Apical periodontitis: when toothache is unbearable. Apical periodontitis Acute and chronic apical periodontitis

Apical periodontitis- This is an ailment of inflammatory origin of periodontal tissues with a topographic manifestation mainly in the apical region of the affected tooth. It is indicated by a defect in the ligamentous apparatus of the tooth, the destruction of a bone of various sizes with possible aggravation in the variant of the jaw fracture. These transformations can be caused by infection, trauma, drugs or irrational medical interventions. At first, the manifestations are acute, but over time they transform into a chronic one. A protracted course with regular actions of damaging factors can exacerbate.

Therapy of apical periodontitis comes down, as a rule, to a conservative cure, which is based on cleaning the root system of the tooth from tissues damaged by inflammation, closing it with a root filling and recreating the crown area with restoration or orthopedic structures. If necessary, surgical methods are added. Therapy is often supplemented with medication and physiotherapy. If recovery is not possible, extraction is performed.

Causes of Apical Periodontitis

The occurrence of apical periodontitis can be due to causes from the outside and from the inside. Factors acting exogenously in correlation to the oral cavity: impact, bruise, fall, cause acute periodontal transformations in the apical region of the tooth. In the absence of intervention, they flow into a protracted direction of apical periodontitis. As a variant of external influence, medical intervention can also be considered, the irrational points of which lead to contact trauma with instruments or highly influencing medicines of the apical part of the periodontium. A traumatic impact of a physical nature is possible during endodontic manipulations at the stages of cleansing from putrid compounds, antimicrobial rinsing of the radix system and sealing the root with a filling.

When cleaning the canal using excessive stress, both on manual and machine tools, it is possible to push the working area beyond the tooth area into the apical region of the periodontium, which further causes the occurrence of inflammatory transformations of the apical part. When cleaning with solutions of the root area with an incorrectly processed upper third of the tooth (without creating a taper or with excessive expansion of the canal), an antiseptic may leak into the apex area. In the case of using sodium hypochlorite 3-5%, this can cause significant burns of periodontal tissues and bone. The last stage of root system therapy is due to the closure of the created space with synthetic compounds. When the top is broken by mechanical action, the filling substance is likely to go beyond the border of the tooth into the apical region of the periodontium. This causes transformations in the form of a burn (arsenic periodontitis), allergies (to an antidote in the variant of using arsenic in therapy - iodine) and other points.

Conditions that indicate their action inside in correlation to the oral cavity can be divided into exogenous and endogenous influencing in relation to the tooth. External actions for the root and apex are due to microbes and long-term trauma. A significant increase in microbial contamination is indicated with the spread of inflammatory phenomena. This is likely with diseases of the teeth and periodontal tissues. The penetration of microbial agents into the cavity of the tooth is likely with deep caries, aggravation (). In severe periodontitis, in case of significant mobility and, accordingly, pronounced expansions in the gum along the edges of the tooth, the infection is likely to pass directly into the apical region through the marginal parts of the periodontium.

Long-term traumatic impact for the occurrence of apical periodontitis can be indicated by inadequately performed dental actions long before the manifestations. The influence causes an overestimation of the bite by overly made fillings and orthopedic structures. Prolonged stress leads to increasing swelling of the pulp tissue and its subsequent necrosis. Since the process is protracted, inflammation of the apical region of the periodontium is chronic. In correlation with factors acting from the inside to the tooth, lymphogenous and vascular shedding of infection into the apical region is indicated. This is likely with diseases of distant organs and systems of the body, with a long-term absence of therapy for these areas.

Symptoms of apical periodontitis

The symptomatology of apical periodontitis is manifested in the ratio of the stage of progression of periodontitis in apical tissues.

Acute apical periodontitis is indicated by regular aching pain that increases with pressure on the tooth. There is also an awareness of tissue bursting in the region of the affected tooth, sensitive responses to temperature actions, increasing manifestations to hot solutions. With the passage of time, the pain begins to increase and be deployed to nearby areas of the oral cavity or to regional areas (nose, eye, ear, temple), combined with symptoms of severe intoxication. These transpositions are determined by the transformation of the serous stage into the purulent one. Acute apical periodontitis passes from several days to two weeks. In the absence of intervention of a therapeutic nature, the acute form is reconstructed into a chronic one.

Chronic apical periodontitis is the result of an acute stage of apical periodontitis, or is designated as an autonomous manifestation in apical tissues. The patient may not distinguish various transformations in well-being.

