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L2.Pulp Root Canal and Peri-radicular Conditions - Part 2 - DMD2 - Handout - 2023_formatted_text

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Pulp, Root Canal and Periapical Conditions - Part 21

Now let’s consider …

  • Periapical / Peri-radicular Conditions

Usually manifest as:

Clinically - may have tenderness to percussion Radiographically - a periapical radiolucency

1. The Progression of Pulp and Periapical Disease

Info

The disease process does not stop once the pulp becomes necrotic and the root canal system is infected. The presence of microorganisms within the root canal system inevitably leads to the development of apical periodontitis, establishing a direct cause-and-effect relationship.

The Progression of Pulp Disease2

  • A clinically normal pulp, when exposed to micro-organisms, can lead to Apical Periodontitis.

The progression from a healthy pulp to an infected root canal system directly causes a subsequent reaction in the periapical tissues.

  • ==Reversible & Irreversible Pulpitis: Apical periodontitis can possibly occur, but not in all cases.==

  • ==Necrobiosis: Some signs of apical periodontitis may begin to appear during this brief transitional phase.==

  • ==Infected Root Canal System: Once the root canal is infected, apical periodontitis is a definite outcome; it is only a matter of time before clinical or radiographic signs appear.==

  • The progression from a clinically normal pulp can follow several paths:

    • Reversible Pulpitis:
      • Acute Reversible Pulpitis
      • Chronic Reversible Pulpitis
    • Irreversible Pulpitis:
      • Both acute and chronic reversible pulpitis can progress to Chronic Irreversible Pulpitis.
      • Chronic Irreversible Pulpitis can become Acute Irreversible Pulpitis.
    • Necrosis:
      • Acute Irreversible Pulpitis leads to Necrobiosis, which can cause Apical Periodontitis.
      • Necrobiosis progresses to a Necrotic and Infected Pulp.
      • Trauma (e.g., luxation, avulsion) can lead directly to Pulp Necrosis.
      • Pulp Necrosis, with or without the addition of micro-organisms, becomes a Necrotic and Infected Pulp.
    • Infection and Apical Periodontitis:
      • A Necrotic and Infected Pulp becomes a Pulpless and Infected Root Canal System.
      • A Pulpless and Infected Root Canal System is the cause of Apical Periodontitis.
      • Micro-organisms, Acute Reversible Pulpitis, and Acute Irreversible Pulpitis can also directly contribute to Apical Periodontitis.

  • The problem starts at the coronal end of the tooth with a break in the integrity of the tooth structure, such as caries, cracks, and breakdown of restorations.

  • ALL allow bacterial entry into the “tooth/pulp system”.

  • … if not treated, it will eventually manifest in the periapical tissues as:

    • Inflammation
    • Infection
    • Abscess
    • Cellulitis
    • Cyst

This progression can be conceptualized as a

Supporting Evidence: Rate of Periapical Pathosis Development (Jansson et al. 1993)3

Study on monkey premolars. Jansson et al Swed Dent J 1993; 17: 85-93

“Closed” Group4

Info

This group simulated a more anaerobic environment, similar to a tooth with a failing restoration or a crack.

  • Histologically:
    • 1 month - No pulp tissue was evident histologically. Osteoclasts were evident.
    • 2 months - Small granulomas were present, with resorption of bone and root.
    • 4 months - Well-developed granulomas, some minor cyst-like areas, and bone & root resorption were observed.
  • Radiographically:
    • 2 months - Some teeth had periapical radiographic changes.
    • 4 months - All had clearly detectable periapical pathosis.

“Open” Group5

Info

This group simulated an environment with no restoration, similar to an open carious cavity. The progression was significantly slower.

  • Histologically:
    • 1 month - Apical pulp was intact, with no periapical inflammation.
    • 2 months - No pulp tissue was present apically, but still no PA inflammation. Histologically, no pulp tissue.
    • 4 months - Minor resorptive widening of the apical foramen was seen, with an intact lamina dura.
    • 7 months - Isolated granulation tissue was present.
    • 10 months - A well-developed granuloma was observed.
  • Radiographically:
    • 7 months - Some teeth had detectable pathosis.
    • 10 months - Some teeth had detectable pathosis.

