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Dental sequalae of pulpitis and management of apical lesions

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Dental sequalae of pulpitis and management of apical lesions

  1. 1. Dental sequalae of Pulpitis  D.C D.C with pulpitis Defensive reaction- Periapical Granuloma or Periapical cyst Bone reaction- Osteomyelitis Soft tissue reaction- Cellulitis Blood reaction- Septicemia
  2. 2. Pathway of Pulpitis Pulpitis Acute Pathway Periapical abscess Osteomyelitis Cellulitis Chronic Pathway Chronic Apical Periodontitis Periapical Granuloma Periapical cyst
  3. 3. Acute Pathway Periapical Abscess:  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- Phoenix abscess  Mostly symptomatic with acutely painful periapical region,but maybe unsymptomatic if there is a path of drainage of purulent material.
  4. 4. Drainage Pathways of acute periapical infection  Surface of gingiva-Parulis(Gum boil)  Palate-Palatal abscess  Maxillary sinus-Psuedocyst  Soft tissue spaces-Cellulitis  Floor of the mouth-Ludwigs Angina
  5. 5. Parulis(Gum boil)  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.
  6. 6. Cutaneous Sinus tract  An abscess that drains on its own,extraorally,through the overlying skin(Draining sinus tract)
  7. 7. Extra oral abscess  Localised collection of pus that has accumulated(consolidated) in a tissue cavity,producing fluctuance.  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.
  8. 8. Cellulitis  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.
  9. 9. Ludwigs angina  Aggressive,rapidly spreading cellulitis involving multiple anatomic spaces:submental,sublingual,submandibular.  Produces massive swelling of the neck that may extend close to the clavicles and cause airway obstruction(bullneck)  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.
  10. 10. 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 sinus.  Life threatening infection cause the cavernous sinus holds the pituitary gland and sella turcica,Cranial nerves-3,4,6
  11. 11. Proliferative Periostitis  Form of chronic osteomyelitis with proliferative periostitis  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.
  12. 12. Chronic focal sclerosing osteomyelitis AKA Condensing osteitis  Localised area of bone sclerosis associated with apices of non-vital teeth.  Most frequent in children and young adults involving mandibular molars/premolars.  No cortical expansion.  Differential diagnosis:Osseous Dysplasia and idiopathic osseosclerosis
  13. 13. Osteomyelitis  Bacterial infection of bone secondary to A)Odontogenic infection B)Traumatic injury C)Necrotising Ulcerative Gingivitis;Noma or cancrum oris Predisposition to decreased vascularity of bone- Paget’s,Osteopetrosis,florid cemento-osseous dysplasia
  14. 14. Chronic Pathway Periapical granuloma 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
  15. 15. Periapical cyst  AKA apical periodontal cyst,radicular cyst.  Inflammatory odontogenic cyst,induced by cell rests of malassez(Hertwigs Epithelial Root Sheath remnants) proliferation.  Radiolucency at periapex of non-vital teeth.  To differentiate from a granuloma,it must be tested histologically.
  16. 16. 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 procedures.  Methods: 1.The conservative root canal treatment, 2.decompression technique, 3.active nonsurgical decompression technique, 4.aspiration-irrigation technique, 5. method using calcium hydroxide, 6. Lesion Sterilization and Repair Therapy, and 7.the Apexum procedure.
  17. 17. Case selection 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 diseases.  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 vitality.  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.
  18. 18.  Patient cooperation 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.
  19. 19. METHODS FOR NONSURGICAL MANAGMENT OF PERIAPICAL LESIONS  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.  Decompression technique 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.
  20. 20. 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 experience. 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 lesions.
  21. 21.  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.  Apexum procedure 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.
  22. 22. Surgical management of Apical lesions  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.
  23. 23. Medical Management of apical lesions  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 weeks.
  24. 24. References  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
  25. 25. Dr.Vikram Perakath B.D.S

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