Exacerbation of apical periodontitis gives a significant transformation of the symptomatic picture. During the period of a protracted course, without signs of escalation, it may be noted: sensitivity with stress on the tooth; visualization on the gums of a fistula with discharge, granulomas with an oral or facial location, swelling in the projection of the division of the radix; calculation of tooth mobility. The patient may indicate a perception of tooth distension that increases with time, which may give a picture of the spread of pus into the bone from the apex and the absence of a passage for exudate to flow. Along with increasing expansion, an increase in tooth mobility is added, determining that inflammation from the apical region of the periodontium moves to the marginal part. Exacerbation of apical periodontitis reflects all of the above phenomena, combined with strongly felt signs of aggravation of the state of the body (temperature, sleep and appetite disorders, headaches).

Acute apical periodontitis

The etiology of apical periodontitis with acute overtones is due to the rapid and active action of defective factors. These changes can cause: acute trauma (blow, fall, bruise), microbial contamination outside and inside the tooth, penetration of medicinal substances into the apical part and traumatization by the working part of the doctor's instrumentation. With a physical impact on the apical region, microbial contamination of the root system and periodontium is not excluded.

The symptomatic picture of apical periodontitis fits into the manifestations due to the stage of the process. In the phase of intoxication, when the process of inflammatory transformations is at the stage of inception, the patient notes precisely defined pain when biting, aching, in the region of the defective tooth or at the point of application of the basic force from the injury, with vertical tapping, the designation of pain is likely. By the end of this stage, as a response to the action of negative aspects, the formation of exudate of a serous nature occurs.

During the period of exudative manifestations of apical periodontitis, in which acute serous periodontitis is transformed into purulent, the range of symptoms increases. There is a long, short interval without pain, sensitivity to touch. The pain is aching, deployed in heterogeneous areas. There is a feeling of bulging of the affected tooth from the arch of the jaw. The rocking of the tooth and swelling of the soft tissues of the oral cavity, especially the gums from the edge of the indicated tooth, are visualized. On the part of the general systems of the body: the submandibular lymph nodes undergo a transformation: they increase, are painful when palpated. The patient identifies a defect in well-being: headache, appetite and sleep disorders, temperature. The period of the general action of acute phenomena in the periodontium is within the threshold of 2-3 days to 2 weeks.

Chronic apical periodontitis

The etiology of apical periodontitis of chronic origin is due to a prolonged low-intensity effect on periodontal tissues or as a result of the transformation of an acute form of periodontal transformations. The factors causing this action, bypassing the acute stage of periodontitis, include trauma from irrationally carried out therapeutic (filling overestimation) and orthopedic (not installed in the occlusion structures) cure, overload of the remaining teeth due to the loss of others. Stage differentiation is based on clinical manifestations and periodontal and bone transformations.

Chronic apical periodontitis is manifested by a small presence of external manifestations. The patient may note a slight pain when biting, or nothing. The color of the tooth changes to a yellowish-grayish gradient. There is no response to thermal interventions, probably the designation of a putrid odor. This stage of apical periodontitis is also the outcome of the cure of other forms of chronic periodontitis. Chronic granulating periodontitis is indicated by severe symptoms. The patient notes severe pain when voltage is applied to the tooth, sensitivity of expansion in the dental arch, when raising or lowering the lip corresponding to the lesion on the gum, it is possible to see a fistula with or without discharge. The fistula is indicated mainly in the projection of the apex of the radix, but can also be indicated in the marginal region of the tooth. At the stage of fistula opening (that is, the presence of discharge), pain may subside slightly, since pus is released from the periodontal region. On the part of the lymph nodes, there is an increase and soreness.

Chronic granulomatous periodontitis as the middle link in clinical symptoms and bone transformations is indicated by mild pain or its absence, mild pain when biting. Occasionally, patients may note swelling of the gums in the projection of the separation of the radix of the buccal roots of molars and premolars, which is indicated by the presence of a granuloma in the region of apical periodontitis. Granulomas can have a different topography, up to the facial location. There may be a change in color, a tooth with various manifestations (from intact to the presence of a cavity or filling).

Exacerbation of apical periodontitis occurs from chronic granulating and granulomatous periodontitis, less often from the fibrous stage of periodontitis. Against the background of the presence of bone destruction, and hence the place for the advancement of pus, the pain is not strongly marked as in the acute period. The pain is constant, combined with collateral swelling of the tissues, the lymph nodes are enlarged, painful. The tooth may have been previously treated or not; in the absence of intervention by a specialist, a cavity filled with contents with an unpleasant odor is indicated. Pain when biting. Hue can be changed. The gum is red, tooth mobility is noted. The phenomena of general intoxication are strongly expressed.

Diagnosis of apical periodontitis

The diagnosis of apical periodontitis is based on the collection of general data, the examination of the facial and intraoral regions, and the conduct of additional methods of medical examination. During the survey, the moments of external influence on the tooth are clarified: past injuries, medical procedures. Somatic ailments also make a significant contribution. They are informed about the previous visit to the dentist and the treatment of the organs of the oral cavity. General examination reflects the state of the facial skull and organs of the oral cavity. When visualizing the facial region, the symmetry of the face is more often noted, the skin without transformations (subcutaneous granuloma in chronic granulomatous periodontitis), the opening of the mouth without restrictions, the lymph nodes are predominantly enlarged, painful.

