Acute and chronic apical periodontitis. Symptoms of chronic granulating periodontitis, x-ray and other diagnostic methods, treatment features What does a granuloma look like on an x-ray

Violation of the environment, poor quality of drinking water, certain diseases, unhealthy lifestyle and genetic predisposition lead to dental problems, one of which is periodontitis. Periodontitis of the tooth - what it is, what are the causes, symptoms of the disease and how the disease looks in the photo, it is important to know for timely detection and subsequent treatment.

What is periodontitis

The disease takes different forms, not always the patient can independently diagnose its appearance. It occurs on milk, single-rooted, multi-rooted and wisdom teeth. The disease spares neither the child nor the adult. The disease is an inflammation of the apical part of the tooth root and tissues that are adjacent to it. The course of the process is associated with such violations:

• destruction of the cortical plate, which covers the teeth and bones, performing a protective function;
• the integrity of the ligaments that hold the tooth in the jaw recess is damaged;
• bone resorption followed by cyst formation.

The reasons

Having learned what periodontitis of the tooth is, you need to understand what reasons influenced its appearance. The disease can cause:

• infection in the root system of the tooth;
• injury;
• Apical periodontitis arises from the negative effects of medications.

The infected form in children and adults develops against the background of advanced caries or unskilled actions of the attending physician. In case of illness, microbes can be transferred deep into the tooth, reaching the roots, pulp. The infection begins to develop there, which leads to damage to the periodontium and the onset of the disease. When a filling is placed, it is important to follow the technology, because if you fill an untreated tooth or advanced pulpitis (pulpoperiodontitis), then the existing foci of inflammation can grow, causing periodontitis.

Trauma is associated with single injuries, such as sports injuries. It also occurs due to incorrect installation of a crown or an overestimated filling. In this case, constant pressure will be exerted on the tooth. The drug form is associated with allergic reactions to materials used for filling. Negative effects are caused by the effect of painkillers.

Symptoms

Timely diagnosis helps to reduce the time of treatment, even save the tooth. To identify the disease, you need to know the symptoms of periodontitis, which are directly related to the form of the disease. The acute form is characterized by:

• aching or sharp pain, which increases with pressure, in a neglected form, it develops into a pulsating focus;
• sensation of protrusion of the tooth from the jaw;
• sleep disturbance, temperature, swollen lymph nodes;
• visually, a carious lesion can be detected on the affected area, the gum will have swelling and redness;
• in some cases, only small expansions in the root fissures can be seen on the x-ray. This is due to the fact that the acute form, due to pronounced symptoms, is detected at an early stage.

Chronic illness has the following symptoms:

• proceeds with minimal manifestations, the pain manifests itself when biting or tapping, but it is moderate and tolerable, in contrast to the acute form;
• visually, carious lesions of a filling or crown can be detected. A fistulous opening of small diameter may periodically form on the gum, from which pus flows;
• it is easy to identify chronic periodontitis in the picture. An x-ray will be able to detect violations of the integrity of the roots.

Periodontitis - photo

Classification of periodontitis

According to the location, apical and marginal periodontitis are distinguished. The focus of the first is located at the base of the root and is often associated with an infectious course. Marginal is formed in the gum area, it is caused by trauma or untreated pulpitis. Depending on the manifestation, acute and chronic forms are classified. The acute course is expressed in the following stages:

• serous - undulating strength of pain, sharp exacerbations, the tooth is motionless;
• purulent - increasing pain, the release of pus, loosening of the tooth.

The stages of the chronic form are manifested as follows:

• fibrous - there is a proliferation of fibrous tissue;
• granulating - bone tissue is destroyed near the top of the root;
• granulomatous - bags are formed on the gums that are filled with pus.

How to treat periodontitis of the tooth

Treatment at home is possible only in the initial stages. It is necessary to take a photo using an x-ray to determine the degree and form of periodontitis. Treatment can include both rinsing with special means, and surgical intervention, tooth extraction. The success of therapy depends on the following factors:

• at what stage the disease was detected;
• degree of neglect;
• channel patency.

