clefts with multinucleated giant cells, red blood cells, and areas of hemosiderin pigment (Figure 3.2c)Uninflamed layers of fibrous tissue at the peripheryPresence of osteoclasts
Sequelae of periapical granuloma:Acute exacerbation can cause rapid enlargement of the lesion and may progress to abscess formationProliferation of the epithelial cell rests of Malassez associated with the inflammation may lead to the development of an inflammatory radicular cyst
3.3.7 Differential Diagnosis
Cracked‐tooth syndrome and acute periapical abscess to be differentiated from acute apical periodontitis
Periapical lesions presenting as radiolucent lesions in the apical region of the roots (e.g. periapical cyst, chronic periapical abscess) to be differentiated from periapical granuloma
Sometimes nasopalatine duct cyst (in maxillary anterior teeth) presents radiographical features mimicking those of periapical granuloma
3.3.8 Diagnosis
History
Clinical examination
Radiography
3.3.9 Management
Apical periodontitis:Identify and eliminate the cause: endodontic therapy is effectiveExtraction of the tooth if exudate is to be drained (apical abscess)Usually, antibiotics are not required for simple (non‐suppurative) cases of periodontitisPain management with analgesics
Periapical granuloma:Endodontic treatmentExtraction of the tooth if tooth cannot be restored
3.4 Apical Abscess (Dentoalveolar Abscess)
3.4.1 Definition/Description
An odontogenic infection characterized by localization of pus in the structures that surround the teeth
3.4.2 Frequency
Shows a wide range of variation
Common in children: accounts for 47% of all dental‐related attendances at paediatric emergency rooms in the United States
3.4.3 Aetiology/Risk Factors
Secondary to dental caries, trauma, or failed root canal treatment
Bacteria and their toxic products enter the periapical tissues via the apical foramen and induce acute inflammation and pus formation
Polymicrobial odontogenic infection:Anaerobic cocci, Prevotella speciesFusobacterium speciesViridans group streptococci
3.4.4 Clinical and Radiographical Features
Non‐vital tooth in most cases
Involved tooth is tender to percussion
Lower molars commonly involved
In the initial stages there is no swelling, only intense, throbbing pain
Gingiva related to the tooth is red and tender
In established abscess buccal or labial painful gingival swellings (Figure 3.3a)
Palatal swelling for maxillary molars is common
Trismus due to pain and swelling
Cervical lymphadenopathy is common
Early dental abscesses, within the first 10 days, may not show any radiographical features
Mild thickening of apical PDL, loss of lamina dura and loss of trabecular bone become evident as abscess advances (Figure 3.3b)
Discharge of pus may occur in established abscess; pain subsides after the discharge of pus
Complications include cellulitis/Ludwig's angina or osteomyelitis
Life‐threatening complications include thrombophlebitis and septicaemia
Complete blood count for leucocytosis
3.4.5 Differential Diagnosis
Acute periodontitis
Infected radicular cyst
Focal sclerosing osteomyelitis
Periapical granulomaFigure 3.3 Apical abscess. (a) Presenting as a fluctuant gingival swelling; a decayed, broken down tooth with pulpal necrosis has caused this apical (periapical) abscess. Note draining pus via an intraoral sinus(source: Damdent, https://commons.wikimedia.org/wiki/File:Abces_parulique.jpg. Licensed Under CC BY‐SA 3.0.(b) Radiographical appearance of an established periapical abscess. Note the loss of periodontal ligament, lamina dura, and trabecular bone.
3.4.6 Diagnosis
History
Clinical examination
Radiography (periapical and panoramic views)
Needle aspirate for aerobic and anaerobic cultures
Blood culture studies
3.4.7 Management
Most dental abscesses respond to incision and drainage, root canal, or extraction. These procedures eliminate the source of infection
Antibiotics are usually not recommended for localized abscesses
If drainage is not possible or if the patient shows signs of systemic involvement, or is immunocompromised, antibiotics are required for a period of seven days
3.5 Condensing Osteitis
3.5.1 Definition/Description
Condensing osteitis refers to focal areas of bone sclerosis associated with apices of teeth with pulpitis or pulpal necrosis
Also known as focal sclerosing osteitis and focal sclerosing osteomyelitis
3.5.2 Frequency
Occurs in 4–7% of population
3.5.3 Aetiology
Low‐grade inflammatory stimulus from an inflamed dental pulp
3.5.4 Clinical Features
Most frequently in young adults
Asymptomatic
Most lesions are discovered on routine radiography
3.5.5 Radiographical Features
Localized increased radiodensity