In the oral cavity, the mucous membrane is predominantly without color change. The tooth is intact or with a filling (with or without overestimation), or with a cavity filled with detritus with a putrid odor. The color of the tooth is changed. In apical periodontitis, probing the cavity does not give sensitivity from the body. Tapping in vertical projection gives a positive response, as the pressure on the pus in the apical part of the periodontium increases. With horizontal tapping, the reaction gives a granulating and granulomatous form of chronic periodontitis, tk. rupture of marginal periodontal ligaments. Feeling the mucosa in relation to the apical region of the tooth gives a painful reaction, on the mucosal capsule, in addition to redness of the gums (probably absent in acute serous and chronic fibrous forms of periodontitis), there may be transformations in the variant of the fistula with and without discharge (the mouth is closed by granulations). The designation of a granuloma is also likely (the submucosal position in the projection of the divergence of the radix of multi-rooted teeth from the buccal side is indicated by swelling of the gums).

Additional methods of medical examination: electroodontometry and X-ray. EOM - a method for calculating the sensitivity of the pulp to an electric current. When applying a current of more than 100 μA, there is no response sensitivity in all types of periodontitis. This is due to necrosis of the pulp tissue. The leading way to diagnose apical forms of periodontitis is x-ray. In an acute variant, against the background of initial transformations of the inflammatory direction, X-ray data will not provide clarifying information. Chronic forms are indicated by clearly distinguishable phenomena. Chronic fibrous periodontitis is indicated by dilatation of the periodontium in the form of darkening on the radiograph. The granulating form is marked by the presence in the apical part of the darkening of an uneven shape, with indefinite edges (this area is filled with pus and therefore is not radiopaque). The granulomatous form is calculated as a darkening of the roundish variant with precise features in the apical part. This form of periodontitis is possible with further spread of cystogranuloma (5-8 mm) and then cysts (more than 8 mm). Exacerbation of chronic variants, in addition to increasing symptoms, on x-rays will give large foci of blackout. The examination is supplemented with a general blood test (a picture of inflammation is noted -, an increase in ESR).

Treatment of apical periodontitis

The general treatment of apical periodontitis is aimed at blocking the inflammatory background in the oral cavity and body systems, to prevent the response of the body in the form of sensitization of the body. The cure consists of therapeutic intervention mainly in the apical area of ​​the periodontium, supplemented by orthopedic and surgical interventions if necessary. Therapeutic cure consists in mechanical treatment, antimicrobial therapy and closing the canal with a filling, recreating the crown of the tooth. Mechanical processing is indicated in the creation of accessibility to the canals of the tooth (opening, expansion of the tooth cavity, removal of detritus), endodontic cleaning of the root system (manual and machine options using means for chemical dilatation of the canal (Edetal)).

Antimicrobial treatment consists in alternating with the physical effect of antiseptics on the apical part of the periodontium: irrigation of the radix system with substances (Chlorhexidine 2%, sodium hypochlorite 3-5%), closing the root system with a substance of anti-infective effect (Septomyxin forte, EndAsept gel), calcium-containing attachments (Kalsept) . The closure of the resulting space is performed with a substance of a temporary and permanent direction. Temporarily apply pastes of antiseptic and osteostimulating action. For permanent filling of apical periodontitis, a paste is used in combination with gutta-percha (lateral and vertical compaction). The filling is checked by X-ray. Reconstruction of the tooth stump with restoration or, according to indications, orthopedic structures.

In the presence of transformations in the gums with apical periodontitis, it is recommended to provide access for the confluence of pus. Therapeutic treatment in the variant of the impossibility of processing the apical region is supplemented by resection of the apex. If the cleaning of the radix system and periodontium is not available, tooth-preserving operations (hemisection, amputation, cystotomy, cystectomy) are performed. If all measures are not available, extraction is performed. The general treatment of apical periodontitis is supplemented with broad-range antibiotics (Tsiprolet), antihistamines (Diazolin), analgesics (Ketorol). Physiotherapy is added not in the acute period: laser, magnetotherapy and others.

In the last article, the general characteristics of apical periodontitis were considered and the features of the course of acute apical periodontitis were examined in more depth. In this article, we will consider in detail chronic apical periodontitis, clinic, diagnosis and treatment features. And also touch on the features of the clinic and treatment of traumatic and drug-induced periodontitis.

