Endodontics – Lecture 1

Classification of pulpal and periapical diseases

Pulp

Dental pulp is an unmineralized oral tissue, composed of soft connective tissue,

vascular, lymphatic and nervous elements that occupies the central pulp cavity of each
tooth.

pulp ‫ ال‬.‫ مش مجرد عصب‬pulp ‫ المفروض ما نستخدم مصطلح "عصب" ألنه ال‬،pulp ‫لما منحكي عن ال‬
.other elements ‫ باإلضافة ل‬vascular and lymphatic tissues ‫بتتشارك معه‬

The pulp is not a nerve tissue. It consists of vascular connective tissue (blood vessels,
lymphatic tissue and cells) contained within the rigid dentin walls.

The dental pulp is that loose delicate connective tissue

occupying the cavity lying in the center of dentin.

root canal ‫ ال‬.root canal system ‫ موجود داخل ال‬pulp ‫ال‬

‫ وال‬root ‫ الموجود داخل ال‬root canal(s) ‫ عبارة عن ال‬system
.crown ‫ الموجود داخل ال‬pulp chamber

.apical foramen ‫ من خالل ال‬root canal system ‫ بيدخل لل‬pulp ‫ال‬

.‫ من جميع الجهات‬،dentin ‫ اللي هو ال‬،hard tissue ‫ محاط ب‬pulp ‫ال‬

‫ انه محاط ب‬،‫ آخر‬tissue ‫ عن أي‬pulp ‫وهون ممكن نشوف خاصية ال‬
‫ ال‬inflammation ‫ عشان هيك في حاالت ال‬.hard structure
،limited space ‫ مش ممكن يحصل ألنه عنده‬pulp ‫ لل‬expansion
.expansion ‫بالتالي بيمنعه يعمل‬

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 Some stimuli may lead to inflammation where the pulp is no more normal and pain is
present.

External stimuli:

1. Bacterial effect - acids of bacteria may cause pulp irritation, or the bacteria itself
present inside the pulp. * most common (e.g. caries)
2. Chemical irritation – acid agent in dental used (phosphoric acid during composite
etching) or sweet and sour food.

‫ ممكن نستخدم‬.filling ‫ مثل ال‬conservative procedures ‫ اللي احنا منستخدمها اثناء ال‬chemicals ‫ال‬
‫ ويعمل‬dentinal tubules ‫ وبالتالي يدخل من خالل ال‬.‫ لفترات طويلة او نستخدمها بطريقة خاطئة‬acids ‫ال‬
.pulp ‫ داخل ال‬inflammation

Some materials as composite restorations- if we put a large increment (a layer >2 mm) and
there is failure during light curing, the resins and monomers do not undergo setting thus
becoming toxic, because these monomers enter the dentinal tubules.

3. Thermal stimulus - working with high or low speed without cooling (the over-heat
over dentin may cause permanent damage of the pulp represented as pain).

‫ مثل أخطاء ممكن‬.pulp ‫ داخل ال‬inflammation ‫ اللي بتتعرض لها السن ممكن تسبب‬insults ‫بعض ال‬
‫ لفترة طويلة بسرعات‬rubber cap ‫ لألسنان ونستخدم ال‬finishing and polishing ‫تصير واحنا منعمل‬
.cooling ‫ إذا كنا نشتغل بدون ما نعمل‬،heat generation ‫عالية تسبب‬

* very A patient may come to the clinic with simple Class I, where the carious lesion is very
important
superficial but the wrong use of the bur or the high friction during finishing of restoration may
cause pulp damage due to overheat.

4. Mechanical damage - due to trauma, iatrogenic or micro-trauma (tooth brushing

and abrasive agents).

.micro-trauma ‫ او‬trauma ‫ نتيجة ل‬mechanical damage ‫ يتعرض ل‬pulp ‫ممكن ال‬

‫ بأدي ل‬inflammation ‫ هذا ال‬.pulp ‫ داخل ال‬inflammation ‫ راح يصير‬insults ‫نتيجة لهاي ال‬
‫ موجود بالوضع‬inflammation ‫ كأي‬vascular leakage ،increase blood flow ،vasodilation
.‫الطبيعي‬

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When the external stimulus lead to inflammation, vasodilation takes place (increasing in blood
flow) represented as swelling, redness, pain, increase in temperature.

