CHRONIC APICAL PERIODONTITIS (APICAL GRANULOMA) -MH. Nil -DH. Large restoration, pins, defective RCT filling, etc. (see acute apical periodontitis) -Symptoms Pain is unusual, if any usually dull, throbbing, not well localized Occasional discharge (bad taste) of sinus. -Signs Large restoration, tooth maybe discolored, sinus may present -Diagnostics Tests Percussion : minor TTP and a slightly dull percussion note Vitality: -ve. May response to heat (due to expansion of gas in the chamber)
40 Radiographs: Apical radiolucency (large & well-defined), previous inadequate RCT filling or pulp dressing may evident. Gutta percha passed along sinus track will pass to apex of affected tooth. -Treatment Endo / extraction. Apical surgery (indicated : if conventional RCT failed or can’t be attempted bcs present of post or core) -Pus tracking Depends upon anatomical rx.~ Post mx teeth –pus track through buccal plate, below buccinators, points into buccal sulcus (IO) ~ Apex of mx 3s & 6s - may be above buccinators attachment. Pus points onto face (extraorally) ~ Palatal root of max 6s –pus tracks into the palate. May track into floor of antrum or rarely, nose. ~ Mx 1s –Pus tracks into labial sulcus or rarely floor of the nose. ~ Mx 2s –Apex is directly palatally, thus pus points into anterior palate. ~ Most lower teeth –Apices are above buccinators. Therefore pus track intraorally into buccal sulcus. However, lower ant teeth, the apices maybe below mentalis, and pus points on the neck. ~ Mn 7s & 8s –Apices are closer to lingual wall of body of mandible > buccal wall. Thus, pus track lingually. Since the apices are below mylohyoid, pus may track into submandibular space and neck. ~ Mn 6s –Apices may be below buccinators therefore pus point extraorally onto the face. 4.ACUTE PERIODONTITIS OF GINGIVAL ORIGIN (LATERAL PERIODONTAL/PARODONTAL ABSCESS) -MH. Common in pts with DM or immunocompromised pts -DH. Hx of gingival disease, abscess, tooth loss, tooth drifting/looseness, dental neglect. -Symptoms Well localized, continuous, dull, throbbing pain. Tooth maybe loose. Bad taste or smell with any discharge into the mouth. Associated painful swelling in the mouth. Extraoral swelling is very rare. Tooth maybe painful on biting and may feel ‘high’ in the bite.-Signs Teeth are mobile and deep pocket will be present. Poor oral hygiene, plaque & calculus. Sinus maybe present or pus are draining from the pocket. Inserting a pocket measuring probe down a pocket will release pus.
41 Probing any sinus will lead to deep pocket Tooth may be in supra-occlusion. -Diagnostics Tests Vitality : +ve (but see perio-endo lesion) Percussion : TTP (particularly to lateral forces), percussion note will be dull (due to accumulation of fluid in PDL space) Radiographs: generalized bone loss (horizontally/vertically).