stimulus from an inflamed dental pulp

Most frequently in young adults

Asymptomatic

Most lesions are discovered on routine radiography

Localized increased radiodensity adjacent to the apex of the tooth ( Figure 3.4)

Widened periodontal ligament space

Normally bone biopsy is not indicated unless significant pathology (other than condensing osteitis) is suspected

The following microscopic features confirm the diagnosis of condensing osteitis:Replacement of marrow spaces and cancellous bone by dense, sclerotic compact boneBone may show prominent incremental linesMay see fibrosis replacing fatty marrow or scant connective tissueInflammatory changes are absent or minimal

Differential diagnoses on radiography include:Periapical cemental dysplasiaOsteomaComplex odontomaCementoblastomaOsteoblastomaHypercementosis Figure 3.4 Condensing osteitis. Note the increased radiodensity around the roots of a carious molar (black arrow).(Source: by kind permission of Professor Charles Dunlap, Kansas City, USA.)

Clinical history is non‐contributory since condensing osteitis is asymptomatic

Most cases of condensing osteitis are incidentally detected on routine radiography

No treatment is required for asymptomatic bony lesions

Tooth that caused the condensing osteitis needs to be identified and treated

1 Abbott, P.V. (2004). Classification, diagnosis, and clinical manifestations of apical periodontitis. Endodontic Topics 8: 36–54.

2 Abbott, P.V. and Yu, C. (2007). A clinical classification of the status of the pulp and the root canal system. Australian Dental Journal 52 (1 Suppl): S17–S31.

3 Braz‐Silva, P.H., Bergamini, M.L., Mardegan, A.P. et al. (2019). Inflammatory profile of chronic apical periodontitis: a literature review. Acta Odontologica Scandinavica 77: 173–180.

4 Dabuleanu, M. (2013). Pulpitis (reversible/irreversible). Journal of the Canadian Dental Association 79: d90.

5 Neville, B.W., Damm, D.D., Allen, C.M., and Chi, C.A. (2016). Pulpal and periapical disease. In: Oral and Maxillofacial Pathology, 4ee, 111–136. St Louis, MO: Elsevier.

6 Odell, E.W. (2017). Pulpitis and apical periodontitis. In: Cawson's Essentials of Oral Pathology and Oral Medicine, 9ee, 73–81. Edinburgh: Elsevier.

1 4.1 Tooth Wear: Attrition, Abrasion, Erosion, and Abfraction

2 4.2 Pathological Resorption of Teeth

3 4.3 Hypercementosis

4 4.4 Cracked Tooth Syndrome

Attrition is a normal physiological process characterized by tooth wear caused by tooth‐to‐tooth contact. Usually this affects the tips of cusps of canines and posterior teeth and incisal edges of incisor teeth

Abrasion is tooth wear caused by an abrasive external agent. It affects both enamel and dentin

Erosion is a process characterized by progressive solubilization of tooth substance, usually by exposure to external or gastric acids

Abfraction is the pathological loss of hard tooth substance caused by biomechanical loading forces

Prevalence of tooth wear varies from region to region

A universal agreement on prevalence of attrition, abrasion, and erosion does not exist