‫ اللي عامل هذا ال‬stimuli ‫ عشان هيك إذا شلت ال‬.pulpal expansion ‫المشكلة هون انه ما في مجال لل‬
vascular ،increase blood flow ،vasodilation ‫ ممكن تتحمل شوية‬pulp ‫ ال‬،inflammation
.‫ للوضع الطبيعي‬pulp ‫ بيرجع ال‬damage ‫ فاذا شلت ال‬.‫ لحد معين‬leakage

‫ راح يزيدوا‬vascular leakage ،increase blood flow ،vasodilation ‫ ال‬،insults ‫ولكن إذا استمرت ال‬
‫ وهون بصير انخفاض بكمية‬،pulp ‫ لل‬blood ‫ وبالتالي بيمنع دخول ال‬pulpal space ‫ داخل ال‬pressure ‫ال‬
.necrosis ‫ مما يؤدي الى ال‬pulp ‫االوكسجين داخل ال‬

The inflammation in pulp differs from any other tissue, because pulp is unmineralized tissue
surrounded by mineralized tissue, lacking for space for vasodilation and swelling, thus blood
pressure increases inside the root canal than the blood supply which comes from the apex,
leading to lack of O2 thus necrosis occurs.

Pulp is totally surrounded by a hard dental tissue, dentin which limits the area for expansion
and restricts the pulp's ability to tolerate edema.

‫ او‬irreversible damage ‫ وممكن يتحول ل‬،reversible additional stimulus ‫إذا المرحلة األولى بتكون‬
‫ من داخل ال‬pulp ‫ إذا ما شلنا ال‬necrosis ‫ اللي راح يتحول بعد هيك ل‬،irreversible inflammation
.canals

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Classification of pulp disease

American Association of Endodontics

1. Normal pulp
2. Reversible pulpitis
3. Irreversible pulpitis:
 Symptomatic irreversible pulpitis
 Asymptomatic irreversible pulpitis
4. Pulp necrosis
5. Previously treated
6. Previously initiated therapy

1. Normal pulp:

Pulp tests → The sensation is ceased seconds.

Teeth with normal pulp do not exhibit any spontaneous symptoms. The pulp will
respond to pulp tests → sensation is present at cold or hot but no pain; and the
symptoms produced from such tests are mild, do not cause the patient distress, and
result in a transient sensation that disappears within seconds when removing the
stimulus.

2. Reversible pulpitis:

Is a sharp hypersensitive response to cold, but the pain subsides when stimulus is
removed.

‫ (ان كان‬stimulus ‫ إذا شلنا ال‬within seconds ‫ وهذا ال ألم بيختفي‬cold ‫بيبدأ المريض يحس بألم وعلى ال‬
.)electrical pulp test ‫ او‬cold

The tooth is irritated so that the stimulation is uncomfortable to the patient but reverses
quickly after irritation.

Pain does not occur spontaneously. stimulus ‫ بدون أي‬pain ‫ما بيكون أي‬

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A tooth with reversible pulpitis reacts normally to percussion, palpation and mobility
(producing no pain).

Radiologically, there is no abnormality.

Confusion can occur when there is exposed dentin, which can sometimes respond
with sharp, quickly reversible pain when subjected to thermal, evaporative, tactile,
mechanical, osmotic or chemical stimuli.

exposed dentin ‫ او‬cervical area ‫ اللي ممكن يكون بال‬- exposed dentin ‫بدنا نعرف نفرق بين ال‬
‫ بتكون ال‬exposed dentin ‫ بال‬.irreversibly inflamed pulp ‫ وبين ال‬-fractured enamel ‫نتيجة ل‬
.dentinal tubules ‫ داخل ال‬fluids ‫ ناتجة عن حركة ال‬sensitivity

We must distinguish between reversible pulpitis and exposed dentin. Exposure dentin in the
cervical area of the tooth accounts for most of the cases diagnosed as dentin sensitivity (due
to aging). Tooth is exposed due to gingival recession, or brushing teeth with forces, or attrition.

In hypersensitivity cases we must close the dentinal tubules using varnish (very thin layer).

