3DefinitionThe 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.
4EtiologyThe 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 entryTypically,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
5One or more of the clinical symptoms pain, swelling, redness, increased temperature and impaired function»characterize 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
6Apical 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.
7On the other hand, if the cyst is completely encased by epithelium and removed from the source of infection, it may be self-sustained (a‘true’ 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
8These changes are of decisive importance in diagnosis and choice of treatment.
9Chronic apical periodontitis The lesion is present over long time of periodeMild state of symptomsHistologic picture of chronic inflammation
10Classification 1) Diffuse type: - small, recurrent amount of tissue damage- cellular infilltration with lymphocytes,plasma cells, phagocytic mononuclearcells, fibroblasts which producegranulation tissues for repair of damagedareaGRANULOMA: formation of large nodule ofgranulation tissue that is slowly increase in sizeResorption of hard tissue, granulation tissuearound apex (outlined by capsule of fibroustissue)
112) Chronic suppurative periodontitis - central cavity which is accompaniedwith fistula and stroma- its known as chronic apical abscess( chronic alveolar abscess)3) Apical cyst- true cyst: pathologic cavity whichcontain fluid or semi-fluid substancethat is lined by epithelium andsurrounded by connective tissuecapsule
12Clinical featuresCAP is generally without symptoms that may stay in the mouth with no-pain untill its revealed by x-rayThe 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
13Diagnosis History Vitality test – no response of pulp Percussion- slightly tender to percussionX-ray – diffuse or demarcated radiolucency around the apex of the tooth, root resorption, loss of bone, granuloma or cyst→ with sclerotic margin to the boneDiff. Dg.Chronic Pulpitis
14Measurement of the tooth canal length Case 1,fig.1a21-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 changesCase 1,fig.1bMeasurement of the tooth canal length
15Final endodontic treatment Foredent and gutapercha Case 1,fig.1cFinal endodontic treatment Foredent and gutaperchaCase 1,fig.1d5 months after the endodontic treatment without any surgical procedure,intraoral x-ray shows chronic apical periodontitis, partial restitution of the periapical region
17Case 2,fig.2c3months after the therapy-Cystectomio sec.PARTSCH II. et resectio apicis dentis N Retrograde root canal endodontic therapy with amalgam Egalisatio,suturaeCase 2,fig.2bIntraoral image D.22-Cystis radicularis processus alveolaris maxillae reg.frontalis purulenta
18Granuloma periapicalis and infection transmission paths Fig.BGranuloma periapicalis and infection transmission paths
19Chronic apical periodontitis 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.
20Periapical radiolucencies associated with mandibular incisors Periapical radiolucencies associated with mandibular incisors. These teeth were vital, and a diagnosis of cemental dysplasia was made.