A Pt with severe periradicular pain has a necrotic pulp, a broken lamina dura, and circumscribed radiolucency of long duration. The periradicular diagnosis:
a- Acute apical periodontitis.
b- Chronic apical periodontitis.
c- Acute exacerbation of chronic apical periodontitis. ***
d- Abscess.
the term apical periodontitis, apical periodontitis, apical periodontitis, apical lesion or endodontic lesion It is defined that complex inflammatory diseases periapical tissues tooth (alveolar bone and desmodont), Acute or chronic character, which arise as a result of Acute or chronic diseases of internal tissues of the tooth (Endodont), or more rarely as a result of the action of irritating or toxic substances used in their treatments for diseases of the pulp. The term periapical / Apical refers to the normal exit to the top of the dental root canal system, resulting from the localization of typical lesions at this location. In some cases, however, the presence of lateral canal level or furcations may lead to a siege pathology in a lateral position along the root or in the furcations.
The acute forms show symptoms of pain in chewing and percussion of the involved tooth, and untreated usually evolve in the context of acute alveolar abscess.
Chronic forms, most commonly known as granuloma and radicular cyst They are usually asymptomatic, less exacerbation (phoenix abscess).
The treatment is common to all forms and provides for the elimination of the cause of inflammation by appropriate endodontic measures of the tooth that supports the pathological process, sometimes with the support of a type of anti-drug treatment. inflammatory or antibiotic.
the term apical periodontitis, apical periodontitis, apical periodontitis, apical lesion or endodontic lesion It is defined that complex inflammatory diseases periapical tissues tooth (alveolar bone and desmodont), Acute or chronic character, which arise as a result of Acute or chronic diseases of internal tissues of the tooth (Endodont), or more rarely as a result of the action of irritating or toxic substances used in their treatments for diseases of the pulp. The term periapical / Apical refers to the normal exit to the top of the dental root canal system, resulting from the localization of typical lesions at this location. In some cases, however, the presence of lateral canal level or furcations may lead to a siege pathology in a lateral position along the root or in the furcations.
The acute forms show symptoms of pain in chewing and percussion of the involved tooth, and untreated usually evolve in the context of acute alveolar abscess.
Chronic forms, most commonly known as granuloma and radicular cyst They are usually asymptomatic, less exacerbation (phoenix abscess).
The treatment is common to all forms and provides for the elimination of the cause of inflammation by appropriate endodontic measures of the tooth that supports the pathological process, sometimes with the support of a type of anti-drug treatment. inflammatory or antibiotic.
classification:
We distinguish the following forms:
- acute apical periodontitis
- chronic apical periodontitis, in turn differentiable in the following forms:
+ exudative chronic apical periodontitis (recurrent abscesses)
+ chronic apical periodontitis granulativa, better known as apical granuloma
+ root cyst
etiology:
The cause much more frequently are bacteria and related toxins and products of bacterial metabolism that come to periapical tissues (periodontal ligament and alveolar bone) through the internal canals of the tooth previously affected by an infectious disease (pulpitis) In turn, it is mostly caused by deep tooth decay, more rarely traumatic fractures or deep carious lesions.
The infection is then the polymicrobial type, with a predominance of facultative / mandatory anaerobic bacteria.
The most frequently implicated species are the genus Bacteroides, Streptococcus, Fusobacterium, Peptostreptococcus, Actinomyces, Spirochetes, and on the other hand, normally present in bacterial plaque.
In particular, Enterococcus faecalis is associated with more difficult remission infections.
Sometimes the disease spreads from a pretreated tooth to a patolgia paste (root canal), even after many years.
In these cases, the source is also bacterial, because of the permanence of the untreated channel areas, by default of instrumentation or difficulties related to the geometry of the root canal.
Less often the source of inflammation may be non-bacterial; this can occur in the case of aseptic loosening necrosis of the pulp tissue, due to progressive occlusion of the internal spaces of the tooth (anoxic necrosis) for excessive production of tertiary dentin, as a result of pathological stimuli (caries dental or caries deep lesions) or iatrogenic (Preparation for crowns and bridges).
Necrosis involves the production of irritating chemicals related to tissue degradation, usually with an image of chronic inflammation, often asymptomatic.
A still different form that is related to chemicals used during disinfection procedures or filling the posterior root (endodontics).
This problem in the past has been made more serious by the use of pasta containing arsenic or paraformaldehyde devitalization, can create serious injury, until 'osteonecrosis, if, inadvertently, pushed on the top of the tooth.
Today, the use of these substances would have been almost completely abandoned, given the associated hazards, so that the moderate spill beyond the top of the substances used in modern root canal treatment rarely cause major problems for inflammation acute modest.
pathogenesis:
The arrival of irritants in the periapical tissue activates the classic inflammatory reaction, with release of the associated mediators and the next reaction vessel (serous phase), which is followed by the arrival of the cellular component (granulocytes) by chemotaxis. These cells, mainly neutrophils, through their release from the degradation of digestive enzymes capable of destroying tissues and irritants (purulent step). The presence of this purulent material will result in aggravation of painful symptoms, and the need for the body to find an elimination route for irritants (abscess drainage and fistulas). In the absence of the possibility of drainage through the tooth, then you will have the phase of acute alveolar abscess.
