Apical periodontitis is an inflammation of the connective tissue complex that forms the dentoalveolar ligament (periodontium), localized around the tip of the root. In the acute form, apical periodontitis manifests itself as pain and swelling in the affected area, a reaction to hot, high body temperature and general malaise. Apical periodontitis is diagnosed during a dental examination based on anamnesis, identified clinical manifestations and X-ray examination. Treatment consists in the preparation of the tooth, canal treatment, the use of anti-inflammatory and antibacterial drugs, physiotherapy and subsequent filling of the canals and the crown of the tooth.
Apical periodontitis is a lesion of the tissues of the dentoalveolar ligament, in which a focus of inflammation forms around the tip of the root and a subsequent gradual destruction of the periodontium occurs. This is the most common form of periodontitis in therapeutic dentistry: it is diagnosed in about 30% of patients aged 21-60 years. Most often, apical periodontitis is a complication of pulpitis. The disease is dangerous with its consequences – in the absence of timely treatment, apical periodontitis can turn into a chronic form, fraught with the formation of granulomas, cysts and fistulas, as well as be complicated by periostitis, parotid abscess, phlegmon, osteomyelitis of the jaw and sepsis. The development of apical periodontitis is especially dangerous during pregnancy.
Based on the etiological criterion, three main types of apical periodontitis are distinguished: infectious, drug-induced and traumatic. It should be noted that periodontitis of traumatic and drug etiology quickly turns into an infectious form:
- Infectious periodontitis is usually a complication of advanced pulpitis. In this case, the death of the dental nerve occurs, as a result of which pathogenic microflora (most often streptococci, staphylococci and anaerobic bacteria) spreads into the periodontal ligament tissue through the apical opening, forming a focus of inflammation around the tip of the tooth root.
- Traumatic periodontitis usually results from mechanical damage (dental injuries), including bruises, microtrauma, tooth fracture, etc.
- Drug-induced apical periodontitis is caused by the ingress of potent drugs or irritating substances into the periodontal tissues; most often occurs due to incorrect treatment of pulpitis.
Infectious, traumatic, drug-induced forms of apical periodontitis along the path of infection are considered intradental. There are also extradental apical periodontitis, the development of which is associated with the transition of the inflammatory process from the tissues surrounding the teeth, for example, with sinusitis or osteomyelitis.
Currently, the classification according to I.G. Lukomsky is widespread, which differentiates acute and chronic apical periodontitis by the nature of the pathological process and possible complications:
Acute apical periodontitis by the type of exudation is divided into serous and purulent, the clinic of which is accompanied by significant painful manifestations;
Chronic apical periodontitis can be granulating, granulomatous and fibrous.
Acute apical periodontitis
It manifests itself as an increasing aching pain in the affected area, intensified by touch. Patients note the feeling of “protruding” of the tooth from the dentition, the painfulness of the reaction to temperature stimuli, especially hot. Subsequently, the pain increases significantly, becomes pulsating, often radiates into nearby anatomical areas, which indicates the flow of the pathological process into the stage of purulent inflammation. There is an increase in the mobility of the diseased tooth, swelling of the tissues around it and an increase in the submandibular lymph nodes.
General well-being worsens, body temperature rises (up to 37-38 ° C), headache often occurs. The acute form of the disease lasts from 2-3 to 14 days. In the absence of adequate treatment, acute periodontitis can turn into a chronic form with the formation of a fistula or cyst, as well as be complicated by more serious pathologies, for example, parotid abscess, phlegmon, osteomyelitis, etc.
Chronic apical periodontitis
It can proceed almost asymptomatically, from time to time manifesting itself as exacerbations accompanied by symptoms of an acute form of the disease. Periods of remission are characterized by minor pain during meals, the appearance of fistulas on the gums and an unpleasant odor from the oral cavity. Chronic granulating periodontitis manifests itself with intermittent mild pain when biting and a feeling of bursting. These signs are often accompanied by the formation of a fistula on the gum with a purulent discharge, which disappears after some time.