Host Defense6

The dynamic at the apex of the tooth can be viewed as a

  • Molecular Mediators
  • Inflammatory Cells
  • Antibodies

2. Classification of Periapical Conditions

Overview of Classification Systems

Note

Similar to pulp conditions, the literature lacks a consistent and comprehensive classification system for periapical conditions.

Summary of classifications from 5 textbooks:

PERIAPICAL DIAGNOSISNormalNormalNormalNormalNormal
Symptomatic apical periodontitisAcute apical periodontitisAcute apical periodontitisAcute apical periodontitisAcute apical periodontitisAcute apical periodontitis (vital and nonvital)
Asymptomatic apical periodontitisChronic apical periodontitisChronic apical periodontitisChronic apical periodontitisChronic apical periodontitisGranuloma
Periapical periodontitis with abscessSuppurative apical periodontitisSuppurative apical periodontitisSuppurative apical periodontitisChronic alveolar abscess (If fistula is present)
Acute apical abscessAcute apical abscessAcute apical abscessAcute apical abscessAcute apical abscessAcute alveolar abscess
Periapical periodontitis with fistulaAcute apical abscessPhoenix abscessPhoenix abscess
Condensing apical periodontitisApical cystApical cystApical cystApical cystCyst
Condensing osteitisCondensing osteitisApical condensing osteitisPeriapical osteosclerosisCondensing osteitis

Comprehensive Clinical Classification of Peri-radicular Conditions (Abbott 2004, 2019)7

Info

This classification system is based on the logical progression of disease in tissue, providing a more comprehensive and clinically meaningful framework.

Abbott, PV. 2019: 215 – 266 Abbott - 2004 Endod Topics

No SIGNS OF DISEASE
CLINICALLY NORMAL PERIAPICAL / PERI-RADICULAR TISSUES
(Based on the history, clinical examination, tests, radiography, etc.)
INFLAMMATORY CONDITIONS
APICAL PERICEMENTITIS - Acute: Primary (?)(x) (e.g., radioopacity, etc.)
Secondary (?)(x) (e.g., radioopacity, etc.)
- Chronic (e.g., radiolucency, etc.)
- Condensing Osteitis (e.g., radioopacity)
(NOTE: a form of chronic apical periodontitis)
FOREIGN BODY REACTION
INFECTIONS
APICAL ABSCESS - Acute: Primary (?)(x) (e.g., radioopacity, etc.)
Secondary (?)(x) (e.g., radioopacity, etc.)
- Chronic (e.g., has a draining sinus)
FACIAL CELLULITIS
EXTRA-RADICULAR INFECTION
CYSTS
PERIAPICAL POCKET CYST
PERIAPICAL TRUE CYST
SCAR
PERIAPICAL SCAR
EXTERNAL RESORPTION
External SURFACE Resorption
External INFLAMMATORY Resorption: Apical $Lateral$
External REPLACEMENT Resorption
External INVASIVE Resorption
External PRESSURE Resorption
External ORTHODONTIC Resorption
External PHYSIOLOGICAL Resorption
External IDIOPATHIC Resorption

Progression Pathway of Periapical Conditions

  • Healthy Tissue
  • *** Injury or stimulus
  • Inflammation
  • If NO treatment
  • Infections
  • Some - ONLY if epithelium present
  • Cysts
  • Some - after treatment
  • Scar

Incidence of Human Periapical Lesions (Nair et al. 1996)8

Study on periapical lesions obtained with extracted teeth. Nair PNR, Pajarola G, Schroeder H. OS:OM:OP:OR:Endod 1996; 81: 93-102

Tip

This landmark study analyzed 256 extracted teeth with attached periapical lesions, changing the understanding of these conditions.

Results9

Of the 256 periapical lesions:

  • 35% - Abscesses
  • 50% - Granulomas
  • 9% - True Cysts
  • 6% - Pocket Cysts

Note: Total cysts - 15% of lesions

Epithelium was present in 52% of the biopsies - irrespective of the histological diagnosis.

