Asymptomatic Apical Periodontitis
Learn about asymptomatic apical periodontitis, its causes, symptoms, and treatment. A condition that causes inflammation at tooth’s root tip.
Introduction
- Apical periodontitis is the local inflammation of the periradicular tissues that originates from pulp disease.
- Periradicular tissues:
- Surrounding alveolar bone
- Periodontium
- Cementum
- Apical periodontitis may occur due to the advancement of dental caries, trauma, or operative dental procedures.
- Pulpal diseases are one of the most common causes of periradicular diseases, as there is an interrelationship between pulp and periradicular tissues through the various foramina of root canals, which give rise to inflammatory and immunologic reactions through the passage of bacterial products and toxins.
- The host defence response to pathogenic microbes is what triggers inflammation and the consequent destruction of periradicular tissues.
- Apical diseases can manifest with various clinical presentations, ranging from no obvious clinical signs or symptoms to severe destruction of the underlying bone with or without a draining abscess.
Classification of Periradicular Diseases
- Symptomatic periradicular diseases
- Symptomatic apical periodontitis (previously known as acute apical periodontitis)
- Vital tooth
- Nonvital tooth
- Acute alveolar abscess
- Acute exacerbation of asymptomatic apical periodontitis (phoenix abscess)
- Symptomatic apical periodontitis (previously known as acute apical periodontitis)
- Asymptomatic periradicular diseases
- Asymptomatic apical periodontitis (previously known as chronic apical periodontitis)
- Chronic alveolar abscess
- Radicular cyst
- Condensing osteitis
- External root resorption
- Persistent apical periodontitis (based upon duration of irritation caused to the periodontium and the damage to the surrounding periradicular tissues)
- symptomatic apical periodontitis
- asymptomatic apical periodontitis
- Diseases of the periradicular tissues of nonendodontic origin
Etiology of Apical Periodontitis
- Bacteria can enter the pulp through cracks, caries, trauma, or exposed cementum.
- The pulp will react to injury via localised inflammatory processes and the formation of a protective, reactive layer of tertiary dentin.
- Severe inflammatory reactions can lead to pulpal cell injury, potentially compromising pulpal vitality and survivability.
- Immune cells and molecules are unable to effectively penetrate dentin to remove pathogens due to the narrow apical foramen of the tooth and the hard enamel surrounding the internal structures.
- Once pulpal vascularity is dysfunctional, progression to pulpal necrosis and apical pathosis is typical.
- The microbial invaders present in the root canal system, or their by-products, can advance into the periapex of the root. In response, the host mounts a defensive mechanism through various cells, intracellular mediators, and humoral antibodies.
- As the invading oral microflora and the immune response clash, the periapical tissues surrounding the tooth’s root, such as the periodontal ligament and alveolar bone, can be destroyed. This destruction causes periodontal lesions, which may vary in clinical manifestations.
- Despite the complex host defensive system, the causative organisms are well-entrenched in the intricate and delicate root canal system, which is beyond the reach of the host immune response.
Therefore, apical periodontitis is not self-healing, and resolution of the disease can only result through surgical or non-surgical endodontic therapy or the removal of the tooth in question.
Pathophysiology of Apical Periodontitis
- Polymorphonuclear leukocytes play a significant role in the host response, as they secrete cytoplastic granules with enzymatic properties.
- Although the primary responsibility of PMNs is to protect the host, they can cause structural damage to tissue cells and extracellular matrices.
- Thus, the accumulation of PMNs plays a significant role in the destruction of periapical tissues during the acute phase of apical periodontitis.
- Other host cells that play crucial roles are lymphocytes, macrophages, and osteoclasts
Sequelae Of Periradicular Diseases
Post-treatment sequelae
Symptomatic Apical Periodontitis
- previously known as acute apical periodontitis.
- is defined as a painful inflammation of the periodontium as a result of trauma, irritation, or infection through the root canal, regardless of whether the pulp is vital or nonvital, producing clinical symptoms including a painful response to biting and percussion.
Causes of Symptomatic Apical Periodontitis
- When in vital tooth:
- Abnormal occlusal contacts
- Recently inserted restoration extending beyond the occlusal plane.
- Wedging of a foreign object between the teeth, such as a toothpick or food
- Traumatic blows to the teeth
- In non-vital tooth:
- sequelae of pulpal diseases, i.e., the diffusion of bacteria and noxious products from an inflamed or necrotic pulp
- Iatrogenic causes include the following:
- Root canal instrumentation forcing bacteria or debris inadvertently through the apical foramen.
- Forcing of irritating irrigants or medicaments through the apical foramen
- Extension of obturating material through the apical foramen to impinge on periradicular tissues.
- Perforation of the root
- Over instrumentation during shaping and cleaning of root canals
Symptoms of Symptomatic Apical Periodontitis:
- Pain
- Tenderness in tooth
- Tooth may be slightly sore sometimes only when it is percussed in a certain direction, or the soreness may be severe.
- Tooth may feel extruded.
- There may be pain on mastication.
Diagnosis of Symptomatic Apical Periodontitis
- Pain on percussion is a classical diagnostic feature of symptomatic apical periodontitis.
- Symptoms can be due to:
- result of irritation originating from endodontic treatment, caused by over-instrumentation of medicinal irritants, or overfilling.(pulpless tooth)
- noxious stimuli irritating the periodontal ligament.(pulp is vital.)
- tooth is tender on percussion
- mucosa overlying the root apex may or may not be tender on palpation.
Radiographic Changes
- Non-Vital Tooth:
- A slight widening of the apical periodontal ligament space
- Loss of apical lamina dura of the involved pulpless tooth
- Vital tooth:
- no radiographic changes seen.
- normal periradicular structures seen.
Differential Diagnosis
- between symptomatic apical periodontitis and an acute alveolar abscess.
- Symptomatic apical periodontitis: an inflammatory reaction of the periodontal ligament
- Acute alveolar abscess: breakdown of periradicular tissues, a further stage in development of the disease
Bacteriology
- The pulp and periradicular tissues may be sterile if periodontitis is due to a blow, occlusal trauma, or chemical or mechanical irritation during endodontic treatment.
- Bacteria or toxic bacterial products present in the root canal may either be forced through or grow beyond the apical foramen and may irritate the apical periodontal tissues.
Histopathology
- An inflammatory reaction occurs in the apical periodontal ligament.
- The blood vessels dilated
- polymorphonuclear leukocytes (PMNs) present
Outcome of Symptomatic Apical Periodontitis
- Spontaneous healing
- Acute alveolar abscess
- “Point” and open to the exterior (fistulation and sinus tract formation)
- Lesion becomes asymptomatic and enters chronic phase.
Treatment
- Treatment consists of determining the costs and relieving the symptoms.
- Determine whether apical periodontitis is associated with a vital tooth or a pulpless tooth.
- Adjustment of high points in hyperocclusion cases
- Removal of irritants in case of nonvital infected pulp
- When the acute phase has subsided, the tooth is treated by conservative means.
Prognosis
Prognosis generally favourable.
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