Sequelae of dental caries & Apical periodontitis

Dental caries being the most common disease in oral cavity is often ignored and untreated it develops further complications, including chronic irreversible pulpitis and further down necrosis of pulp.

The pulpal necrosis is followed by periradicular diseases of either immediate symptomatic type such as,

• Primary symptomatic apical periodontitis
• Cellulitis
• Acute apical abscess
• Other periradicular diseases of non odontogenic origin.

Or the diseases can be chronic asymptomatic type such as,

• Chronic apical periodontitis or Asymptomatic apical periodontitis
• Chronic apical abscess

In the worst case scenario this develops into radicular cyst or condensing osteitis

Apical periodontitis

As the name suggests it is the inflammatory disease of the apical part of the periodontium.

This can be acute in nature as Apical / primary symptomatic apical periodontitis or chronic as Asymptomatic apical periodontitis and secondary apical periodontitis

Although apical periodontitis is sequelae of dental caries it is not only cause for its development, it may be due to occlusal trauma or overinstrumentation etc.,. 

Acute apical periodontitis

It is also known as Primary symptomatic apical periodontitis

Definition : It is a painful inflammation of periodontium as a result of trauma, irritation or inflammation through the root canal regardless of whether the pulp is vital or non-vital producing clinical symptoms including painful response to biting and percussion.

Causes : It may occur in vital teeth due to abnormal occlusion, in a recent restoration extending beyond the occlusal plane, wedging with toothpick or food, or traumatic blow to teeth.

It occurs in non vital tooth as a sequelae of pulpal disease or by iatrogenic (i.e., caused by treatment by a doctor).

Diagnosis: Pain on percussion is a classical diagnostic feature of primary symptomatic apical periodontitis.

Differential diagnosis: the key difference between primary and chronic apical periodontitis is the periradicular radiolucency that is absent in primary periodontitis but present in chronic type.

Treatment & prognosis: It includes determining the cause and reliving it and symptomatic treatment regardless of vitality of the tooth. Prognosis in most cases is favourable.

Chronic apical periodontitis

It is also called Asymptomatic apical periodontitis or Periapical granuloma

Definition: Asymptomatic apical periodontitis is the symptomless sequelae of symptomatic periodontitis and is characterized radiographically by periradicular radiolucency and histologically by lesions dominated with marcophages, lymphocytes, and plasma cells.

Causes: it is caused by mild infection or irritation of periradicular tissues that stimulate protective cell mediated response as a chronic, low grade defensive mechanism of alveolar bone. It develops only after some time the pulp has died.

Symptoms: it is clinically asymptomatic and may only exhibit subjective reaction.

Diagnosis: The presence of asymptomatic apical periodontitis is generally discovered by routine radiographic examination.

Treatment and prognosis: Root canal treatment may be sufficient in case of asymptomatic apical periodontitis. Prognosis for long term retention of teeth is excellent. In cases of poor prognosis extraction of the tooth is suggested.   

Secondary apical periodontitis

Also known as Acute exacerbation of apical periodontitis or Phoenix abscess

Definition: this condition is an acute inflammatory reaction superimposed on an existing asymptomatic apical periodontitis.

Symptoms: tooth may be tender on palpation and as the inflammation progresses the tooth gets raised from socket and becomes sensitive. The mucosa over periradicular tissues is red and swollen and is usually sensitive to palpation.

Clinically secondary symptomatic apical periodontitis is an acute apical abscess with distinct radiographic features through which it can be differentiated from each other.

Treatment and prognosis: treatment is same as that of the acute apical periodontitis and prognosis is good once the symptoms subside. If the symptoms remain unchanged then the tooth is suggested for extraction.

Contributor – Medico Prashamsh Chandra Kulkarni