Warning

A key finding was that epithelium was present in 52% of all biopsies, regardless of the final diagnosis. This demonstrated that the mere presence of epithelium does not equate to a cyst. The structure and formation of a complete cavity are the defining features.

+ EpitheliumNo Epithelium
Granuloma55%45%
Abscesses40%60%
Cysts100%-
Total52%48%

3. Detailed Analysis of Periapical Conditions of Endodontic Origin8

  • Acute = moderate-severe pain, recent onset, patient seeks relief
  • Chronic = v. mild or no pain, present for long time, no urgency

Clinically normal periapical tissues10

Info

This diagnosis is based on clinical and radiographic findings that suggest the tissues are normal. Histologically, this shows intact cementum, periodontal ligament, and alveolar bone, with the neurovascular bundle entering the pulp.

Nair 1997

Inflammation = Apical periodontitis11

Acute Apical Periodontitis

  • Primary Acute Apical Periodontitis
    • Infected root canal
    • No widening of the periodontal ligament space

Info

The tooth is often very tender to percussion or touch, as significant bone resorption has not yet occurred. The periodontal ligament space may appear normal or only slightly widened.

  • Secondary Acute Apical Periodontitis
    • Infected root canal
    • Widening of the periodontal ligament space OR a periapical radiolucency

Info

This is an acute exacerbation of a pre-existing chronic condition. It occurs when bacteria from the canal cause a flare-up of the chronic lesion.

Chronic Apical Periodontitis (Granuloma)10

Can present with or without epithelium. Nair 1997

NO EpitheliumWITH Epithelium

Condensing Osteitis12

A form of chronic apical periodontitis.

Info

It is characterized by a radiopaque (more dense) appearance of the bone. It typically results from long-term, low-grade irritation, often associated with chronic pulpitis. The body’s response is to stimulate osteoblasts to lay down more bone rather than resorb it. If the pulp progresses to necrosis and infection, a radiolucency may eventually develop within or around the area of condensing osteitis.

Foreign body reaction13

  • An inflammatory response to a foreign material within the periapical tissues.
    • Don’t always get FBR to extruded materials.
  • Most commonly reported FBR’s to:
    • Root canal sealers / cements
    • Gutta percha
  • Other reports of FBR to:
    • Irrigants, medicaments, paper points, talcum powder, etc. Nair 1997

Infections

**Abscess =

Warning

It is critical to use this term correctly. An abscess is not just any infection; it must involve a localized collection of pus.

“localised collection of pus”** Can present with or without epithelium.

Info

This is a long-standing, low-grade inflammatory response that is often asymptomatic. It typically appears as a periapical radiolucency on a radiograph. Histologically, it is composed of inflammatory tissue (granuloma).

Nair 1997

NO EpitheliumWITH Epithelium
  • Acute Abscess
    • Primary
    • Secondary

Info

Primary Acute Apical Abscess: Occurs without a pre-existing radiolucency and is often extremely painful due to pressure buildup. Secondary Acute Apical Abscess: Develops from a pre-existing chronic lesion, so a radiolucency is present.

  • Chronic Abscess
    • i.e. has a draining sinus present

Info

This is characterized by the presence of a draining sinus tract (often called a

Cellulitis1415

Also known as a spreading infection or facial cellulitis.

The infection is no longer localized but is spreading through the fascial planes between muscles. It presents as a diffuse, widespread swelling. This is a severe infection that often develops from an untreated acute abscess.

Extra-radicular infection

  • Micro-organisms have established colonies on the external root surface within the periapical region.
  • A sequel to an infected root canal system & apical periodontitis.
  • Example: Periapical Actinomycosis

Warning

These infections often do not heal with conventional root canal treatment alone and may require surgical intervention.

Nair 1997

Cysts161617

  • A sequel to apical periodontitis.

Info

Cysts develop from apical periodontitis in cases where epithelial rests of Malassez are present and stimulated to proliferate.

  • Epithelial lining forms.
  • Two types: “Pocket” and “True”.