Chronic

To treat the fibrous form, you need to open access to the focus of the disease, remove the crown or remove the filling. Then rinse the cavity with special preparations 2 times a week, the course consists of 3-5 procedures. With a granulating or granulomatous disease, a medical temporary filling is placed for 3-6 months. During this period, they regularly visit the dentist for examinations and x-rays.

If periodontitis is in an advanced stage or the granules exceed 1.5 mm, then resection of the root of the upper or lower tooth is applied. At the same time, it is removed along with the granule that has formed on it. After healing, a decision is made on prosthetics.

Periodontitis is not a rare problem, so it is worth talking about it in more detail. In particular, about the symptoms and reasons why this disease appears. What is periodontitis?

The name comes from the word periodontium - a complex of special tissues that surround the tooth and allow it to attach to the bone and hold firmly in the hole without falling out or moving. This tissue is located along the perimeter of the root and starts from the gum itself.

Periodontitis has several forms, but each of them means that an inflammatory process has begun in the periodontal connective tissue. The disease can occur for various reasons, completely regardless of age.

That is why it is worth knowing the main symptoms of various forms of such inflammation in order to contact a specialist in time and take the necessary measures.

Differences from pulpitis

Pulpitis should not be confused with the disease in question. They have a significant difference in localization, despite often similar symptoms.

The fact is that pulpitis is also an inflammatory disease, but all processes occur exclusively in the pulp of the tooth. The pulp is the soft tissue that is located inside the teeth.

With any form of pulpitis, there are absolutely no changes in the surrounding tissues, and the tooth is firmly held in the gum. Periodontitis can occur as a complication of pulpitis when the infection travels down to the top of the root and out through the root canals.

Diagnostics

Usually, an experienced doctor, after describing the manifestations, can suggest the appearance of this disease. Here is what a classic clinical diagnosis includes:

• questioning by the doctor of the patient;
• visual examination of the oral cavity;
• probing the entrance to the tooth;
• passing temperature tests;
• palpation (feeling);
• if there is mobility, then determine its degree.

Diagnosis in children causes quite a lot of difficulty, as they often cannot accurately describe their feelings for various reasons. In this case, it is advisable to take an x-ray.

X-ray with periodontitis is done not only for children, as it clearly shows the localization of the process and the condition of the tissues.

Why does it appear?

With the development of all types of periodontitis, there may be individual factors that lead to its occurrence and development. It is on them that the differentiation of different forms of the disease takes place. However, a short general list of causes can be drawn up, covering all the characteristic types of disease.

This list includes both groups of causes - infectious and non-infectious.

Various types and classification

Classify periodontitis in two main areas.

Disease causing factor

• infectious. They can be divided according to the way in which the infection penetrates the tissues - extra- and intradental, that is, from the inside or outside.
• traumatic. They can be acute and chronic, which are characterized by different symptoms and the nature of injuries.
• Medical. Including consider the disease that arose as a result of allergic reactions to administered drugs.

By the nature of the secretions and the flow

• Spicy. There are purulent and serous varieties.
• Chronic. Subspecies: granulomatous, granulating or.
• Separately goes exacerbation of the chronic form.

acute form

The acute form is characterized by the fact that its development occurs in a limited area, where there is a strong protective reaction of the surrounding tissues.

The course is accompanied by various types of secretions, initially serous, and then purulent. In this case, the emerging microabscesses merge into one purulent inflammatory focus.

There are many symptoms by which this form can be determined and they are quite specific.

• Moderate pain that occur in the area of ​​the affected tooth. This pain can occur quite spontaneously, without any particular reason. More often - as a reaction to hot or warm drinks and food.
• The duration of the "painful" periods is different. This usually goes on for several hours. At this time, the amplification of sensations and their disappearance is gradual. There are even painless periods of complete disappearance.
• When biting food or anything on the affected tooth, the pain usually intensifies and becomes acute..
• At night or while the person is lying down (that is, the body is in a horizontal position), often there is a feeling that the tooth has grown and become larger. This can be explained by the fact that in this position there is a redistribution of the total mass of blood. It rushes to the inflammatory focus, thereby increasing swelling.
• When the process of inflammation becomes purulent, all sensations become stronger.. The pain becomes constant, quite strong and has a aching character. The process of chewing is almost impossible, as it leads to a significant increase in pain.
• Quite a common occurrence inability to close the mouth, since when the jaws are closed, there is pressure on the affected tooth.
• Fever (37-37.5°C), which lasts for a long time.
• Enlarged and sore lymph nodes(perhaps one, from the side of the inflammatory focus).
• Swelling of the gingival mucosa and tooth mobility first or even second degree.
• All this causes indirect symptoms - constant fatigue, poor sleep, stress, weakness and deterioration in general condition.