No endodontic treatment is indicated for these teeth.

Generally, the pain is on cold stimulus.

Pain due to hot stimulus is present in irreversible pulpitis.

The smaller stimulus causing pain  inflammation is more advanced.

Causative factors include caries, exposed dentin, recent dental treatment, and defective
restoration. Conservative removal of the irritant will resolve the symptoms.

Confusion can occur when there is exposed dentin, without evidence of pulp pathosis, which
can sometimes respond with sharp quickly reversible pain when subjected to thermal,
evaporative, tactile, mechanical, osmotic or chemical stimuli. This is known as dentin
sensitivity (or hypersensitivity). Exposed dentin in the cervical area of the tooth accounts for
most of the cases diagnosed as dentin sensitivity.

In reversible pulpitis, patient feels pain at cold, and the pain is removed within seconds. This
is not a normal sensation compared to normal pulp.

.irreversible pulpitis ‫ ممكن يتحول ل‬reversible pulpitis ‫إذا ما عالجنا ال‬

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 3. Irreversible pulpitis:

The patent feels pain at hot and cold stimuli or spontaneous pain (no external stimulus).

Treatment to remove the diseased tissue is necessary.

 Symptomatic irreversible pulpitis- we can remove the caries and treat the patient
without RCT.
 Asymptomatic irreversible pulpitis- RCT is needed because the inflammation in
pulp is irreversible and cannot be treated, thus pulp removal is needed.

In some cases, the carious lesion in pulp is detected clinically and x-ray radiograph, but the
patient does not feel pain.
* The difference between symptomatic
irreversible and asymptomatic irreversible
pulpitis.
Why there are no symptoms? The patient has high fresh herpetic pain, or the patient takes
some medications for other symptoms (analgesics) or the patient is addicted.

 Symptomatic irreversible pulpitis:

Exhibit intermittent or spontaneous pain.

‫ وما في‬،irreversible ‫ صار‬inflammation ‫ ألنه ال‬،‫المريض راح يحكيلك عن وجود ألم بدون أي محفز‬
.RCT ‫مجال نعالجه غير انه نعمل‬

Cold stimuli will elicit heightened and prolonged episodes of pain even after the
thermal stimulus has been removed.

The pain in these cases may be sharp or dull, localized, diffuse or referred.

‫ وببدأ يصير‬the pain is not localized anymore ‫ ولكن مع مرور الوقت‬localized ‫األلم في البداية‬
.dull ‫ في البداية ومع مرور الوقت يصير‬sharp ‫ ممكن يكون‬.diffuse

.‫ للمريض وللطبيب‬confusing ‫ ممكن يكون‬irreversible pulpitis ‫ولذلك ال‬

Typically, there are minimal or no changes in the radiographic appearance of the

periradicular bone.

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 ‫ او إذا انتقل من‬،‫ ولكن في مراحل متقدمة‬periapical area ‫ ممكن تالحظ شوي تغيرات على ال‬x-ray ‫على ال‬
.PDL ‫ على ال‬whitening ‫ ممكن نشوف شوي‬periradicular tissue ‫ لل‬inflammation ‫ال‬

Teeth exhibit intermittent or spontaneous pain. Rapid exposure of teeth to dramatic

* Pain may be
temperature changes (especially to cold stimuli) will elicit heightened and prolonged episodes
sharp or dull,
localized, of pain even after the thermal stimulus has been removed.
diffuse or Typically, there are minimal or no changes in the radiograph appearance of the periradicular
referred.
bone. With advanced irreversible pulpitis a thickening of the periodontal ligaments may
* The external
become evident on the radiograph, and there may be some suggestion of pulpal irritation by
stimulus lasts
for long period. virtue of extensive pulp chamber and root canal space calcification.
Typically, when symptomatic irreversible pulpitis remains untreated, the pulp will eventually
become necrotic.

 Asymptomatic irreversible pulpitis:

On occasion, deep caries will not produce any symptoms, even though clinically or
radiographically the caries may extend well into the pulp.

