Requires a non-vital tooth
It is an accumultaion of Acute inflammatory
cells(PMNs) at the apex of a non-vital tooth.
May arise as an exacerbation of a chronic lesion-
Mostly symptomatic with acutely painful periapical
region,but maybe unsymptomatic if there is a path of
drainage of purulent material.
Drainage Pathways of acute
Surface of gingiva-Parulis(Gum boil)
Soft tissue spaces-Cellulitis
Floor of the mouth-Ludwigs Angina
Associated with acute periapical inflammation
Purulent material perforates through
bone,periosteum,soft tissue and epithelium,drains
through intraoral sinus tract
Consists of Fluctuant mass of inflamed granulation
tissue leading to an epithelialised sinus tract.
Cutaneous Sinus tract
An abscess that drains on its own,extraorally,through
the overlying skin(Draining sinus tract)
Extra oral abscess
Localised collection of pus that has
accumulated(consolidated) in a tissue
Can serve as a nidus for sacrophytic bacterial growth
Antibiotics cant reach center of large
abscesses,because blood supply is along the
periphery,therefore draining is very important for
effective antibiotic treatment.
Diffuse spread of an acute inflammatory process
through the fascial planes of soft tissue,producing
erythema,oedema,warmth and pain.
It is a board-like,diffuse,hard swelling.
Trismus is a common secondary to cellulitis due to loss
of function of muscles of mastication.
Requires immediate antibiotics and drain placement.
Aggressive,rapidly spreading cellulitis involving
Produces massive swelling of the neck that may extend
close to the clavicles and cause airway
Causes elevation of the floor of the mouth and
protrusion of tomgue(woody tongue)
Can be fatal due to airway obstruction,must establish
an airway,drain and give I.V antibiotics.
Cavernous sinus thrombosis
Maybe associated with spread of infection from
maxillary teeth(classic canine space infection)
It is the formation of a blood clot within the cavernous
Life threatening infection cause the cavernous sinus
holds the pituitary gland and sella turcica,Cranial
Form of chronic osteomyelitis with proliferative
Periosteal reaction in which layers of reactive vital
bone are formed,producing cortical expansion(onion
skinning) The periosteum is not destroyed,but lifted
up,when bone is formed beneath its layers.
Chronic focal sclerosing
osteomyelitis AKA Condensing
Localised area of bone sclerosis associated with apices
of non-vital teeth.
Most frequent in children and young adults involving
No cortical expansion.
Differential diagnosis:Osseous Dysplasia and
Bacterial infection of bone secondary to
C)Necrotising Ulcerative Gingivitis;Noma or cancrum
Predisposition to decreased vascularity of bone-
It is a misnomer,it is not a granulomatous reaction.
Mass of chronically inflamed granulation tissue at
apex of non-vital teeth,designed to wall off
bacterial invasion at apex.
Associated with chronic apical periodontitis
AKA apical periodontal cyst,radicular cyst.
Inflammatory odontogenic cyst,induced by cell rests
of malassez(Hertwigs Epithelial Root Sheath
Radiolucency at periapex of non-vital teeth.
To differentiate from a granuloma,it must be tested
Management of apical lesions
Non-surgical management: Periapical lesions develop as
sequelae to pulp disease. They often occur without any episode
of acute pain and are discovered on routine radiographic
examination. It is accepted that all inflammatory periapical
lesions should be initially treated with conservative nonsurgical
1.The conservative root canal treatment,
3.active nonsurgical decompression technique,
5. method using calcium hydroxide,
6. Lesion Sterilization and Repair Therapy, and
7.the Apexum procedure.
The current philosophy in the management of periapical lesions includes the initial
use of nonsurgical methods. When this treatment approach is not successful a
surgical approach may be adopted.The following factors must be considered, while
deciding on the management approach:
Diagnosis of the lesion
Many bone destroying lesions closely resemble endodontically related periapical
lesions on radiographs. Some of these nonendodontic lesions include
ameloblastoma, central fibroma, giant cell lesions, fibrous dysplasia, central
hemangioma, primary malignancies, metastatic neoplasms, and inflammatory bone
Proximity of the periapical lesion to adjacent vital teeth
When in proximity to a vital tooth,adopting a surgical approach may result in injury
to the blood vessels and nerves of the adjacent teeth, thereby compromising their
Encroachment on anatomical structures
Surgery increases the risk of damage to the anatomic structures such as mental
foramen, inferior alveolar nerve Also, the aspiration–irrigation technique, a
nonsurgical method, is not recommended where adjacent tissue spaces or sinus
cavities are involved.
Considerable pain or discomfort can be experienced by the patient during or after a
surgical procedure. A nonsurgical approach would be recommended for
apprehensive and uncooperative patients.
Obstructions in the root canal system
Ledges, calcified canals, separated instruments may prevent access to the apical
foramen and may warrant a surgical approach in managing periapical lesions
related to such teeth.