Let's remember the classification. According to some classifications, apical periodontitis is:

ICD classification - 10

K04.4 Acute apical periodontitis of pulpal origin

K04.5 Chronic apical periodontitis

Apical granuloma

K04.6 Periapical abscess with fistula

• Dental
• Dentoalveolar

K 04.60 Having communication with the HF sinus

K 04.61 Having communication with the nasal cavity

K 04.62 Having communication with the oral cavity

Crusade Crusade Crusade Crusade Crusade Crusade Crusade Crusade Crusade (04.63) Skin-communicating

K 04.69 Periapical abscess with fistula, unspecified

K04.7 Periapical abscess without fistula

• Dental
• Dentoalveolar
• Periodontal abscess of pulpal origin
• Periapical abscess without fistula, unspecified

K 04.8 Root cyst

K 04.89 Root cyst, unspecified

K04.9 Other unspecified diseases of pulp and periapical tissues

Classification of periodontitis according to I. G. Lukomsky

1. Acute periodontitis

• Serous
• Purulent

1. Chronic periodontitis

• Fibrous
• Granulating
• Granulomatous

1. Exacerbation of chronic periodontitis

Chronic apical periodontitis

Chronic apical periodontitis is most often an asymptomatic inflammation in the tissues of the apical periodontium, which is manifested by radiological changes at the tops of the roots of the tooth.

Many dentists use the clinically convenient classification of I. G. Lukomsky. It simplifies the diagnosis.

Chronic fibrous periodontitis

Occurs as an outcome of acute periodontitis or a cure for granulating and granulomatous periodontitis. Traumatic etiology is also important due to the overload that occurs with the loss of a large number of teeth or non-physiological articulation.

Chronic fibrous periodontitis is detected on x-ray as an expansion of the periodontal gap in the apex and is almost never accompanied by destruction of the adjacent bone.

Chronic granulating periodontitis

It is the most active form among all chronic periodontitis, is the outcome of an acute process.

The patient complains of unpleasant, slightly painful sensations when biting on the causative tooth.

Outwardly, the patient looks as usual, sometimes there is an increase in the submandibular lymph nodes. In the oral cavity we see hyperemic mucosa in the area of ​​the tooth, painful on palpation. A distinctive feature of this type of periodontitis is the presence of a fistula in the projection of the root apex. It may ooze pus or swell granulations. Young granulation tissue grows through damaged cementum or even dentin into the bone marrow spaces, often growing along the walls of the fistulous tract. The tooth is destroyed or intact. Percussion is weakly positive.

On the radiograph, we see a focus of enlightenment due to bone destruction in the region of the root apex. The focus has fuzzy contours, it can be of different sizes.

Chronic granulomatous periodontitis

This type of periodontitis is asymptomatic, clinically manifested only during exacerbations. These manifestations can be of the type of granulating periodontitis in the form of fistulas and mucosal hyperemia.

The difference between granulomatous periodontitis and granulating periodontitis is the presence on the radiograph of the focus of enlightenment on the tops of the roots of a clear rounded shape (apical granuloma).

Currently, doctors are moving away from the gradation of the size of the focus (0.5 cm - granuloma, 0.6-0.8 cm - cystogranuloma, more than 0.8 cm - radicular cyst.

Cyst - what is it and why

A cyst is a cavity that has an epithelial lining and cystic contents. There are two types of cysts - true and pocket.

The true one is completely covered by the epithelial lining, and the pocket one communicates with the root canal, as if it grows from it.

Cyst formation occurs in 3 stages.

At the first stage, it is most likely that the epithelial cells of the islets of Malasse proliferate under the influence of growth factors.

During the second stage, an epithelial cavity is formed.

These epithelial cells are sent from their source of nutrition, die, neutrophils pull their remnants into the area of ​​necrosis. Microcavities are formed, which then merge into one and become limited by the stratified squamous epithelium.

There is another theory - the theory of the closure of all open connective tissue areas by the epithelium, as a result of necrosis.

In the third stage of cyst formation after the death of neutrophils, there are reserves of prostaglandins, as well as cytokines produced by macrophages and T lymphocytes. Together they activate osteoclasts and trigger bone resorption.

Pocket cysts have a different mechanism of development. Near the apical foramen there is a large accumulation of neutrophils in response to root canal infection. The cells, as before, die, and this microabscess is closed by the proliferating epithelium. The so-called epithelial ring is formed. Neutrophils that remained outside the channel, dying, form a microcavity. The presence of infection outside the channel further attracts neutrophils, expanding the microcavity to a large size. A pocket cyst is called such because of the similarity of the expansion of the root canal to the enlargement of the periodontal pocket.

Traumatic periodontitis

Periodontal trauma is one of the initiating factors for the occurrence of hemorrhage and the development of ischemia, which directly leads to the formation of pulp necrosis. The focus of necrosis attracts bacteria, colonizes them and infects the periodontium. With an increase in the number of microorganisms, acute inflammation begins. Traumatic periodontitis develops.