‫ او على ال‬x-ray ‫ على ال‬.symptoms ‫ في ال‬reversible pulpitis ‫مشابه لل‬

‫ ولكن المريض ما بيشعر ب‬pulp ‫ واصل لل‬caries ‫ بكون ال‬bitewing
.symptoms

In cases of asymptomatic irreversible pulpitis, endodontic treatment should be

performed as soon as possible, so that symptomatic irreversible pulpitis does not take
place and result in severe pain and patient distress.

‫ عشان هيك مهم‬.‫ على طول‬pulp ‫ راح ينكشف ال‬،caries ‫ او حاولت تشيل ال‬excavation ‫مجرد ما عملت‬
.symptomatic ‫ ل‬asymptomatic pulpitis ‫ ألنه في أي لحظة ال‬،‫جدا نميز هذول المرضى ونعالجهم‬

On occasion, deep caries will not produce any symptoms, even though clinically or
radiographically the caries may extend well into the pulp. Left untreated, the tooth may
become symptomatic or the pulp will become necrotic.

The patient has inflammation but the fresh herpetic pain is high, thus the patient does not feel
any pain. Treatment is needed because asymptomatic may become symptomatic and cause
pain.

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 4. Pulp necrosis:

The pulpal blood supply is nonexistent and the pulpal nerves are non-functional.

‫ ممكن يزيد ال‬،irreversible pulpitis ‫ حتى في مرحلة ال‬pulp ‫ او ما شلنا ال‬inflammation ‫إذا استمر ال‬
‫ ويمنع دخول الدم وبذلك تقل كمية االوكسجين‬canals ‫ او داخل ال‬pulpal space ‫ أكثر داخل ال‬pressure
.pulpal space ‫ داخل ال‬necrosis ‫ويحصل‬

After the pulp becomes completely necrotic, the tooth will typically become
asymptomatic until such time that symptoms develop as a result of extension of the
disease process into the periradicular tissues.

The tooth may become symptomatic to percussion or exhibit spontaneous pain.

‫ اللي يقدر ينقل ال‬tissue ‫ ألنه ما ظل أي‬،‫ المريض ما بيشعر بأي إحساس‬،pulp ‫ بال‬necrosis ‫بعد ما يصير‬
‫ وإذا جربت ال‬،‫ وعشان هيك المريض ما بيشعر بألم ال على بارد وال على سخن‬.‫ من داخل السن‬sensation
‫ والمريض‬response ‫ ما راح يكون في أي‬stimuli ‫ إذا عرضت السن ألي‬.‫ ما راح يشعر بأي شيء‬cold test
.‫ما بيشعر بأي شيء‬

Radiographic changes may occur, ranging from a thickening of the periodontal

ligament space to the appearance of a periapical radiolucent lesion.

periodontal ligament ‫ في ال‬thickening ‫ منشوف انه في‬radiograph ‫بأغلب الحاالت إذا فحصنا ال‬
.surrounding tissue ‫ في ال‬radiolucency ‫ وممكن يكون في بداية ل‬space

When pulpal necrosis occurs, the pulpal blood supply is nonexistent and the pulpal nerves are
nonfunctional.

This condition is subsequent to symptomatic or asymptomatic irreversible pulpitis.

The tooth will not respond to electric pulp test or to cold stimulation (the patient may not feel
any pain due to lack of sensation).

However, if heat is applied for an extended period of time, the tooth may respond to this
stimulus. This response could possibly be related to remnants of fluid or gases in the pulp canal
space expanding and extending into the periapical tissues.

Reversible  irreversible  necrosis, if the case is not treated.

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Pulp necrosis is detected by x-ray radiograph. We can see caries near the pulp.

The tooth will not respond to cold or hot stimuli.

Loss of pain does not mean normal pulp.

In some cases of pulp necrosis, the inflammation migrates around the tooth and patient feels
pain on percussion and during biting.

After the pulp becomes necrotic, bacterial growth can be sustained within the canal. When this
infection extends into the periodontal ligament space, the tooth may become symptomatic to
percussion or exhibit spontaneous pain.

Generally, in reversible and irreversible pulpitis there is no pain in percussion but at cold and
hot stimuli.

5. Previously treated:

A clinical diagnostic for those cases that present where the tooth
has already had nonsurgical root canal therapy performed and the
root canal system has been filled with some type of root canal
obturating material.

