Asymptomatic Apical Periodontitis
Learn about asymptomatic apical periodontitis, its causes, symptoms, and treatment. A condition that causes inflammation at tooth’s root tip.
Table of Contents
Introduction
Did you know that your tooth can die without you even realizing it? Apical periodontitis often develops silently, with no visible symptoms at first. In fact, the infection can spread to the bone around the root without causing pain until it’s too late—turning what might have been a simple dental issue into a serious, painful condition.
The scariest part? It’s not self-healing and could require immediate treatment to save your tooth. Keep reading to learn how this hidden dental danger works and what you can do to prevent it.
What is Apical Periodontitis?
Apical periodontitis is an inflammation or infection that affects the tissue at the tip (apex) of a tooth’s root. It typically occurs when the dental pulp (the soft tissue inside the tooth) becomes infected, usually due to a cavity, trauma, or a failed root canal.
This infection can spread to the surrounding bone and tissues, leading to symptoms like pain, swelling, and sometimes abscess formation.
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
Apical Periodontitis Causes
- Bacteria can enter the pulp through cracks, caries, trauma, or exposed cementum.
When the tooth pulp is injured, it triggers an inflammatory response in the affected area. In an effort to protect itself from further damage, the pulp produces a special layer of dentin known as “tertiary dentin.” This protective layer acts as a shield, preventing additional harm and attempting to halt the spread of infection.
However, if the inflammation intensifies, it can cause severe damage to the pulp cells. This damage may compromise the pulp’s vitality—the ability to remain healthy and function properly—ultimately leading to the death of the pulp.
- At this stage, the body’s immune cells and molecules are called upon to fight the infection. But, due to the narrow apical foramen and the hard enamel surrounding the tooth’s internal structures, these immune defenses are unable to effectively penetrate the dentin to remove the pathogens, allowing the infection to persist and spread.
Once the blood flow to the pulp is disrupted, the tissue begins to die, a condition known as pulpal necrosis. This process often extends beyond the pulp, leading to further damage in the surrounding tissues at the tip of the tooth, a condition referred to as apical pathosis, which causes additional infection and inflammation.
- When microbial pathogens or their by-products infiltrate the root canal system, they can spread to the periapical area, which is located at the apex (tip) of the tooth root. In response, the body activates its immune defense mechanisms.
- This involves the recruitment of various immune cells, the release of intracellular mediators, and the production of humoral antibodies to contain and neutralize the infection, as well as to protect the periradicular tissues from further damage.
- Despite the complex host defensive system, the harmful bacteria causing infection can become deeply embedded in the complex and narrow structure of the root canal.
- This area is difficult for the immune system to reach effectively, limiting its ability to fight off the infection and making the bacteria harder to eliminate. As a result, the infection can persist, leading to further complications if not properly treated.
- 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.
Summary
- Infection Entry and Response: Bacteria can enter the pulp through cracks, caries, or trauma, triggering an inflammatory response and the formation of protective tertiary dentin.
- Progression to Necrosis: If inflammation worsens, it can lead to pulpal necrosis, spreading infection to surrounding tissues and causing apical pathosis.
- Immune Limitations and Treatment: The immune system struggles to eliminate the infection due to the narrow root canal, requiring endodontic therapy or tooth removal for resolution.
Pathophysiology of Apical Periodontitis
- Polymorphonuclear leukocytes (PMNs), a type of white blood cell, play a crucial role in the body’s defense against infection. They release cytoplasmic granules that contain enzymes, which help break down and neutralize pathogens.
- These enzymes are essential in the immune response, as they can directly target and destroy harmful bacteria and other microorganisms that invade the body, especially in the case of infections like apical periodontitis.
- While polymorphonuclear leukocytes (PMNs) are essential for defending the body against infections, their aggressive action can sometimes lead to unintended harm. When PMNs release their enzymes to fight off invading pathogens, these enzymes can also damage healthy tissue cells and the extracellular matrices surrounding them.
- This collateral damage can contribute to the destruction of tissues, exacerbating the inflammation and tissue loss seen in conditions like apical periodontitis.
Summary
- PMNs Role: Polymorphonuclear leukocytes (PMNs) defend against infections by releasing enzymes that break down pathogens, especially in apical periodontitis.
- Collateral Damage: These enzymes, while targeting harmful bacteria, can also damage healthy tissues and extracellular matrices.
- Inflammation Worsening: The damage caused by PMNs contributes to increased inflammation and tissue destruction, worsening apical periodontitis.
Sequelae Of Periradicular Diseases
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 common and distinctive symptom used to diagnose symptomatic apical periodontitis. This means that when the dentist taps on the tooth, the patient experiences pain or discomfort.
- 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.)
- mucosa overlying the root apex may or may not be tender on palpation.
Radiographic Changes
A non-vital tooth (tooth that has lost its blood supply)
Slight widening of the apical periodontal ligament (PDL) space: The periodontal ligament is a structure that attaches the tooth to the surrounding bone. When the tooth becomes non-vital, inflammation or infection can cause the PDL space to appear slightly wider than normal on an X-ray. This is a sign that there might be an issue with the tooth’s root, often indicating inflammation or infection around the root apex.
Loss of apical lamina dura: The lamina dura is a thin layer of bone that surrounds the root of a tooth and appears as a dense white line on X-rays. When a tooth is non-vital, the lamina dura around the tooth’s root apex may become resorbed or lost. This is often a result of chronic inflammation or infection affecting the bone surrounding the root.