Chronic form

Quite often, this form of the disease goes away with little to no severe symptoms.

• Quite often, the only manifestation of chronic periodontitis will be mild pain when pressed, biting on the causative tooth, as well as when tapping it.
• In some cases, on the gum, at the site of the projection of the focus of inflammation, there is fistulous opening. Small amounts of purulent discharge will appear from it. Often, patients do not notice it for a long time, since it is located quite far from the neck of the tooth.
• Enamel may change color. It ceases to be shiny, fades and becomes grayish.
• Rarely, especially in the presence of colds, may appear feeling of unpleasant heaviness in the area of ​​​​the diseased tooth.

The chronic form is in many ways worse than the acute form, as it does not prompt a person to contact a specialist until severe pain appears. This is the most common cause of tooth loss. With a long course, even the formation of a root cyst is possible.

Manifestation of exacerbation of the chronic form of periodontitis

Here the symptoms will be almost the same as in the acute form. The only difference is that the patient talks about the presence of long-standing minor pain with pressure on the affected area, including when pressing on the gum.

However, with the appearance of a fistulous tract, inflammation can greatly decrease. Then the pain and other manifestations almost disappear.

toxic form

There are several major drugs that cause toxic or drug-induced periodontitis when they enter the tissues surrounding the tooth. This is arsenic, tricresol or formalin.

Now such cases are quite rare, since more modern drugs are used in the treatment of complex dental diseases.

The toxic form of periodontitis in almost all cases proceeds in the same way as the acute one. Symptoms are identical, which causes great difficulties in diagnosis:

• very strong sensitivity of the tooth and pain when pressed, the nature of the pain is almost always aching, prolonged;
• feeling that the tooth has grown and at the same time strongly protrudes from the general row;
• often there is mobility (usually the first, less often the second degree).

One of the specific manifestations is a general increase in sensitivity from the side where the inflammation is located.

One of the common symptoms is bad smell resulting from inflammation. This manifestation is characteristic of almost all types and forms of the disease.

Traumatic form

This variety also has two forms of flow - chronic and acute. Chronic manifests itself in almost the same way as the general infectious variety. it minor pain when pressed or biting.

The acute form, which may appear as a result of a sports or any other injury, is more diverse in terms of symptoms. Almost always it is either a root fracture or dislocation.

• Sudden and unexplained pain.
• Mobility of the crown.
• Unpleasant sensations arising from the closing of the jaws.
• Staining of the visible (crown) part in a light pink color. This usually occurs when the pulp ruptures in the cervical region and hemorrhages. Later, a change from light pink to yellowish is possible.

Among the complications of periodontitis, there are many that lead to tooth extraction. Therefore, if even minor symptoms appear, you should contact the dental clinic.

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Inflammation of the root of the tooth and its surrounding tissues is called periodontitis, and this is one of the most common dental diseases after caries (photo). Radiography of painful areas is one of the most effective and informative diagnostic methods. We will find out what chronic periodontitis looks like on an x-ray, and what description this pathology has.

More about the disease

By origin, periodontitis is divided into infectious, traumatic and medical. In the first case, the disease manifests itself after improper treatment, in the second - as a result of injuries, in the third - as an allergy to medications.

According to the nature of the course of the disease, it is divided into the following types:

1. Spicy. Occurs without any prerequisites, proceeds painfully with the appearance of fistulas.
2. Chronic. It becomes a consequence of an uncured acute form, proceeds slowly, with relapses and exacerbations. Chronic periodontitis is divided into fibrous, granulomatous and granulating. It is manifested by an increase in the mobility of the teeth, the appearance of large gaps between them, inflammation of the gums. Chronic periodontitis is determined on x-ray.