In chronic long-term trauma, periodontal restructuring occurs gradually, first due to its adaptation, then as chronic inflammation with lacunar resorption of the compact plate.

The main cause of the development of pathology is the inflammatory response. As a result of occlusal trauma, inflammatory mediators are produced in the pulp, they are considered a protective reaction to mechanical aggression. They disrupt microcirculation and increase vascular permeability. The pulp dies.

When pulpal necrosis reaches the apical periodontium, due to its cytotoxic action by interleukins, it activates osteoclasts and bone resorption.

Medical periodontitis

Drug-induced periodontitis develops when aggressive liquids or medicines enter the periodontium, such as arsenic paste, formalin, tri-cresol formalin, phenol. Penetration into the periodontium occurs through the root canal.

This also includes periodontitis, which develops in response to the removal of phosphate cement, resorcinol-formalin paste, pins and other filling materials into the periodontium during the treatment of pulpitis. Drug-induced periodontitis also includes periodontitis due to allergies as a result of the use of drugs that can cause a local immune response (antibiotics, eugenol, etc.).

Foreign bodies

Gutta-percha, paper pins, calcium residues, and a wide variety of other things can be found in the periapical tissues.

The apical periodontium always reacts to foreign bodies. They can enter through the root canal, traumatized mucosa, or periodontal pocket.

In case of penetration of a paper pin, it should be remembered that the human body cannot process cellulose, therefore a bacterial plaque surrounds the foreign body, which supports inflammation.

Gutta-percha is a biocompatible material. However, at the same time, it can give a reaction from the apical periodontium. Studies in guinea pigs have shown that large gutta-percha particles are encapsulated, surrounded by collagen fibers, and small particles support a local tissue reaction. And magnesium and silicon, which are contained in an excess of gutta-percha, can cause resorption.

Diagnosis of chronic apical periodontitis

Diagnosis of chronic apical periodontitis is similar to that of acute apical periodontitis. So we use basic, additional diagnostic methods.

The main ones include clarification of the patient's complaints, anamnesis, probing, percussion, palpation and determination of tooth mobility.

The patient's complaints are most often absent, but they may complain of discomfort while eating when biting.

Probing is painless, palpation of the mucosa in the apex is also painless. Percussion is weakly positive.

Additional special methods include determining the electrical excitability of the pulp (reduced to 200 µA), determining occlusion (presence or absence of a traumatic factor), fistulous tract, and temperature tests.

NB! We need to do x-rays.

Treatment of chronic apical periodontitis, traumatic and drug-induced periodontitis

After the diagnosis, they begin to draw up a treatment plan for chronic apical periodontitis, based on the data of the clinical and radiological pictures.

Treatment of traumatic periodontitis begins with the identification and elimination of the traumatic factor.

Treatment of drug-induced periodontitis consists in antiseptic treatment of the root canal system, refilling when a foreign body is detected in the apical periodontium. When exposed to aggressive liquids outside the apex, a cotton ball is placed on the mouth or a cotton turunda is placed in the canal moistened with an antidote (for example, for arsenic anhydride, the antidote is 5% unitiol solution or 2-3% tincture of iodine). With arsenic periodontitis, pain is observed when biting on a tooth, pathological changes are rarely seen from the mucosa.

When sodium hypochlorite is removed from the top, there is a sharp arching pain, bruising, and swelling on the side of the lesion. Root canals are abundantly washed with saline, the area of ​​the root apex is cut off with saline in an amount exceeding the volume of hypochlorite by 10 times. The filling is started on the next visit in the absence of progression of the pathological process.

Prescribe antibiotics, anti-inflammatory and antihistamines.

Common among the treatment of all types of apical periodontitis is endodontic treatment of the causative tooth.

The article was written by O. Vishniak. Please, when copying the material, do not forget to include a link to the current page.

Chronic Apical Periodontitis-Clinic Diagnosis Treatment updated: April 30, 2018 by: Valeria Zelinskaya

Apical periodontitis is an inflammation of the connective tissue (periodontium) surrounding the root of the tooth in the apex area. It is manifested by sharp pain in the area of ​​the affected tooth, aggravated by the slightest touch to it, swelling of the gums, swelling of the cheek, pathological tooth mobility, and fever. It can cause the appearance of a jaw cyst, perimaxillary abscess, phlegmon, osteomyelitis, fistulas, therefore, it often requires removal. In the treatment of periodontitis, absorbable pastes and preparations that potentiate bone tissue regeneration are widely used. In acute inflammation, drainage of the periodontal gap is important.