‫ منقدر نعرف هذا‬.‫ معمول له عالج عصب‬previously treated ‫في بعض األحيان المريض بييجي والسن‬
gutta ‫ في‬canal ‫ (داخل ال‬obturation ‫ معمول‬canals ‫ ونشوف انه داخل ال‬x-ray ‫االشي عن طريق ال‬
.)percha

‫ ما في داعي‬.‫" ألنه المريض بيشعر بأوجاع او عنده مشاكل بهذا السن‬previously treated" ‫منستخدم مصطلح‬
‫ مش ألنه السن‬،negative ‫ راح تكون‬results ‫ ألنه ال‬tests ‫ ألنه مش راح نستفيد من ال‬vitality test ‫نعمل‬
.‫ من العالج السابق‬pulp ‫ وانما بسبب فقدان ال‬necrotic

The tooth has already had nonsurgical RCT performed and the root canal system has been
filled with some type of root canal obturating material. In this situation the tooth may or may
not present with signs or symptoms but will require additional RCT to retain the tooth. In most
of these cases there will no longer be any vital or necrotic pulp tissue present to respond to
pulp testing procedures, thus these cases are detected by x-ray radiograph.

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 6. Previously initiated therapy:

Clinical diagnostic category for those cases that present with partial endodontic
therapy has been performed.

emergency ‫ المريض كان موجوع كثير وعمل‬.‫ممكن تكون حالة انه المريض بدأ بالعالج وما كمل حتى النهاية‬
‫ او ممكن انعمل له‬.‫ وما كمل العالج‬pulpotomy ‫ او‬partial pulpectomy ،pulpectomy ‫ او‬treatment
apexification ‫ او ممكن‬.)obturation ‫ ولكن بدون‬instrumentation ‫ (يعني انعمل له‬full pulpectomy
.‫ وما كمل العالج‬apexogenesis ‫او‬

‫ منقدر نعرف هذا‬.‫ معمول له عالج عصب‬previously treated ‫في بعض األحيان المريض بييجي والسن‬

Partial endodontic therapy has been performed. Tooth in this category would include cases
where only a pulpotomy or pulpectomy had been performed before presenting for root canal
therapy. In most instances the pulpotomy or pulpectomy was performed as an emergency
procedure for symptomatic or asymptomatic irreversible pulpitis cases. In other situations,
these procedures may have been performed as part of vital pulp therapy procedures, traumatic
tooth injury, apexogenesis therapy. At the time these cases present for the RCT it would not
be possible to make an accurate pulpal diagnoses since all or part of the pulp tissue has already
been removed.

Detection by x-ray radiograph: the pulp chamber is accessed and de-roofing is made but
treatment did not finish.

.‫ ممكن المشكلة تنتقل لحوالين السن‬pulp ‫إذا ما قمنا بعالج ال‬

If the patient suffered from irreversible pulpitis or pulp necrosis and did not get any treatment,
the inflammation will spread to the periradicular or periapical area (periodontal ligaments or
the bone surrounding the tooth).

We have to diagnose in order to know the state of the periodontal ligaments so we can decide
the treatment and the steps.

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Classification of periapical lesions

1. Normal periapical tissues

2. Symptomatic apical periodontitis
3. Asymptomatic apical periodontitis
4. Acute apical abscess
5. Chronic apical abscess
6. Condensing osteitis

1. Normal periapical tissues:

In normal periapical tissue the tooth is surrounded by PDL, which has normal structure
with normal thickness without widening. Normal intact lamina dura. The patient feels
no pain and there is no abnormally sensation to palpation and percussion and biting.

‫ ماشية مع‬lamina dura ‫ ال‬،‫إذا منشوف هون على صورة االشعة‬

‫ عند ال‬bone ‫ ال‬.distortion ‫ وما فيها أي‬intact ‫ وهي‬root ‫ال‬
.intact ‫ كمان‬periradicular area ‫ وحول ال‬apex

The patient is asymptomatic and the tooth responds normally to percussion and palpation
testing. The radiograph reveals an intact lamina dura and periodontal ligament space around
all the root apices (normal periapical tissue- no lesion).

