Periapical Pathology Flashcards by Agnes Zlotnicka

define periapical inflammation pathology

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what is periapical inflammatory pathology usually a consequence of?

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Name a useful tool in identifying features of periapical inflammatory pathology

radiographs

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when identifying features of periapical inflammatory pathology, radiography is not a screening tool, therefore what points need to be covered prior?

history
examination
review of prior imaging

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what is the go-to radiograph when trying to assess periapical inflamm pathology?

periapical

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what technique is used when taking a periapical to assess periapical inflamm pathology?

paralleling technique

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what other radiographs other than periapicals can be used to assess periapical inflamm pathology?

maxillary occlusal
lateral obliques
OPG
cone beam CT

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when may we consider an OPG when assessing periapical inflamm pathology?

when periapical already taken and lesion not demonstrated v well, so we may want a larger view

or it may be a dose benefit for a pt with grossley decayed teeth

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when may a cone beam CT be used when assessing periapical inflamm pathology?

often used for troubleshooting when plain films can’t answer ur clinical question

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what would you expect to see on a radiograph of normal periapical tissues?

radiolucent (black) line of PDL space
- even width around the tooth
radiopaque (white) lines that represents lamina dura
- continuous around the root

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what would you expect to see on a radiograph of normal trabecular bone in the mandible?

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what would you expect to see on a radiograph of normal trabecular bone in the maxilla?

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what would you expect to see on a radiograph of normal periapical tissues of developing teeth?

circumscribed area of radiolucency at the apec - the apical papilla
radiopaque line of the lamina dura is intact
developing root is funnel shaped

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list some radiolucent shadows (superimposition) that can mimic pathology

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list some radioopaque shadows (superimposition) that can mimic pathology

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what is this superimposition?

maxillary antrum

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what is this superimposition?

soft tissue of the nose

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what is this superimposition?

zygomatic buttress

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what is this superimposition?

mental foramen

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what is this superimposition?

submandibular fossa

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list the causes of periapical pathology

caries
trauma
large/deep restorations
sub-optimal root fillings
perio bone loss

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list the history/clinical signs of periapical inflammation

swelling
pain
heat
redness
loss of function

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following pulpal necrosis/ bacterial ingress an inflammatory exudate accumulates in the apical tissues.

What is the the type of inflammation response at the apex dependant on?

the infecting organism and its virulence
host response/ defence mechanisms

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describe the spectrum of clinical presentations

rapidly spreading acute periapical abscess to slowly progressing chronic apical granuloma or radicular cyst

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on a plain radiograph, is it possible to differentiate between an abscess, granuloma or cyst?

explain the steps in which this periapical periodontitis shown has occured

1) bacterial ingress via caries/ cracks . fractures / marginal gaps in restorations 2) reversible pulpitis ---> irriversible pulpitis ---> pulp necrosis ---> root canal system becomes infected 3) inflamm response happens 'periapical periodontitis' occurs to confine infection/ bacterial ingress 4) the body results in resorption, formation of granulation tissue (cysts may also occur) resulting in radiolucency 5) bone foramtion may also occur - may result in corticated (white) margin and/or general sclerosis of adjacent bone (to wall off infection)

we need to be aware of varying terms of apical inflamm pathology, name a few?

radiographic appearance of acute inflamm reactions: what impact does the initial acute inflammation have on the PDL space?

inflamm exudate accumulates in the apical PDL ---> widening of the apical PDL space

radiographic appearance of acute inflamm reactions: what impact does the initial acute inflammation have on the lamina dura?

will be intact or partially visible

radiographic appearance of acute inflamm reactions: as initial inflammation spreads, we have resorption of apical bony socket. What effect does this have on the apical lamina dura?

loss of apical lamina dura

radiographic appearance of acute inflamm reactions: as initial inflammation spreads, we have resorption of apical bony socket. Comment on the radiolucencies that develop

- established periapical radiolucency 'rarefying osteitis' - ill-defined, poorly circumscribed, non-corticated radiolucency

radiographic appearance of acute inflamm reactions: as initial inflammation spreads, we have resorption of apical bony socket. as periapical radiolucency increases in size, will it may appear more or less radiolucent?

when a patient has an acute abscess or any acute periapical inflamm process, how many days may it take for radiographic appearance of the abscess after the clinical diagnosis?

7-10 days

when a patient has an acute abscess or any acute periapical inflamm process, why may it take 7-10 days for radiographic appearance of the abscess after the clinical diagnosis?

we need about 30% of bone resorption for it to show up on a radioraph, and this takes about 7-10 days

what is a hallmark of chronic inflammatory reactions in the periodontal tissues?

Simultaneous destruction and healing

radiographically, what will periapical chronic inflammatory reactions transform into as a result of simultaneous destruction and healing

either into a combo of bone formation and bone resorption

what types of inflamm reactions are we expecting if the periapical inflammation is chronic?

- Granulomas - radicular cysts - sclerosing osteitis.

Chronic inflammation: Granulomas and Radicular Cysts: With time, granulation tissue forms at the site of bone resorption resulting in a what?

periapical granuloma

Chronic inflammation: Granulomas and Radicular Cysts: With time, granulation tissue forms at the site of bone resorption resulting in a periapical granuloma. Epithelial rests of Malassez within granulation tissue can proliferate to form what?

radicular cyst

list the symptoms of a periapical granuloma and a radicular cyst

both largely asymptomatic unless infected

what is the radiographic appearance of a periapical granuloma and a radicular cyst?