The reasons

Classification

Symptoms and Diagnosis

1. Symptoms of acute form of periodontitis -

• aching or sharp pain in the tooth,
• biting on a tooth causes increased pain,
• if left untreated, aching pain gradually turns into throbbing, tearing, with very rare painless intervals,
• weakness, fever, sleep disturbance,
• it may feel like the tooth has moved out of the jaw.

1. Symptoms of the chronic form of periodontitis -

• fibrous form,
• granulating form,
• granulomatous form.

Diagnosis of chronic periodontitis by x-ray

• granuloma(sizes up to 5 mm),
• cystogranuloma (sizes from 5 to 10 mm),
• radicular cyst(dimensions over 1 cm).

1. Symptoms of exacerbation of chronic periodontitis - the chronic form of periodontitis is characterized by an undulating course with periods of periodic exacerbation, during which the symptoms become characteristic of an acute form of periodontitis, i.e. severe pain, possibly swelling and swelling of the gums. Usually, an exacerbation of a chronic inflammatory process is associated with hypothermia or other causes of a decrease in immunity.

Treatment

Methods of treatment of periodontitis in adults

The main stages of the treatment of periodontitis

Surgical techniques for the treatment of periodontitis

• a small area of ​​the mucous membrane exfoliates in the area of ​​the affected tooth;
• damaged tissues are removed;
• the top of the root is cut off and sealed; the operation site is sutured.

Many will agree that toothache is one of the most annoying and frightening. But even more people are afraid of dentists, so they are ready to endure discomfort for months, delaying a visit to the doctor. But in vain. After all, ordinary caries, diagnosed in most patients, if left untreated, can lead to pulpitis, which, in turn, to apical periodontitis. Why is this pathology dangerous?

What is apical periodontitis

Apical periodontitis is a disease in which there is an inflammatory process in the tissues surrounding the top of the tooth root, and destruction of the periodontium.

Apical periodontitis is also called periapical, apical, which is not surprising, because the apex of the root in the medical literature is the apex.

As a rule, apical periodontitis is a consequence of pulpitis and is diagnosed equally in both women and men aged 20 to 60 years.

Classification and reasons

Depending on what caused the pathology, the following types of apical periodontitis are distinguished:

• traumatic - in this case, an acute (deformation of the crown, bruise, fracture of the tooth, errors during endodontic therapy - root canal cleaning) or chronic (inflated or deformed filling, violation of jaw closure) act as a provoking factor;
• infectious - is a consequence of pulpitis, and also develops as a result of the spread of infection (staphylococci, streptococci, etc.) from nearby areas, for example, the maxillary sinuses. In this case, the death of the nerve and pulp occurs;
• medication - in the process of endodontic treatment, a highly toxic antiseptic is able to penetrate into periodontal tissues, thereby causing an acute inflammatory reaction.

In addition, according to the nature of the course, apical periodontitis is divided into:

• acute, which may be serous or purulent;
• chronic - fibrous, granulating, granulomatous. In the absence of competent treatment, granulomatous apical periodontitis can provoke the formation of a cystogranuloma or root cyst.

Chronic apical periodontitis is characterized by periods of remission (temporary calm) and exacerbation.

Symptoms

Acute apical periodontitis is accompanied by throbbing pain, which gives the patient a lot of problems. In addition, the patient has symptoms such as:

• swelling in the area of ​​the diseased tooth;
• an increase in body temperature to 37.1 - 38 ° C;
• enlargement of the submandibular lymph nodes;
• tooth mobility;
• headache;
• reaction to cold and hot;
• reddening of the gums.

In the chronic form, the clinical picture is less distinct. During the period of remission, an asymptomatic course can be observed at all. Sometimes the patient experiences slight discomfort at the time of eating, and also notices bad breath. Signs during an exacerbation are not much different from those in acute periodontitis.

The course of chronic and acute forms of apical periodontitis - table

Diagnostics

If characteristic symptoms appear, you should contact your dentist as soon as possible. The specialist will without fail examine the patient, carry out a survey on the subject of complaints and send him for an X-ray examination. X-ray is the gold standard in the diagnosis of apical periodontitis. Depending on the changes in the picture, the doctor can judge the development of one form or another of the pathology.

Differential diagnosis of apical periodontitis is carried out with purulent diffuse pulpitis, as well as maxillary sinusitis and osteomyelitis, in which a similar clinical picture is observed. To clarify the diagnosis, an electroodontometry (EOD) is performed, which is designed to determine the degree of pulp damage.

Treatment Methods

Regardless of the form of apical periodontitis, therapy involves several stages:

1. Mechanical preparation, which consists in opening the tooth, in which the inflammatory process occurs, and cleaning the cavity from the affected pulp and tissues affected by caries. The task of the dentist is to stop the development of pathology and eliminate pain.
   