When the inflammation spreads from the pulp to the PDL and the bone, the osteoclasts cause
bone resorption, thus the lamina dura at the apical area disappears and the area around the
tooth at the apical area appears as black circle (radiolucency  - the minerals ).

On x-ray radiograph – periodontal space, surrounded by lamina dura and normal bone
structure; no pain on percussion but pulp is necrotic. When not treated  symptomatic apical
periodontitis.

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 2. Symptomatic apical periodontitis:

Defined as painful inflammation of periodontium as a result of

trauma, irritation or infection through root canal, regardless of
whether tooth is vital or non-vital.

‫ ممكن يصير عنا‬periapical area ‫ ما تعالج وانتقل لل‬inflammation ‫إذا ال‬

‫ في ال‬inflammation ‫ اللي هو عبارة عن‬،symptomatic apical periodontitis
‫ اللي بتختلف عن ال‬،apical periodontitis ‫ عشان هيك منحكي‬،‫ المحيط في السن‬periodontium
‫ إذا ما تعالج السن‬.periodontal disease ‫ الناتجة ل‬gingival problems ‫ او ال‬periodontal problems
‫ او عن‬apical foramen ‫ عن طريق ال‬periodontal tissue ‫ بينتقل لل‬root ‫ في ال‬inflammation ‫ال‬
‫ المحيط نتيجة لنشاط‬tissue ‫ لل‬distortion ‫ وببدأ يصير‬،root ‫ الموجودين داخل ال‬lateral canals ‫طريق ال‬
.osteoclasts ‫ال‬

Signs and symptoms:

 Dull throbbing constant pin.

 Pain on biting or percussion, or spontaneous pain.
 Negative or delayed vitality test response, because the inflammation is beyond
the canal and reached the periapical area. Sensation may be present in multi-
rooted teeth.
 Widening of PDL space.
 May be associated with apical radiolucency (in advanced stages where
inflammation is more developed).
 Cold may relieve pain, because in decreases the dilation and blood flow to that
area.
 Heat exacerbate pain, due to increased vascularity.

Treatment:

 If tooth is restorable → RCT.

 If tooth in hyper occlusion → relieve occlusion.
 If tooth infected → initiate endodontic therapy.

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 3. Asymptomatic apical periodontitis:

Defined as a clinical asymptomatic condition of pulpal origin with

inflammation and destruction of periapical tissues.

‫ (نتيجة لل‬lamina dura ‫ ولل‬bone ‫ لل‬distortion‫ و‬lesion ‫لما يكون في‬

‫ ولكن المريض ما بيحس بأي‬radiolucency ‫) والسن محاط ب‬inflammation
.symptoms

If symptomatic apical periodontitis is not treated, the lesion becomes wider, the radiolucency
increases, but the patient feels no pain on percussion, because the pulp is necrotic and the
periodontal area is chronic (no pain on biting or percussion), but on -ray radiograph it is well
seen, the periapical tissue is not normal → resorption of bone.

* very We must test the tooth vitality. If the tooth is vital, the problem may be because of the bone
important
itself (cancer, tumor, blood vessels, neuron).

Etiology:

 Extension of pulpal inflammation into periapical tissues.

 In non-vital tooth it is associated with sequelae of pulpal infections.
 Over instrumentation in previously treated tooth.
 Foreign body reaction due to spreading of materials to the periapical area.
 Extrusion of necrotic pulp or obturating materials.

Signs and symptoms:

 Generally, presents with no clinical symptoms.

 Does not respond to pulp vitality tests (even in multi-rooted teeth), because
inflammation is in advanced stage.
 No pain on percussion or biting.
 Slight sensitivity to palpation.
 Radiographically, interruption in lamina dura and exhibit an apical
radiolucency.
 Destruction of periapical tissues.

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Treatment:

 Removal of necrotic or inflamed pulp within the canal (no extending beyond
the apical foramen).
 Complete obturation.
 If there is extended material beyond the apical foramen, we pull in out if
possible. If not, we must extract this tooth.

Whether it's symptomatic or asymptomatic apical periodontitis, the treatment is RCT.

The inflammation at bone will disappear as soon as we remove its cause (bacteria at canal);
generally, removal of necrotic tissue will heal the bone.