Pocket Cyst

  • Communicates with the root canal.
  • Will usually respond to routine endodontic treatment.

Theory

It is analogous to a pocket in clothing. Because it is sustained by the bacteria in the canal, it has the potential to heal following non-surgical root canal treatment that eliminates the intra-radicular infection.

Nair 1997

Diagram Description: Periapical Pocket Cyst

  • Infected root canal
  • Tooth root
  • Periodontal ligament
  • Cyst communicating with root canal
  • Epithelium (lining most - but not all - of the cyst)
  • Chronic apical periodontitis (periapical granuloma)
  • Cystic lumen (containing fluid)

True Cyst18

  • NO communication with the root canal.
  • Has a COMPLETE lining.
  • Often has cholesterol crystals.
  • A self-propagating lesion.
  • Will not respond to root canal treatment.
  • Will require surgical removal.

Theory

The cyst is a completely enclosed, epithelium-lined cavity that has become a self-propagating lesion, independent of the original infection in the tooth. It will not heal with non-surgical root canal treatment alone because the source of irritation is now contained within the cyst itself.

Nair 1997

Diagram Description: Periapical True Cyst

  • Infected root canal
  • Tooth root
  • Periodontal ligament
  • Chronic apical periodontitis (periapical granuloma)
  • Cystic lumen (containing fluid + cholesterol crystals)
  • Epithelium (completely lining the cyst; no communication with root canal)

Periapical scar19

  • A physiological healing response.
    • Repair by fibrous / connective tissue
  • More commonly occur after periapical surgery.
  • But can also occur after any inflammatory response with bone resorption.
    • i.e. even without surgery

It appears as a persistent but stable or reduced-size radiolucency after treatment.

Diagnosis: A definitive diagnosis of a scar can only be made retrospectively. It requires a series of radiographs showing that an initial, larger radiolucency has significantly reduced in size and then remained stable over a long follow-up period. A single radiograph of a lesion cannot be diagnosed as a scar.

Radiographic Example: Possible Periapical Scar

  • Pre-operative
  • WL
  • RCF - 18 mths
  • 4 yrs - Review

4. Clinical Diagnosis and Implications2021

Progression Scenarios of Periapical Conditions

  • Short-term Irritation (e.g. trauma, canal instrm): Can lead to spontaneous healing if no more irritation occurs.
  • Long-term irritation from an Infected Root Canal:
    • Can lead to 1° Acute Apical Periodontitis.
    • If not treated, this can cause an intensification of inflammation and symptoms, leading to:
      • Facial Cellulitis
      • Periapical Cyst (pocket/true)
      • Chronic Apical Abscess (i.e. draining sinus)
    • 1° Acute Apical Periodontitis can also progress to a 1° Acute Apical Abscess or Chronic Apical Periodontitis.
    • Chronic Apical Periodontitis can lead to 2° Acute Apical Periodontitis.
    • Both 1° and 2° Acute Apical Abscesses can also lead to an intensification of inflammation and symptoms.

Progression Pathway

  1. An infected canal first causes Primary Acute Apical Periodontitis (symptomatic, no radiolucency).
  2. If untreated, this often transitions to Chronic Apical Periodontitis (asymptomatic, radiolucency develops).
  3. This chronic state can persist for months or years, sometimes punctuated by flare-ups of Secondary Acute Apical Periodontitis (symptoms return). The body may overcome this, returning the condition to a chronic state.
  4. Eventually, the condition may worsen, leading to a Secondary Acute Apical Abscess, Chronic Apical Abscess (with sinus tract), or Cellulitis, which finally prompts the patient to seek treatment.
  • Most common scenario:
    • Infected Root Canal / Long-term irritation
    • → 1° Acute Apical Periodontitis
    • → Chronic Apical Periodontitis
    • → 2° Acute Apical Periodontitis
    • → Intensification of inflm + symptoms
    • → Chronic Apical Abscess (i.e. draining sinus)
    • → Then find a dentist !!!

The Diagnostic Challenge of a Periapical Radiolucency222324

A periapical radiolucency is a sign of Apical Periodontitis, but it could be several different conditions which require different management:

Warning

The initial thought should be some form of apical periodontitis, but it is crucial to remember that a radiolucency is not a diagnosis in itself.