- Well-defined circumscribed periapical radiolucency - May be corticated / surrounded by sclerotic dense bone

Is it possible to differentiate between a granuloma and radicular cyst?

not entirely as it is a histopathlogical difference mainly, however there are some differences

If we have a periapical radiolucency, what size does it need to be to most probably be a granuloma?

<1cm

If we have a periapical radiolucency which is 1-1.5cm, which is it more likely to be, a granuloma or a cyst?

could be either equally

If we have a periapical radiolucency which is >1.5cm, which is it more likely to be, a granuloma or a cyst?

cyst

if you have a radicular cyst, you have taken the tooth out and it has persisted, what does it become?

residual cyst

what is shown on this picture?

periacpical granuloma

Chronic inflammation: Sclerosing osteitis what else can this be called?

Also called condensing or focal sclerosing osteitis

Chronic inflammation: what does Sclerosing osteitis happen in response to?

low grade chronic inflammation

Chronic inflammation: what are the symptoms of sclerosing osteitis?

often symptomless

Chronic inflammation: what is the radiographic appearance of Sclerosing osteitis?

- Dense sclerotic (radiopaque) bone around the apex - Varying degrees of apical ligament space widening and radiolucency

Endo-perio lesions what may they also be referred to as?

perio-end or combined

what do endo-perio lesions involve?

both the pulp and perio tissues

what is a common presentation of a perio-endo lesion?

non-vital tooth with periodontal pocketing extending apically

what are the causes of a perio-endo lesion?

- May arise without root damage - Periodontitis causing pulp necrosis - Apical periodontitis extending along the periodontal ligament space - Or as a result of root damage - Root fracture, perforation, external root resorption

what is thet common radiographic appearance of an endo-perio lesion?

Signs of apical pathology with a wide periodontal ligament space or communicating periodontal defect.

where along the root does most inflammatory pathology manifest?

typically apically

Although most inflammatory pathology manifests apically, why may it manifest anywhere along the root surface?

due to the presence of: - Normal anatomy – lateral and furcal canals - Iatrogenic – perforation - Pathologic – perforations, cracks, fractures

what may “Double dense” shadows on a radiograph relate to clinically?

a clinically apparent chronic sinus

In terms of “Double dense” shadows on a radiograph, what does image appearance reflects on a radiograph?

Imaging appearance reflects perforation of the cortices and degree of bone loss which is present.

sometimes as a Sequalae of long term periapical inflammatory pathology, we may get external inflammatory root resporption. What may this look like on a radiograph?

Root may look irregular in outline or have a blunted apex

sometimes if the body isnt able to contain the infection within a periapical granuloma, you may get infection spreading into the meducllary cavity of the bone itself. What is infection of the bone called?

Osteomyelitis

what is Osteomyelitis?

Infectious inflammation of bone and bone marrow

what is a predisposing factor of getting osteomyelitits during a periapical infection?

immunocompromised - meds, poorly controlled diabetics

what is the cause of Osteomyelitis?

- untreated apical pathology - surgery - trauma - idiopathic

list the Variable clinical and imaging features of Osteomyelitis

- Indolent to aggressive - Sclerosis - Lytic / moth eaten appearance - Bony sequestra - Periosteal bone formation

list the steps in what you can see on a radiograph as periapical inflammatory pathology develops

A radiolucency may persist following endodontic treatment, even if satisfactory why?

Healing with fibrous tissue may leave residual radiolucency

following apical surgery, what may be the effect on the previous radiolucency?

- may increase in size or become more apparent

list the other common causes of periapical radiolucencies and radiopacities

Normal anatomy, artefact, superimposition. Benign Cemento-osseous dysplasia Hypercementosis Dense bone islands

when might we suspect that a patient has any of the following rather than periapical pathology? Normal anatomy, artefact, superimposition. Benign Cemento-osseous dysplasia Hypercementosis Dense bone islands

if the patient is asymptomic and the tooth is vital

define hypercementosis

proliferation of cementum at the root surface

which area of the mouth is periapical cemento-osseous dysplasia very common within?

anterior mandibular region

what gender is periapical cemento-osseous dysplasia most common within?

females

which ethnicity is periapical cemento-osseous dysplasia most common within?

black or asian

describe periapical cemento-osseous dysplasia

benign condition in which normal bone is replaced by fibrous tissue which slows starts to mineralise

what can dense bone islands mimic?

scherosing or condensing osteitis

what is the main giveaway that a dense bone island is a dense bone island and not scherosing or condensing osteitis?

PDL is preserved

what are dense bone islands?

bit of rlly dense cortical bone shouldnt see any resorption, desplacement or symptoms u usually leave them alone

Malignancy can mimic a localised area of infection What can be a potential sign of concern?

- Spiking resorption and an irregular radiolucency with a poorly defined border - Tooth mobility in the absence of periodontal disease or ‘floating’ teeth - Hair on end / Sunburst appearance - Altered sensation or anaesthesia - No improvement despite treatment