In the case after the acute phase does not proceed to the removal of the source of irritation through appropriate endodontic treatment, the persistence of the situation will lead to the exsudative period of chronic apical periodontitis, with the formation of a fistula more or less stable, allowing drainage infection severely limits the symptomatology, even in the frequent case of closure with the abscess reform that then tends to rhyme, in an irregular cycle defined plaintiff abscess.
If the acute phase is very weak from the beginning or the source of the irritation is eliminated, you will over time evolve the typical image-type of chronic hyperplastic inflammation-granulomatosis. The arrival and activation of macrophages and other cells of the immune system will result in the replacement of normal tissue of encapsulated periapic granulomatous tissue, which will replace the normal ligament and alveolar bone structure, in order to to contain the irritative stimulus coming from the inside of the tooth. With the continuation of this over time, epithelial residues present in the granulation tissue (Malassez Cells) can develop cystic cavities coated with multilayer epithelium filling serous fluid, which involve the transformation of the cystic granuloma granuloma, then actual cyst (root cyst), and its gradual extension, usually slow-growing.
complications:
As we have seen, the formation of acute alveolar abscess more than one complication should be considered as the normal course of the infectious process, in which the body is activated to eliminate the source of the infection, and containing expel responsible bacteria according to the lines of weakness of the surrounding tissues. The most typical outsourcing sites of the order of frequency are those of the vestibule of the mouth, less frequently on palate or from the lingual side of the oral cavity, more rarely the maxillary sinus or on the external face of the skin, mainly in the chin area. Should not treat the responsible tooth, may remain fistula, often weak and asymptomatic, which will result in more uncertain prognosis time for the responsible tooth.
The appearance of fistolarizzazione in maxillary sinus It should be considered for the posterior teeth of the upper sector. The possible complication is that constant drainage through this structure can endure chronic sinusitis or complaining of difficult remission unless we detect and treat the responsible tooth.
In the less frequent case where the outsourcing of infectious processes occurs along the tooth-bearing period, with the possibility of one of the lighter symptoms and a clinical picture that tends to mimic periodontal disease, the persistence of the This situation will lead over time to an endo-periodontal lesion, in which the infection will assume the characteristic of both forms, whose prognosis is more uncertain for the tooth.
More frightening, but fortunately, rare are the cases where, for a situation of falling of the immune defenses infection instead of being contained nell'ascesso can spread quickly in the surrounding tissues (flemmone). The most common picture is that of Ludwig's angina, in which diffusion occurs along the submaxillary fossa, descending along the cervical band. Fortunately even rarer are cases of sepsis related to infectious diseases orally.
Rarely acute forms or chronic erosion significantly scale deep structures of the teeth responsible for the disease or the people nearby. In rare rare cases of massive root cyst growth, however, it may lead to the compression of local nerve structures, leading to loss of sensitivity, and to deforming bones and facial structures for externalization.
treatment:
The curative treatment of all forms of apical periodontitis, both acute and chronic elimination, is targeted from this source of inflammation in the channels of the responsible tooth, the root canal. In the case where the acute phase (or exacerbations) is still localized at the top of a single tooth, the initial opening of the endodontic space to ensure drainage through the channels that you will often be able to drastically reduce symptomatology. A symptomatic pharmacological treatment aiming at reducing the framework of the inflammation and in particular the associated pain can be useful (NSAID). If there is a suspicion or have already appeared symptoms of infection can spread into the surrounding tissues, in the absence of signs of contracting out of infection, antibiotic therapy becomes recommended. The moment has arrived at a spontaneous drainage of infection, also in the context of acute alveolar abscess, antibiotic therapy is however not considered more necessary.
For a chronic injury, the treatment of the root canal can induce at the beginning of an aggravation of the image of the symptoms, with the appearance of painful episodes where there were no symptoms. This should not be considered abnormal because during treatment is an almost inevitable leak of small amounts of irritant material, mostly present before the endodontic procedure.
In the case of traditional root canal treatment (orthograde) is prevented by the presence of broken instruments or difficult extraction pins in the canals (and thus in a previously unsuccessfully treated tooth), it will be necessary to adopt the retrograde surgical approach (apical resection).
If the responsible tooth is too compromised to its original pathology (too destructive caries) or other reasons (presence of additional associated diseases, such as one, or why not high-grade strategic) periodontitis for normal function (wisdom tooth) , the therapy of choice will be extraction.
In the case of cysts plus the probability of spontaneous remission after endodontic treatment will be less, and it may be necessary surgical enucleation of the same.
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Endodontics