  • Apical Periodontitis
    • 2º Acute Apical Periodontitis
    • Chronic Apical Periodontitis
    • Foreign Body reaction
  • Infection
    • 2º Acute Apical Abscess
    • Chronic Apical Abscess
    • Extra-Radicular Infection
  • Periapical Cyst
    • Pocket Cyst
    • True Cyst
  • Periapical Scar
  • Other Pathosis: non-endodontic origin

Remember - NOT EVERY periapical radiolucency will be due to pulp pathosis.

Case Example: Non-Endodontic Pathosis2526

  • 51 yr old male
  • 8 yr history of pain and “numbness of the palate”
  • Endodontic treatment - three times by three dentists

Red Flags

  1. Numbness (paresthesia): This is not a typical symptom of endodontic pathosis and suggests nerve involvement from a more aggressive lesion.
  2. Atypical Radiograph: The periodontal ligament space appeared largely intact around the root, which is not characteristic of an endodontic lesion.
  • Diagnosis: Adeno-Cystic Carcinoma
  • Treatment: Hemi-maxillectomy and radiotherapy

Outcome

The patient had undergone years of inappropriate and ineffective dental treatment, delaying the correct diagnosis of a malignancy with a 10-year prognosis. This highlights the life-threatening consequences of misdiagnosis.

Comparison of Diagnostic Terminologies22

J Endod 2009; 35: 1634. 6 Conditions:

  1. Normal apical tissues
  2. Symptomatic apical periodontitis
  3. Asymptomatic apical periodontitis
  4. Acute apical abscess
  5. Chronic apical abscess
  6. Condensing osteitis

Abbott Classification (2004)27

Abbott - Endod Topics 2004 14 Conditions:

  • Clinically Normal Periapical Tissues
  • Apical Periodontitis
    • Acute Primary Secondary
    • Chronic Radiolucency Condensing Osteitis
    • Foreign body reaction
  • Infections
    • Abscess
      • Acute Primary Secondary
      • Chronic
    • Cellulitis
    • Extra-radicular infection
  • Cysts Pocket True
  • Periapical Scar

Abbott vs. AAE Critique

  • Mapping AAE terms to Abbott’s classification:
    • Symptomatic Apical Periodontitis maps to Acute Apical Periodontitis.
    • Asymptomatic Apical Periodontitis maps to Chronic Apical Periodontitis.
  • The AAE Classification has a SHORTFALL of 8 conditions that have been shown to occur - plus INAPPROPRIATE and INCONSISTENT terminology !!!

The AAE classification is criticized for being:

  • Incomplete: It omits at least eight known conditions, including cysts (pocket and true), extra-radicular infections, foreign body reactions, cellulitis, and periapical scars.
  • Inconsistent: It uses the terms symptomatic/asymptomatic for periodontitis but switches to acute/chronic for abscesses, lacking consistent terminology.
  • Conditions shown to occur by research but not included in AAE classification:
    • Nair - 1997:
      • Extra-Radicular Infection - Actinomycosis
      • Periapical Pocket Cyst
      • Periapical True Cyst
      • Foreign Body Reaction
      • Periapical Scar
    • Ricucci et al - 2014:
      • Periapical True Cyst
      • Extra-Radicular Infection

Importance of Correct Diagnosis2829

  • It is imperative that clinicians are able to correctly diagnose the status of the periapical tissues.
    • This implies that they must understand the disease processes that can occur:
      • Diseases of endodontic origin
      • Other diseases
    • This leads to correct treatment.

Quote

A correct and complete diagnosis is paramount because different conditions require different treatments. A poor understanding leads to inappropriate and ineffective treatment.