According to the damage caused by the disease, the following is distinguished:

1. Easy degree. The tissue located around the diseased element is affected by no more than 4 mm. Also, a mild degree is manifested in bleeding and discomfort when pressed.
2. Average degree. Inflammation that has grown to more than 6 mm, in which the roots are exposed, and mobility is observed, are identified with an average degree of damage.
3. Heavy. The disease has penetrated 9 mm or more, purulent-serous discharge is added to the rest of the symptoms.

Granulomatous periodontitis on x-ray is manifested by the presence of pathological formations separated from healthy tissues surrounding it. It may be preceded by pulpitis or advanced caries. Connective tissue forms on the inflamed area, which eventually grows to volumes that can appear on the picture.

The description of periodontitis on x-rays affects the zone of partial rarefaction of the bone structure. With radiodiagnosis, granulomas traced in the teeth look like oval spots with clearly defined contours. Often, they are located under the root or apex of the tooth, and can range in size from 2 mm to 5 mm.

Exacerbation of granulomatous periodontitis in the picture is manifested by the following symptoms:

• deformation of the tissues and structure of the tooth;
• the presence of focal formations;
• an increase in the gap of the tooth apex.

In addition, it can be revealed:

• caries;
• mucosal edema;
• gum damage.

Diagnosis of granulating periodontitis

Periodontitis of the tooth on the X-ray is most often traced in the region of the molars on the bottom row. Granulating periodontitis on x-ray is significantly different from granulomatous. In the picture, it looks like a layering of foci of destruction with fuzzy and torn edges, resembling "tongues of flame." Fibrous periodontitis is characterized by the formation of fistulas, which can even go beyond the oral cavity (photo).

Diagnosis of this type of chronic stage of the disease requires the use of contact radiographs located inside the oral cavity. Most often, these are lateral radiographs and orthopantomograms.

A visit to the dentist is quite an unpleasant procedure for many people, so in most cases they postpone a visit to the doctor, ignoring a toothache or trying to drown out the pain with various analgesics. This position is very dangerous, because the familiar caries, which in the early stages is easily treated for several hours in the chair at the dentist, in an advanced stage can gradually develop into granulating periodontitis.

Causes of chronic granulating periodontitis

Chronic granulating periodontitis is an inflammation in the connective tissues of the tooth (periodontium), which is characterized by the formation of granulation tissue at the apex of the tooth root and the destruction of bone tissue with deformation of the periosteum. The main cause of the inflammatory process is an infection that penetrates into the periodontal tissues from the root canal of the tooth (streptococci, staphylococci, yeast-like fungi, aerobic and anaerobic polyinfection).

If treatment is not started in time, inflammation and proliferation of granulation tissue will gradually spread to soft tissues, purulent fistulas on the gums, abscesses will appear. The ingress of waste products of pathogenic microorganisms into the blood can cause various diseases of internal organs (arthritis, glomerulonephritis, rheumatic carditis, etc.) and blood poisoning.

Granulating periodontitis is a fairly common disease and ranks third after caries and pulpitis in dental practice in terms of incidence. Most often, this form of periodontitis occurs as a result of neglected forms of the first two diseases or their poor-quality treatment.

There are several main reasons for the development of granulating periodontitis:

Symptoms of the disease

Granulating periodontitis is characterized by dynamic development, periods of exacerbation and short-term remissions, minor painful sensations in the diseased tooth, which are aggravated by tapping or biting.

The main symptoms of the disease:

• periodic toothache, which can occur when a mechanical effect on a diseased tooth (during biting, chewing, cold or hot food);
• inflammation of soft tissues, swelling, hyperemia of the gums;
• slight looseness of the tooth;
• enlargement of the lymph nodes from the side of the infection;
• discharge of pus from under the dental crown;
• bad breath;
• general deterioration in health - weakness, nausea, loss of appetite, fever, drowsiness.

If timely treatment is not carried out, painful fistulas appear at the site of the infiltrate, from which pus or sulfur is released. Granulation tissue grows around the fistula.

Purulent formations can occur not only in the oral cavity, but on the face or neck. With the outflow of pus, the pain gradually subsides, the disease passes into the chronic stage.