   All manipulations are carried out under local anesthesia.

2. Antiseptic treatment, which includes an increase in root canals and their further disinfection through ultrasound therapy or electrophoresis. In addition, pastes with antibacterial and anti-inflammatory effects are used to destroy pathogenic bacteria, drugs are used in the area of ​​​​the tooth root. The patient may also be shown rinsing the mouth with various decoctions of herbs (including chamomile), as well as taking antibiotics.
3. Canal filling with obligatory X-ray control. In some cases, for example, with severe tooth decay, a crown is placed.

Video about the disease

Surgical intervention

With the ineffectiveness of endodontic treatment and the development of complications, surgical intervention is indicated, in particular:

Tooth extraction is considered an extreme measure and is carried out only when the destruction is so global that the tooth loses its functional significance and cannot be used for a crown.

Treatment prognosis and possible complications

As a rule, the prognosis is favorable. In 85% of cases, it is possible to completely heal the affected tooth. Early diagnosis and well-conducted therapy can minimize complications. However, in some cases, the following effects may be observed:

• cyst formation;
• inflammation of the bone and jaw tissue;
• sepsis, which provokes the appearance of diseases of the liver and other organs;
• odontogenic sinusitis;
• fistulas.

Prevention

In order to avoid the development of apical periodontitis, it is necessary to adhere to the following recommendations:

• observe oral hygiene (brush your teeth regularly, use dental floss, rinses);
• avoid mechanical impact on the teeth;
• undergo preventive examinations at the dentist;
• eat right (reduce the amount of sweets in the diet, consume as little coffee, carbonated drinks as possible, etc.);
• treat inflammatory diseases in a timely manner.

Apical periodontitis is a disease that, with timely diagnosis, responds well to treatment. Do not ignore the symptoms of pathology, since the lack of therapy can lead to the development of dangerous complications. And remember, the disease can be prevented by observing the elementary rules of prevention.

Periodontitis- this is an inflammation of the periodontium, characterized by a violation of the integrity of the ligaments that hold the tooth in the alveolus, the cortical plate of the bone surrounding the tooth, and bone resorption from small sizes to the formation of large cysts.

What causes chronic apical periodontitis:

Infectious periodontitis is mainly a complication of caries. Both primary (when the process is a consequence of untreated caries, and then pulpitis or periodontal disease), and secondary (when the process has an iatrogenic cause).

According to the method of penetration of bacteria, periodontitis is divided into intradental and extradental (intradental and extradental). The latter include periodontitis, which develop as a result of the transition of the inflammatory process from the surrounding tissues (osteomyelitis, sinusitis).

Traumatic periodontitis occurs as a result of both a significant, single impact (a blow when falling or hitting hard heavy objects in the face), and as a result of a minor, but chronic injury (an overestimated filling, biting off a wire or thread in the absence of adjacent teeth). In trauma, the process usually proceeds acutely.

Medical periodontitis develops most often with improper treatment of pulpitis, when potent drugs enter the periodontium (for example, a paste containing arsenic, formalin, phenol) or irritating materials (phosphate cement, pins). Also, periodontitis, which occurs as a result of allergic reactions, which can cause a local immunological reaction, is also referred to as medication.

The main reason for the development of periodontitis in children is infection, when microorganisms, their toxins, biogenic amines, coming from the inflamed necrotic pulp, spread into the periodontium.

Pathogenesis (what happens?) during Chronic Apical Periodontitis:

Currently, it is believed that the inflammatory process in the periodontium occurs as a result of the entry of infectious-toxic contents of the root canals through the apical foramen. Moreover, the virulence of the microflora is given less importance than the effect on the periapical tissues of endotoxin, which is formed when the shell of gram-negative bacteria is damaged, which leads to the formation of biologically active products that increase vascular permeability.

Symptoms of Chronic Apical Periodontitis:

With this form of complaints, there may be no or slight pain when biting. The tooth may be filled or intact, but there is often a carious lesion communicating with the tooth cavity. Root canal entry, percussion and palpation are painless. Periodically, hyperemia of the mucous membrane may develop along the transitional fold and a white dot (abscess) may appear - a fistula. The root canal is usually partially obturated. The tooth is discolored. On the radiograph, pronounced destructive changes in the bone tissue with clear or slightly blurred boundaries are found.

Chronic fibrous periodontitis.
Diagnosis of this form is difficult, since patients do not complain and also because a similar clinical picture can be given, for example, by chronic gangrenous pulpitis.

Objectively, in chronic fibrous periodontitis, there are changes in the color of the tooth, the crown of the tooth may be intact, a deep carious cavity, probing is painless. Percussion of the tooth is often painless, there are no reactions to cold and heat. In the cavity of the tooth, a necrotically altered pulp with a gangrenous odor is often found.