Consequences of Incorrect Diagnosis

  • Dentists commonly diagnose endodontic disease as an “abscess” or a “cyst”.
    • Often even when there is pulpitis !!!
  • This leads to incorrect treatment - such as:
    • Periapical surgery
    • Antibiotics

Inappropriate Periapical Surgery30

Inappropriate Antibiotic Use24

  • Whitten et al 1996: % of US dentists who would prescribe antibiotics for:

    DiagnosisGDPEndo
    Irreversible Pulpitis51%25%
    Chronic Ap. Periodontitis35%35%
    Acute Ap. Periodontitis62%67%
    Chronic Ap. Abscess62%29%
    Acute Ap. Abscess95%97%

  • Abbott 2000, AEJ (Antibiotic Use in Australia):

    DiagnosisNo. Pt’s% had Ab’s
    Pulpitis5076 %
    Infected canals + apical periodontitis7074 %
    Non-endodontic pain9100 %
    Total12970 %
    • 90 patients had been prescribed antibiotics
    • But only 4 pt’s NEEDED the antibiotics

Conclusion

This demonstrates a profound misunderstanding of the disease process, leading to massive overuse of antibiotics. Antibiotics should not be used as a placebo or for pain relief in inflammatory conditions.

!!!

Framework for a Complete Diagnosis31

Four things to consider and assess:

  1. Identify the TOOTH to be diagnosed
  2. Assess the status of the PULP
    • Or the ROOT CANAL SYSTEM (when there is NO pulp present)
  3. Assess the status of the PERIAPICAL TISSUES
  4. Determine the CAUSE(S) of the disease(s)

Some Common Examples of Diagnoses of Pulp, Root Canal and Periapical Conditions

  • Tooth 36 - pulpless, infected root canal system with chronic apical periodontitis - due to caries and restoration breakdown
  • Tooth 45 - acute irreversible pulpitis with primary acute apical periodontitis - due to caries and a crack
  • Tooth 21 - root-filled and infected root canal system with a chronic apical abscess - due to restoration breakdown and a crack
  • Tooth 16 - pulpless, infected root canal system with secondary acute apical periodontitis - due to caries and restoration breakdown
  • Tooth 22 - necrotic and infected pulp with a primary acute apical abscess - due to an uncomplicated crown fracture
  • Tooth 14 - chronic reversible pulpitis with pulp canal calcification and clinically normal periapical tissues - due to caries

5. References32

Clinical Classification of Pulp and Root Canal ConditionsClinical Classification of Peri-Radicular Conditions
Australian Dental JournalENDODONTICS 7
Abbott & Yu ADJ 2007Abbott, P.V. Vol. 1 Chapter 8 2019
Endodontic Topics
Abbott - 2004 Endod Topics

Further Reading

  • An article on resorption published recently in the journal Dental Traumatology.
  • An article on non-endodontic lesions (for further reading on differential diagnosis).
graph TD
    L --> M1
    M1 --> M2
    M2 --> N1
    M2 --> N2
    M1 --> Q
    Q --> P1
    M2 --> P2
    M2 --> P3
    M2 --> P4
    N1 --> O
    N2 --> O
    N2 --> M1
    O --> M1

Periapical and Peri-Radicular Conditions31

Prof. Paul V. Abbott AO

Diagnosis

Four things to consider and assess:

  1. Identify the TOOTH to be diagnosed
  2. Assess the status of the PULP
    • Or the ROOT CANAL SYSTEM (when there is NO pulp present)
  3. Assess the status of the PERIAPICAL TISSUES
  4. Determine the CAUSE(S) of the disease(s)

Some Common Examples of Diagnoses of Pulp, Root Canal and Periapical Conditions

  • Tooth 36 - pulpless, infected root canal system with chronic apical periodontitis - due to caries and restoration breakdown
  • Tooth 45 - acute irreversible pulpitis with primary acute apical periodontitis - due to caries and a crack
  • Tooth 21 - root-filled and infected root canal system with a chronic apical abscess - due to restoration breakdown and a crack
  • Tooth 16 - pulpless, infected root canal system with secondary acute apical periodontitis - due to caries and restoration breakdown
  • Tooth 22 - necrotic and infected pulp with a primary acute apical abscess - due to an uncomplicated crown fracture
  • Tooth 14 - chronic reversible pulpitis with pulp canal calcification and clinically normal periapical tissues - due to caries

Footnotes

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