Granulating periodontitis has several stages of development:

1. At the first stage, the gum swells slightly, sometimes it can bleed. Plaque appears, which eventually turns into tartar. Toxins and enzymes cause inflammation of the gums and lead to gingivitis.
2. A periodontal pocket appears on the gum, the necks of the teeth are exposed (more in the article: what to do if the necks of the teeth are exposed?).
3. The final stage is characterized by the acute development of the inflammatory process and the destruction of connective and bone tissues.

Diagnostic methods

To diagnose chronic granulating periodontitis, the following diagnostic methods are used:

X-ray allows you to make an accurate diagnosis even in the chronic form of the disease, if there are no pronounced symptoms. From the picture, you can determine the form of the disease (granulating periodontitis is characterized by the presence of layers in the periapical region of the tooth and an uneven contour of the spread of the inflammatory process - in the form of flames). Also, using this method, you can determine the cause of the disease (cracks in the teeth, fractures, medical errors when installing seals, the presence of fragments of foreign objects).

Electroodontometry (EOM) measures the level of sensitivity of the dental pulp when irritated by an electric current. Based on these indicators, it is possible to diagnose initial, medium and deep caries, pulpitis and periodontitis. Normal indicators vary between 6-8 μA.

Increasing the threshold of sensitivity allows you to determine the severity of the disease:

• 25-60 µA - pulpitis, more than 60 µA - the inflammatory process has spread to the root canals;
• 100 µA and more - complete destruction of the pulp;
• 100-160 μA - periodontitis in the chronic stage;
• 180-200 µA - exacerbation of the disease.

Features of treatment

Methods of treatment directly depend on the severity of the disease. The main task of the dentist when choosing a treatment method is to save the tooth. However, this is only possible if the patient is treated in the early stages of the disease. Otherwise, the tooth is removed.

Treatment of granulating periodontitis includes three stages:

If periodontitis has developed into a chronic stage, in some cases, a number of related procedures should be performed to completely remove granulating tissues:

• partial removal of the root of the tooth with an area of ​​​​inflammation;
• amputation of the tooth root (more in the article: how is the amputation of the tooth root performed?);
• hemisection of the tooth - removal of one of the roots of the tooth;
• interradicular granulectomy - removal of a granuloma between the roots of large molars;
• in extreme cases, the tooth is completely removed.

To prevent chronic granulating periodontitis, the following rules must be observed:

• meticulous care of the oral cavity;
• regular visits to the dentist - twice a year;
• timely treatment of pulpitis and caries;
• giving up bad habits - smoking, sugary carbonated drinks and coffee.

7.7.2. Chronic periodontitis

Chronic periodontitis (apical) is a chronic inflammation of the periodontium, which occurs as a transition from an acute process to a chronic one or forms, bypassing the acute stage. Chronic periodontitis is more common than acute; a significant number of diseases diagnosed as acute periodontitis, with an in-depth examination, turns out to be exacerbated chronic periodontitis.

The morphological and clinical picture of chronic periodontitis is diverse. Distinguish granulating, granulomatous, and fibrous periodontitis. It has been established that many cases of chronic granulating and granulomatous periodontitis are associated with insufficient endodontic treatment.

Granulating periodontitis. Pathologicalanatomy. Microscopically, in this form of chronic periodontitis, a significant thickening and hyperemia of the root sheath is found in the apical part of the tooth root. The surface of the altered periodontal area is uneven and represents the growth of sluggish granulations.

Microscopic examination of the tissues of the near-apex region indicates the growth of granulation tissue in the region of the root apex, gradually increasing and spreading to the adjacent sections of the periodontium and the wall of the alveolus. An increase in such a focus is accompanied by resorption of bone tissue around the inflammatory focus and replacement of the bone marrow by granulation tissue. At the same time, resorption of the cement and root dentin areas is observed. On the periphery of the inflammatory focus in some areas, a new formation of bone tissue occurs. Often in the central parts of the periapical focus, especially during exacerbation, there are separate foci of purulent fusion of granulation tissue. As a result of exacerbations of the inflammatory process, the granulating focus in the periodontium gradually spreads to new areas of the alveolus, mainly towards the vestibule of the mouth, which in some cases leads to the formation of a pattern in the compact plate of the alveolar process. X) rot_pus and germination of granulations contribute to the occurrence of a fistulous ^ course. Sometimes the granulating focus spreads into the adjacent soft tissues.