In the clinic, the diagnosis of chronic fibrous periodontitis is made on the basis of an x-ray, which shows the deformation of the periodontal gap in the form of its expansion at the root apex, which is usually not accompanied by resorption of the bone wall of the alveolus, as well as the cement of the tooth root.

Fibrous periodontitis can occur as an outcome of acute inflammation of the periodontium and as a result of the treatment of other forms of chronic periodontitis, pulpitis, or occurs as a result of overload with the loss of a large number of teeth or traumatic articulation.

Chronic granulating periodontitis. It often manifests itself in the form of unpleasant, sometimes weak pain sensations (a feeling of heaviness, fullness, awkwardness); there may be slight pain when biting on a diseased tooth, these sensations occur periodically and are often accompanied by the appearance of a fistula with purulent discharge and the ejection of granulation tissue, which disappears after a while.

Hyperemia of the gums in the diseased tooth is determined; when pressing on this part of the gum with the blunt end of the instrument, a depression occurs, which does not disappear immediately after the removal of the instrument (symptom of vasoparesis). On palpation of the gums, the patient experiences discomfort or pain. Percussion of an untreated tooth causes increased sensitivity, and sometimes a pain reaction.

Often there is an increase and soreness of regional lymph nodes.
X-ray in chronic granulating periodontitis, a focus of bone rarefaction in the region of the root apex with fuzzy contours or an uneven line, destruction of cement and dentin in the region of the apex of the tooth is detected. Chronic granulomatous periodontitis often penetrates asymptomatically, less often patients complain of discomfort and slight pain when biting.

Anamnestically, there are indications of past periodontal trauma or pain associated with the development of pulpitis. When the granuloma is localized in the region of the buccal roots of the upper molars and premolars, patients often indicate a bulging of the bone, respectively, the projection of the tops of the roots.

Objectively: the causative tooth may not have a carious cavity, the crown is often changed in color, there is a carious cavity with decay of the pulp in the canals, and finally, the tooth can be treated, but with poorly filled canals. Percussion of the tooth is often painless, with palpation on the gum from the vestibular surface, painful swelling can be noted, according to the projection of the granuloma.

An x-ray examination reveals a picture of a clearly defined rarefaction of the bone tissue of a rounded shape. Sometimes you can see the destruction of the tissues of the tooth in the apex and hypercementosis in the lateral parts of the root.

A favorable outcome of granulomatous periodontitis with timely and correct treatment is the transition to a fibrous form. In the absence of treatment or incomplete filling of the root canal, the granuloma turns into a cystogranuloma or root cyst of the tooth.

Exacerbated chronic periodontitis. More often gives an exacerbation of granulating and granulomatous periodontitis, less often - fibrous. Since the exacerbation occurs in the presence of destructive changes in the periodontium, the pain when biting on the tooth is not as sharp as in acute purulent periodontitis. As for the remaining symptoms (constant pain, collateral swelling of soft tissues, reaction of the lymph nodes), they can increase in the same sequence as in acute purulent periodontitis.

Objectively, the presence of a deep carious cavity is noted (the tooth can be untreated or sealed), the absence of pain during probing, sharp pain during percussion, both vertical and horizontal, to a lesser extent. The tooth can be changed in color, mobile. On examination, Vtec is determined, hyperemia of the mucous membrane and often the skin, over the area of ​​​​the causative tooth, the smoothness of the transitional fold, palpation of this area is painful. There is no reaction of tooth tissues to temperature stimuli.

Exacerbation of chronic fibrous periodontitis X-ray is accompanied by a decrease in the clarity of the boundaries of rarefaction of bone tissue, the appearance of new foci of rarefaction and osteoporosis, respectively, the inflammatory focus.

The X-ray picture of granulomatous periodontitis in the acute stage is characterized by a loss of clarity of the boundaries of bone tissue rarefaction in the apical part of the tooth, the fuzziness of the periodontal line in the lateral parts of the periodontium, and the enlightenment of the bone marrow spaces along the periphery from the granuloma.

The exacerbated chronic granulating periodontitis is radiologically characterized by a more pronounced pitting of the contours of the rarefaction focus against the background of a general blurring of the pattern.

The electrometric reaction from the periodontium in all forms of periodontitis is over 100 μA or is completely absent. Therapeutic measures for periodontitis go beyond the treatment of only the causative tooth and consist in the active release of the body from the infectious focus, thereby preventing the sensitization of the body, preventing the development of inflammatory processes in the maxillofacial region and diseases of internal organs.

Treatment of Chronic Apical Periodontitis:

Treatment of chronic periodontitis comes down to treating the cause due to which the disease arose - caries, pulpitis, etc. Canal cleaning, cavity filling, caries elimination - this is the main method of treatment.