In the case of chronic granulomatous periodontitis, obvious symptoms are most often absent, unpleasant sensations occasionally occur, but they are insignificant. If the granuloma is localized in the buccal roots of the molars and premolars of the upper jaw, there is often a bulging of bone tissue in accordance with the projection of the root tips. In the absence of proper treatment, granuloma eventually turns into a cystogranuloma or a near-root cyst.
Chronic fibrous periodontitis is also not accompanied by obvious symptoms: the crown of the tooth is intact, probing and percussion are painless, there is no reaction to temperature changes. It is characterized by the presence of a deep carious cavity, in which there is often a necrotic pulp with a gangrenous odor.
Apical periodontitis is diagnosed by a dentist on the basis of anamnesis, identified clinical manifestations of the disease and the results of X-ray examinations. For an accurate diagnosis is carried out:
- Electrodontometry. With the help of EDI, the degree of pulp lesion is determined. Acute forms of periodontitis are characterized by EDI readings in the range of 180-200 mkA, for chronic – 100-160 mkA.
- Dental x-ray. In the case of chronic granulating periodontitis, a rarefaction area of bone tissue with indistinct boundaries ranging in size from 1 to 8 mm is found in the apical region. Chronic granulomatous periodontitis is characterized by clearly defined rounded contours of the area of destruction of the bone structure around the tip of the tooth root. Chronic fibrous periodontitis on the X-ray shows itself as an expanded periodontal space in the apical region in the absence of resorption of the bone wall of the alveoli.
Acute apical periodontitis should be differentiated from diseases similar in symptoms:
- purulent diffuse pulpitis;
- acute maxillary sinusitis;
- near – root cyst;
- osteomyelitis and periostitis.
Treatment of any form of apical periodontitis is carried out in several visits and includes three main stages:
- Mechanical training. At the first stage, under local anesthesia, the affected tooth is opened and the cavity is cleaned of the remains of the dead pulp and carious tissues, after which the root canals are treated and expanded – conditions are created for the outflow of exudate.
- Antiseptic treatment. Ultrasound therapy is often used to disinfect the channels. In the future, anti-inflammatory and antibacterial drugs in the form of pastes are placed in the area of the root of the tooth.
- Sealing of channels. If the inflammatory process in the periodontium has been stopped, at the final stage of treatment, a thorough filling of the root canals is carried out, followed by X-ray quality control. If the manipulations are successful, the treatment ends with the installation of a permanent seal, and in case of severe tooth destruction, it is closed with a crown.
Complex treatment also includes rinsing the oral cavity with warm mineral water and decoctions of medicinal plants (chamomile, eucalyptus), taking sulfonamide preparations, and, if necessary, broad–spectrum antibiotics (for example, doxycycline or cephalexin). Physiotherapy procedures are widely used: UHF, infrared laser exposure, sollux, etc.
Timely treatment, as a rule, demonstrates its effectiveness – according to statistics, apical periodontitis is completely cured in 85% of cases. When bone tissue is involved in the inflammatory process as a result of improper or untimely treatment with therapeutic methods, it is often impossible to achieve success in treatment. In this situation, surgical intervention is resorted to – resection of the root apex or cystectomy. If all therapeutic measures are unsuccessful, the diseased tooth is removed.
Prognosis and prevention
Timely treatment to the dentist and timely treatment of acute apical periodontitis, as a rule, provide a positive prognosis and avoid the transition of the disease to a chronic form, periostitis, osteomyelitis, abscess, phlegmon and sepsis. However, with advanced forms of chronic periodontitis, the lack of adequate treatment increases the risk of complications: granulomas, cysts, etc., which often lead to the need to remove the affected tooth.
The most important measures for the prevention of apical periodontitis are simple hygiene rules that prevent the occurrence of dental diseases, as well as regular visits to the dentist for preventive examination and timely treatment of emerging foci of caries. In addition, to prevent the development of complications of acute periodontitis, you should contact a specialist as soon as possible.