Time involved for treatment
Enhanced healing kinetics are observed after performing apical surgery in teeth
with periapical lesions.
Cases refractory to nonsurgical management methods
Inflammatory apical true cysts and the presence of cholesterol crystals have been
suggested as possible causes that prevent healing of periapical lesions.Surgery is
recommended for such cases.
METHODS FOR NONSURGICAL
MANAGMENT OF PERIAPICAL
Conservative root canal treatment without adjunctive therapy
Instrumentation should be carried 1 mm beyond the apical foramen when a
periapical lesion is evident on a radiograph. This may cause transitory inflammation
and ulceration of the epithelial lining resulting in resolution of the cyst.
The decompression technique involves placement of a drain into the lesion, regular
irrigation, periodic length adjustment, and maintenance of the drain, for various
periods of time.
Active nonsurgical decompression technique
This technique uses the Endo-eze vacuum system to create a negative pressure,
which results in the decompression of large periapical lesions. The high-volume
suction aspirator is connected to a micro 22-gauge needle, which is inserted in the
root canal and activated for 20 minutes, creating a negative pressure, which results
in aspiration of the exudate. When the drainage partially stops, the access cavity is
closed with temporary cement, which helps in maintaining bacterial control.
Aspiration and irrigation technique
Hoen et al, suggested aspiration of the cystic fluid from the periapcial lesion using
a buccal palatal approach. In this technique, an 18-gauge needle attached to a 20
ml syringe is used to penetrate the buccal mucosa and aspirate the cystic fluid. A
second syringe filled with saline is then used to rinse the bony lesion. The new
needle is inserted through the buccal wound and passed out through the palatal
tissue creating a pathway for the escape of the irrigant.
Aspiration through the root canal technique
In this technique, aspiration of the cystic fluid is done through the root canal by
passing the aspirating needle through the apical foramen. This technique
eliminates the creation of buccal and palatal wounds, as in the traditional
aspiration–irrigation technique. This minimizes the discomfort that the patient may
However, it is advisable not to use either aspiration–irrigation or aspiration through
the root canal techniques where adjacent tissue spaces or sinus cavities are
involved, when there is no fluid aspiration from the lesion, or in infected periapical
Method using calcium hydroxide
Calcium hydroxide is a widely used material in endodontic treatment because of its
bactericidal effects.It is thought to create favorable conditions for periapical repair
and stimulate hard tissue formation..Souza et al,. suggested that the action of
calcium hydroxide beyond the apex may be four-fold: (a) anti-inflammatory activity,
(b) neutralization of acid products, (c) activation of the alkaline phosphatase, and
(d) antibacterial action.
Lesion sterilization and repair therapy
‘Lesion Sterilization and Tissue Repair (LSTR)’ therapy that uses a triple antibiotic
paste of ciprofloxacin, metronidazole, and minocycline, for disinfection of oral
infectious lesions, including dentinal, pulpal, and periradicular lesions. Repair of
damaged tissues can be expected if lesions are disinfected.Metronidazole is the
first choice because it has a wide antibacterial spectrum against
anaerobes.However, some bacteria are resistant to metronidazole, and hence,
ciprofloxacin and minocycline are added to the mix.
Surgical removal of the periapical, chronically inflamed tissue allows a fresh blood
clot to form, thereby converting a chronic inflammatory lesion into a new
granulation tissue, where healing might proceed much faster.The Apexum
procedure uses two sequential rotary devices, the Apexum NiTi Ablator and
Apexum PGA Ablator (Apexum Ltd, Or Yehuda, Israel), designed to extend beyond
the apex and mince the periapical tissues on rotation in a low-speed handpiece,
followed by washing out the minced tissue.
Surgical management of Apical
Apical lesions maybe managed surgically to reduce
healing and recovery time
Indicated for emergency cases.
Incision and drainage,with antibiotic therapy of the
lesion,followed by R.C.T with apisectomy is the usual
modality of surgical treatment of apical lesions.
Medical Management of apical
Antibiotic therapy is used to treat minor apical
lesions,in order to relieve the symptoms.This enables
easier surgical or non0surgical management of the
lesion.Thus medical management of apical lesions is
used in conjunction with Surgical or non surgical
management of apical lesions.
Cellulitis-Cefazolin 1g i.v Q8H*7-10 days or cloxacillin
500-1000mg p.o Q6H*7-10 days.
Acute osteomyelitis-Cefazolin 2g i.v Q8H
Ludwigs angina-Clindamycin 600mg i.v Q8H*2-3
J Conserv Dent. 2010 Oct-Dec; 13(4): 240-
245.doi: 10.4103/09720707.73384PMCID: PMC3010029Nonsurgical management
of periapical lesions Marina Fernandes and Ida de Ataide
Manual in maxillofacial surgery for senior house officers-Dental 2,c.m.c,vellore
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