1. DIFFERENTIAL DIAGNOSIS OF PERIAPICAL DISEASES To enumerate different periapical diseases of pulpal origin. To know the radiographic diagnostic criteria for each periapical lesion. To know the differentiating radiographic features among them. Specific learning objective DR.S.KARTHIGA KANNAN PROFESSOR ORAL MEDICINE & RADIOLOGY

2. Essentials of Dental Radiography and Radiology Eric Whaites Nicholas Drage Fifth edition – Elsevier – Page No- 274-280

3. ACUTE APICAL PERIODONTITIS. From the necrosed pulp, the inflammatory exudate accumulates in the apical periodontal ligament space (swelling)., setting up an acute apical periodontitis. CLINICAL FEATURES: ✓ Pain(Dolor) ✓ Mild tooth extrusion from socket. ✓ The patient avoids biting on the tooth (loss of function). ✓ Unilateral chewing habit ✓ Tenderness to (vertical) percussion ✗ Heat (calor) and redness (rubor) are clinically undetectable. RADIOGRAPHIC FINDINGS: ✓ Radiolucency (caries) or a radio opaque filling close or involving the pulp chamber or # (fracture) of crown ✓ Intact lamina dura ✓ Widening of PDL (periodontal ligament )space at root apex of affected tooth.

4. Periapical Radiolucency Apical periodontitis Periapical Radiolucency Apical periodontitis

6. PERIAPICAL ABCESS If the virulence of infecting micro organism is more The host defense is less, The infection from apical periodontitis progress to frank suppuration at the root apex resulting in periapical abcess. CLINICAL FEATURES 1.Types – Acute and chronic 2.Deep caries/large filling/discolored tooth/ fractured tooth 3.Pain – severe in acute and dull intermittent or no pain in chronic. 4.Inta oral swelling in gums at the root apex may be present. 5.Intra oral or extra oral sinus may be present. Parulis – hyperplastiv mocsal mass aound an intra oral sinus opening. 6.Pain on percussion present and tenderness on periapical region. RADIOGRAPHIC FEATURES ✓ Radiolucency (caries) or a radio opaque filling or # (fracture) of crown close or involving the pulp chamber. ✓ Loss of lamina dura at root apex ✓ Periapical radiolucency at root apex of affected tooth, with illdefined margin. ✓ Gradual widening of adjacent PDL (not apex) space is evident. ✓ Less than 1 cm in size.

7. Periapical Radiolucency Periapical abcess Periapical Radiolucency Periapical abcess

9. 1. Loss of lamina dura at the root apex. 2. Gradual widening of adjacent PDL space. 3. Periapical radiolucency with illdefined border, gradual blending trabecular pattern of lesion to normal bone. 4. Size less than 1 cm.

10. PERIAPICAL GRANULOMA If the virulence of infecting micro organism is less The host defense is more, The infection from apical periodontitis progress to formation of granulation tissue at the root apex resulting in periapical granuloma. CLINICAL FEATURESRADIOGRAPHIC FEATURES 1.Deep caries/large filling/discolored tooth/ fractured tooth 2.Asymptomatic 3.No Pain - no pain on percussion present and no tenderness on palpation on gums over periapical region. 4.No swelling ✓ Radiolucency (caries) or a radio opaque filling or # (fracture) of crown close or involving the pulp chamber. ✓ Loss of lamina dura at root apex ✓ Periapical radiolucency at root apex of affected tooth, with well defined margin. ✓ Complete or partial corticated or sclerotic border may be seen ✓ Gradual widening of adjacent PDL (not apex) space may be evident. ✓ Less than 1 cm in size.

11. Periapical Radiolucency Periapical granuloma Periapical cyst Periapical Radiolucency Periapical granuloma Periapical cyst Granuloma - < 1cm Cyst - >1cm

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13. PERIAPICAL CYST CLINICAL FEATURESRADIOGRAPHIC FEATURES 1.Deep caries/large filling/discolored tooth/ fractured tooth 2.No pain – pain only when infected. 3.Extra oral swelling and intra oral oblitration of buccal or labial sulcus adjacent to tooth is present. 4.Soft, cystic, egg shell crackling and fluctuant on palpation. 5.Pain on percussion absent and no tenderness on palpation. 6.Aspiration shows yellowish straw colored fluid. ✓ Radiolucency (caries) or a radio opaque filling close or involving the pulp chamber ✓ # (fracture) of crown ✓ Loss of lamina dura at root apex ✓ Periapical radiolucency at root apex of affected tooth, with well defined margin. ✓ Complete or partial corticated or sclerotic border seen ✓ Gradual widening of adjacent PDL (not apex) space may be evident. ✓ More than 1 cm in size.

16. CONDENSING OR SCLEROSING OSTEITIS Radiographic features ✓ Radiolucency (caries) or a radio opaque filling or # (fracture) of crown close or involving the pulp chamber. ✓ Either widening of PDL space or periapical radiolucency at root apex of affected tooth, with well or ill defined margin. ✓ Loss of lamina dura at root apex. ✓ Diffuse periapical radio-opacity surrounding the periapical radiolucent lesion with illdefined border, gradually blends with normal bone. ✓ size may vary from small in mm to large in cms

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18. Thank You Any questions??? Dedicated to my teacher Prof.Dr.Gnanasundaram