Rice. 7.2. Skin fistulas on the face with granulating periodontitis.

a - in the infraorbital region; b - in the lower part of the cheek.

nor, forming a subperiosteal, submucosal, or subcutaneous granuloma. After opening them, fistulas remain, including on the skin of the face.

clinical picture. Granulating periodontitis is the most active form of chronic periodontitis and gives a very diverse clinical picture.

Complaints with granulating periodontitis are different. More often, patients complain of soreness when taking solid and hot food, sometimes the pain increases with pressure.

With granulating periodontitis, there are often exacerbations of varying intensity. The activity of the inflammatory process is manifested in

periodic pain in the tooth when pressing on it or biting.

The mucous membrane covering the alveolar process in the region of the apex of the tooth root with a granulating focus in the periodontium is usually slightly edematous and hyperemic; when pressed with tweezers or a probe on the gum, an instrument imprint remains.

When adjacent soft tissues are involved in the pathological process, a fistulous tract occurs on the mucous membrane, which is located more often at the level of the apex of the affected tooth in the form of a pinhole or a small area of ​​protruding granulations. Sometimes the fistulous tract closes for a while. However, with the next exacerbation, swelling and hyperemia of the mucous membrane appear at the site of the former fistula, a small accumulation of pus is formed, which then flows into the oral cavity. After the treatment of chronic granulating periodontitis, a small scar is visible at the site of the healed fistula.

With the germination of a chronic granulating focus from the periodontium under the periosteum and into the soft tissues surrounding the jaws - submucosal and subcutaneous tissue, an odontogenic granuloma occurs.

II There are 3 types of odontogenic granuloma: sub-|| periosteal, submucosal and subcutaneous.

The clinical course of the process with granulating periodontitis complicated by odontogenic granuloma is calmer. Often there are no complaints about pain in a tooth or a focus in soft tissues.

At subperiosteal granuloma observe the bulging of the bone of the alveolar process, rounded, corresponding to the affected tooth. The mucous membrane over this area is often not changed, sometimes there may be small inflammatory phenomena that increase with an exacerbation of the inflammatory process.

Submucosal granuloma is defined as a limited dense focus located in the submucosal tissue of the transitional fold or cheek in the immediate vicinity of the tooth that was the source of infection, and associated with it with the help of a cord. The mucous membrane over the focus is not soldered. Often there is an exacerbation of the process and suppuration of the submucosal granuloma. In this case, pain appears in the lesion. The mucous membrane is soldered to the underlying tissues, acquires a bright red color. Abscessing of the submucosal focus and the release of the contents to the outside through the formed fistula sometimes lead to the reverse development of the aggravated process. Most often, the fistulous tract is scarred and the clinical picture of the submucosal granuloma again takes a calm course.

a - granulating, b - granulomatous, c - fibrous

For percutaneous granulomas a rounded infiltrate in the subcutaneous tissue is characteristic, dense, painless or slightly painful. From the dental alveoli to the focus in the soft tissues there is a connecting cord. Subcutaneous granuloma can suppurate, creating a picture of exacerbation. In such cases, the skin becomes soldered to the underlying tissues, acquires an intense pink or red color, and a softening area appears. The abscessing focus opens outward, breaking through the thinned area of ​​the skin. Through the resulting fistulous tract, the contents pour out.

The localization of such fistulas is quite typical for processes emanating from certain teeth (Figure 7.2, a, b). So, skin fistulous passages on the chin occur with chronic granulating periodontitis of the lower incisors and canine, and in the cheek area and at the base of the lower jaw - the lower large molars, in the zygomatic region - the first upper large molar, at the inner corner of the eye - the upper canine. Relatively rarely, fistulas open on the skin of the lower neck.