4. Acute apical abscess:

Defined as a localized collection of pus in the alveolar bone at the

root apex of the tooth.

Swelling will be present intraorally and the facial tissues adjacent to the
tooth will almost always present with some degree of swelling. The patient
will frequently be febrile, and the cervical and submandibular lymph nodes
will exhibit tenderness to palpation.

Following the death of pulp and extension of infection through apical foramen into
periapical tissues.

In the stage of necrosis or degeneration, there may be liquefactive necrosis  cheesy material
(pus), inflammation may cause degeneration of tissue leading to pus  abscess.

The pus lead to perforation in the bone, accumulating under the periosteum (condense between
periosteum and bone). Thus the swelling is under the periosteum.

Sometimes the swelling spreads to the spaces in the floor of the mouth or the cheeks.

The patient feels pain due to the pressure caused by pus which dehiscence of periosteum from
bone.

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Etiology:

 Pus is produced as a result of liquefaction necrosis of pulp.

 Severe inflammatory response of microbial and non-microbial irritants.

Signs and symptoms:

 Rapid onset and rapid spreading.

 Spontaneous pain.
 Moderate to severe discomfort with swelling.
 No response to vitality tests (negative vitality test because pulp is not vital) and
exhibits varying degrees of mobility.
 Pain on percussion, palpation and biting.
 Radiographically, widening of PDL to periapical lesion (apical radiolucency).

Treatment:

 Removal of cause- either necrotic tissue or foreign material.

 Release of pressure (incision), drainage.
 Root canal treatment in later visits.

5. Chronic apical abscess:

It's an inflammatory lesion of pulpal origin characterized by

presence of long standing lesion with drainage into mucosal
(pus discharge) or skin (sinus tract).

‫ مستحيل يكون في‬.chronic apical abscess ‫ موجود ولكن بيكون‬abscess ‫في بعض األحيان بيكون ال‬
‫ ← العالمة المميزة لهذا‬sinus tract ‫ اال إذا كان عنا‬.)acute ‫ (يعني مش‬swelling ‫ وما يكون في‬abscess
.‫ حول المنطقة للسن المصاب‬sinus tract ‫ انه يكون في‬diagnosis ‫النوع من ال‬

Etiology:

Has burrowed through bone and soft tissue to form sinus tract.

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 Signs and symptoms:

 Asymptomatic- no clinical symptoms.

 Generally, not sensitive to
 Do not respond to pulp vitality tests.
 Generally, no pain.
 Presence of sinus tract.
 Radiographically, apical radiolucency.

Treatment:

 Drainage.
 Endodontic treatment (RCT).

How to differ between asymptomatic apical periodontitis, chronic apical abscess and acute
apical abscess?

* In all cases the  Acute apical abscess: swelling and pain are present; radiolucency on radiograph.
treatment is
RCT, but differ
 Chronic apical abscess: radiolucency in radiograph; search for fistula.
in steps.  Asymptomatic apical periodontitis: radiolucency in radiograph.

6. Condensing osteitis:

‫ وبالتالي‬osteoblasts ‫ بتشتغل ال‬osteoclasts ‫ بدل ما تشتغل ال‬،inflammation ‫في بعض األحيان نتيجة لل‬
.‫ حول االسنان المصابة‬radiopacity ‫بتزيد ال‬

.non-vital ‫ او‬vital ‫في اختالف على هذه الحالة إذا السن‬

Sometimes, instead of increasing the activity of osteoblasts, the activity of osteoclasts

increases, and the periapical area appears more radiopaque. Test tooth vitality  necrotic but
at the periapical area the bone density is increased. This is called Condensing osteitis. It is a
diffuse radiopaque lesion representing a localized bony reaction to a low-grade inflammatory
stimulus usually seen at the apex of the tooth.

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  A variant of asymptomatic apical periodontitis.
 Irritant from canal to periapical tissues is the cause.
 Mainly in mandibular posterior teeth.
 Occurs in association with apex of any tooth.

Signs and symptoms:

 Asymptomatic or associated with pain.

 Not respond to electric or thermal stimuli.
 May or may not be sensitive to percussion.
 Radiographically, radiopacity around root of tooth.

Treatment:

 Root canal treatment (when indicated).

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