- Vital tooth:
No radiographic changes: There are no signs of infection, inflammation, or structural damage around the root or periradicular tissues (the tissues surrounding the root of the tooth). The X-ray will appear normal with no dark spots, widening of the periodontal ligament space, or other abnormalities.
Normal periradicular structures: The periradicular structures, including the periodontal ligament (PDL) and the lamina dura (the bone that surrounds the root), will appear normal on the X-ray. The PDL space will have a uniform width, and the lamina dura will be intact, indicating no disease or damage around the root of the tooth.
Summary
Non-Vital Tooth:
- Slight widening of the apical periodontal ligament (PDL) space, indicating potential inflammation or infection around the root apex.
- Loss of apical lamina dura, a sign of resorption due to chronic inflammation or infection affecting the bone surrounding the root.
Vital Tooth:
- No radiographic changes, with no signs of infection, inflammation, or damage around the root.
- Normal periradicular structures, such as the PDL and lamina dura, with no abnormalities on the X-ray.
Differential Diagnosis
- Symptomatic Apical Periodontitis (SAP) Vs Acute Alveolar Abscess (Acute Apical Abscess)
Symptomatic Apical Periodontitis (SAP)- Symptoms:
- Pain on percussion: The tooth is tender to tapping.
- Pain on palpation: The soft tissues around the tooth may be tender.
- Pain: The pain is often localized, throbbing, and worsens when pressure is applied.
- No fluctuation: There is no pus or fluctuation under the gum (no abscess formation).
- Radiographic findings:
- Slight widening of the apical periodontal ligament (PDL).
- No clear radiolucency or bone loss around the apex.
- No evidence of infection spreading beyond the apex of the tooth.
Acute Alveolar Abscess (Acute Apical Abscess)
- Symptoms:
- Severe pain: Pain is often spontaneous, throbbing, and intense.
- Swelling: Visible swelling in the gum or face, typically near the root apex.
- Fluctuation: A soft, compressible area (fluctuation) may be palpable, indicating the presence of pus.
- Pain on percussion and palpation: Both symptoms are present, and the pain is often more severe compared to symptomatic apical periodontitis.
- Systemic symptoms: In some cases, there may be fever or malaise (unwell feeling).
- Radiographic findings:
- A well-defined radiolucency (dark spot) around the root apex, indicating bone loss.
- Possible widening of the PDL space due to the inflammatory process.
- Evidence of acute infection beyond the apex, sometimes accompanied by periapical abscess formation.
- Symptoms:
Summary
Pain and Symptoms:
- SAP: Localized, throbbing pain that worsens with pressure; no pus or abscess.
- Acute Abscess: Severe, spontaneous pain with visible swelling and fluctuation (pus present).
Radiographic Findings:
- SAP: Slight widening of the PDL with no clear radiolucency or bone loss.
- Acute Abscess: Well-defined radiolucency around the root apex indicating bone loss and infection spreading.
Systemic Symptoms:
- SAP: Localized symptoms, no systemic issues.
- Acute Abscess: May include fever and malaise (feeling unwell).
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
Assessing the Tooth’s Condition
Vital Tooth: If the tooth is still alive, the treatment focuses on addressing the source of irritation or pressure causing the inflammation. This could be due to trauma, improper bite, or high points on the tooth’s surface.
Non-Vital Tooth: If the tooth has become non-vital (meaning the pulp is dead), the infection is more severe. The treatment usually involves addressing the infection in the pulp and the surrounding tissues.
2. For Teeth with Hyperocclusion (Too Much Pressure)
If the inflammation is caused by high pressure on the tooth (hyperocclusion), the first step is to adjust the high points of the tooth that may be causing improper biting. This will help relieve pain caused by uneven pressure and reduce the irritation in the affected area.
3. For Non-Vital Teeth with Infected Pulp
Removing Irritants: For non-vital teeth, the root canal treatment is often required. The infected pulp (the soft tissue inside the tooth) needs to be removed. The root canal is then cleaned thoroughly to eliminate bacteria and any debris. After that, the root canal is sealed to prevent future infections.
4. After the Acute Phase
Once the acute symptoms (such as pain and swelling) have subsided, the treatment typically becomes more conservative. This means the dentist may clean the area and use medications to reduce the infection and promote healing. In some cases, a crown may be placed to protect the tooth, especially if the tooth structure is weakened.
Prognosis
Prognosis generally favourable.
FAQs
How do I know if I have Apical Periodontitis?
You might have apical periodontitis if you feel sharp, throbbing pain around a tooth, especially when you chew or press on it. Your gums might be swollen or red, and you could feel discomfort around the tooth. If you notice pus or swelling near the tooth, it’s important to see a dentist right away.
Can I ignore the pain and hope it goes away?
No, ignoring the pain can make the situation worse. If left untreated, the infection can spread, leading to more severe problems, like an abscess, bone damage, or even tooth loss. It’s best to see a dentist as soon as possible.
Will it hurt when I get treated for Apical Periodontitis?
Most people find the treatment to be manageable. Dentists use local anesthesia to numb the area, so you won’t feel pain during the procedure. Afterward, you might feel some discomfort, but this can usually be managed with over-the-counter pain relievers.
What is the best way to relieve pain from apical periodontitis at home?
Saltwater Rinse: Mix 1 teaspoon of salt in a glass of warm water. Swish this solution around your mouth to help reduce inflammation and clean the area.
Cold Compress: Apply a cold compress on the outside of your cheek near the affected tooth. This can help numb the area and reduce swelling and pain.
***home remedies can help alleviate pain and discomfort but cannot cure it.
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