Discharge from such fistulous passages is insignificant. They are serous-purulent or bloody-purulent. In some patients, granulations swell from the mouth of the fistulous passage. Sometimes the opening of the fistulous passage is covered with a bloody crust. For some time, the fistula may close. Gradually, as a result of cicatricial changes in the tissues in the circumference of the fistulous tract, the mouth of the fistula is retracted and ends up in a funnel-shaped depression of the skin

It is not always easy to establish a connection between a pathological process in the area of ​​a certain tooth and a fistulous tract on the skin. Difficulties occur, for example, in the presence of chronic foci in the periodontium in several adjacent teeth. In some cases, palpation of the outer surface of the alveolar process or jaw can reveal a dense cicatricial band in the region of the transitional fold at the level of one or more

another tooth. This helps to establish the "causal" tooth. X-ray with a contrast material introduced through the fistulous tract can confirm the clinical suspicion.

Diagnostics based on the clinical picture and x-ray data. On the radiograph with granulating periodontitis, typical changes are found - a focus of rarefaction of bone tissue in the region of the root apex. The periodontal line in this section is not visible due to the infiltrating growth of granulation tissue, leading to resorption of the walls of the hole, as well as cement and root dentin. Their surfaces become uneven. This unevenness is revealed more clearly from the side of the bone tissue, into which small outgrowths go from the periodontium. A compact plate of the alveolar wall is found only in the lateral sections (Fig. 7.3, a). In the presence of odontogenic granulomas in soft tissues, the destructive focus at the root apex always has a small size. In patients with marginal granulating periodontitis, similar changes are detected in the marginal periodontium, where bone resorption occurs both horizontally and vertically.

Differential diagnosis. Granulating periodontitis should be differentiated from periradicular cysts, chronic osteomyelitis of the jaws, fistulas of the face and neck, and actinomycosis. With granulating periodontitis with subperiosteal granuloma and periradicular cyst, there is a bulging of the alveolar process. However, with a cyst, a displacement of the teeth is observed, sometimes there is no bone in the area of ​​the bulge, and on the radiograph there is a focus of bone resorption of considerable size with clear, even contours.

The presence of a fistula on the face, oral mucosa, suppuration from it cause the similarity of granulating periodontitis and limited osteomyelitis of the jaw. However, odontogenic osteomyelitis of the jaw is characterized by an acute stage of the disease, accompanied by symptoms.

volumes of intoxication. In the chronic stage, on the radiograph, foci of bone resorption are found, in the center of which are shadow sequesters. Neighboring intact teeth become mobile.

Fistulas on the face and neck with granulating periodontitis may resemble branchial formations. Probing of the fistula, radiography of the tooth, fis-tulography of the branchiogenic fistula contribute to the correct diagnosis.

Fistulas are similar in chronic granulating periodontitis and actinomycosis of the face and neck. However, in chronic periodontitis, the fistula is single; in actinomycosis, the horns are located in the center of diffuse or separate small infiltrates. The study of the discharge and the finding of drusen of actinomycetes in actinomycosis help to differentiate inflammatory diseases. Tuberculous foci, as a rule, are multiple, not associated with the jaw area and teeth. Distinguishing from them of dense curdled masses is characteristic. In place of tuberculous foci, characteristic star-shaped scars remain. Microscopy, cytology and morphological examinations make it possible to establish the correct diagnosis.

Granulomatous periodontitis (granuloma) - the form of a near-apical chronic inflammatory process often develops from granulating periodontitis and proceeds less actively.

Pathological anatomy. Microscopically note the growth of granulation tissue in the circumference of the root apex. On the periphery, the granulation tissue matures, forming a fibrous capsule, and a granuloma occurs.

In the apical part of the root, directly adjacent to the growths of the granulation tissue, there are areas of cement resorption, and sometimes dentin. In areas of the root that are in contact with its capsule, a new formation * of cement is often noted, and sometimes the deposition of excess cement.

Depending on the structure of the granuloma, there are: 1) a simple granuloma, consisting of elements of connective (granulation) tissue; 2) epithelial granuloma, in which there are strands of epithelium between the areas of granulation tissue; 3) racemose granuloma containing cavities lined with epithelium.

clinical picture. The course of granulomatous periodontitis is different. Often, the granuloma does not increase for a long time or grows extremely slowly. In this case, patients often do not complain. Only by chance, an X-ray examination reveals a granulomatous focus.

Granulomas, as well as foci of chronic granulating periodontitis, are often located not at the very top of the tooth root, but several

just on the side. At the same time, on the surface of the alveolar process, respectively, the projection of the root apex, as a result of the ongoing restructuring of the bone tissue and the phenomena of ossifying periostitis, a slight painless swelling without clear boundaries can be detected.

In some patients, the granuloma gradually increases. This is usually associated with exacerbations of the inflammatory process and corresponding changes in the granuloma tissue (hyperemia, edema, an increase in the number of neutrophilic leukocytes, abscess formation). With exacerbation of the chronic process, the integrity of the granuloma capsule is violated, and reactive inflammatory and dystrophic processes occur in the surrounding tissues with a predominance of resorption of the adjacent sections of the walls of the dental alveolus. Clinically, these exacerbations manifest themselves differently. In some cases, some sensitivity appears, and sometimes soreness during percussion and pressure on the tooth, while in others - the phenomena of acute periodontitis. In the future, as the inflammation subsides, a capsule is again formed in the circumference of the enlarged periapical inflammatory focus.

Diagnostics based on the clinical picture, but most often on x-ray data. On the radiograph with granulomatous periodontitis in the near-apical region, a rounded focus of rarefaction of bone tissue with clear, even boundaries is visible. With properly performed conservative treatment, changes characteristic of fibrous periodontitis or the formation of a site of sclerotic bone tissue are detected at the site of the granulomatous focus (see Fig. 7.3.6).

Differential diagnosis. Chronic granulomatous periodontitis should be differentiated from the periradicular cyst, especially when the cortical plate of the alveolar process bulges. On the radiograph with granulomatous periodontitis, a bone resorption area of ​​0.5-0.7 cm in diameter is found, with a cyst, significant bone resorption with clear contours is visible.

Fibrous periodontitis. Under the influence of therapeutic measures, sometimes and spontaneously, scarring of a granulomatous or granulomatous focus in the periodontium and restoration of bone tissue in this area can occur spontaneously. At the same time, a limited inflammatory focus is formed in the circumference of the root apex due to the growth of fibrous tissue - fibrous periodontitis. However, there are data on the basis of which it can be assumed that it sometimes develops independently, i.e. without previous granulating or granulomatous periodontitis. Often the cause of fibrous periodontitis is occlusal overload of the tooth.

veolar-rhushki

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) peri-nene

the rosary-prove-granu-"actor->azova-sh" is visible in the chesky cipher (see Fig.

Pathological anatomy. Microscopically, with fibrous periodontitis, the periodontal area of ​​the extracted tooth is thickened and dense. Thickened areas of the root membrane in the area of ​​localization of the pathological process, as a rule, are pale pink in color. These changes in the root shell capture in some cases only the circumference of its apex, in others the process is diffuse and extends to the entire periodontium. Very often, fibrous periodontitis is accompanied by excessive formation of cement - hypercementosis.

Microscopic examination reveals bundles of coarse-fibered connective tissue that are poor in cells, between which foci of round-cell infiltration are occasionally located. Often among the fibrous tissue, it is possible to identify areas of granulation tissue of various sizes. In areas of the root, previously subjected to resorption, there are deposits of secondary cement. Sometimes masses of such excess cement are deposited over almost the entire surface of the root. In some cases, sclerosis of the bone tissue adjacent to the fibrous-modified periodontium occurs.

clinical picture. With fibrous periodontitis, patients usually do not complain. When chewing or percussion and feel pain in the tooth. When examining the oral cavity, a tooth with a necrotic pulp can be found.

Only with a rare exacerbation of the process does pain appear when chewing. Examination of the tooth and tapping on its crown along the longitudinal axis may be mildly painful.

Diagnostics based on x-ray data. On the radiograph, an extension of the periodontal line is revealed, mainly at the apex of the tooth root. Sometimes, as a result of hypercementosis, a significant thickening of the apical portion of the root is found. The bone plate, limiting the extended periodontal line, is often thickened, sclerosed (Fig. 7.3, c). Differential diagnosis is carried out according to the x-ray picture.