The document provides an overview of periapical diseases and their classification. It begins with an introduction to periapical diseases and their causes. The document then classifies periapical diseases into symptomatic and asymptomatic categories. Within each category, it describes specific conditions such as symptomatic apical periodontitis, acute alveolar abscess, chronic alveolar abscess, radicular cyst, and condensing osteitis. For each condition, it discusses causes, symptoms, diagnosis, differential diagnosis, and treatment. The document provides a comprehensive review of different periapical diseases and conditions that can affect the tissues around the root apex.

1. PRESENTED BY-
ABHISHEK VERMA
FINAL YEAR
PCDS & RC, BHOPAL
PERIAPICAL DISEASES AND
CLASSIFICATION

2. CONTENTS
• Introduction
• Causes of the
periapical diseases
• Classification of the
periapical disease
• Symptomatic apical
periodontitis
• Phoenix abscess
• Asymptomatic apical
periodontitis
• Chronic alveolar abscess
• Radicular cyst
• Condensing osteitis
• External root resorption

3. INTRODUCTION
• Pulpal diseases is only one of the several
possible causes of diseases of the Periradicular
tissues.
• Because of the inter-relationship between the
pulp and the Periradicular tissues, pulpal
inflammation causes inflammatory changes in the
periodontal ligament even before the pulp
becomes totally necrotic.

4. SEQUELAE OF PULPITIS

5. PATHWAYS OF SPREAD OF INFECTIONS

6. CAUSES
• Bacteria and their toxins, immunologic agents,
tissue debris, and products of tissue necrosis from
the pulp reach the Periradicular area through the
various foramina of the root canals and give rise
to inflammatory and immunologic reactions.
• Neoplastic disorders, periodontal conditions,
developmental factors, and trauma can also cause
Periradicular diseases.

7. CLASSIFICATION
A. SYMPTOMATIC PERIRADICULAR DISEASES
(a) Symptomatic apical periodontitis (previously known as acute
apical periodontitis)
i. Vital tooth
ii. Non vital tooth
(b) Acute alveolar abcess
(c) Acute exacerbation of asymptomatic apical periodontitis (phoenix
abscess)
B. ASYMPTOMATIC PERIRADICULAR DISEASES
(a) Asymptomatic apical periodontitis(previously known as chronic
apical periodontitis)
i. Chronic alveolar abscess
ii. Cystic apical periodontitis
(b) Persistent apical periodontitis

8. C. CONDENSING OSTEITIS
D. EXTERNAL ROOT RESORPTION
E. DISEASES OF THE PERIRADICULAR TISSUES
OF NON ENDODONTIC ORIGIN

9. SYMPTOMATICPERIRADICULAR DISEASES
 SYMPTOMATIC APICAL PERIODONTITIS
Symptomatic apical periodontitis is a painful
inflammation of the periodontium as a result of
trauma, irritation, or infection through the root
canal, regardless of whether the pulp is vital or non
vital, producing clinical symptoms including painful
response to biting and percussion.

10. CAUSES
• In a vital tooth-
Abnormal occlusal contacts
Recently inserted restoration extending beyond the
occlusal plane
Wedging of a foreign object between the teeth, such
as a toothpick or food
Traumatic blow to the teeth
• In a non vital tooth-
Sequelae of pulpal diseases
Iatrogenic

11. • Root canal instrumentation
• Forcing of irritating irrigants or
medicaments through the apical foramen
• Extension of obturating material through the
apical foramen to impinge on
Periradicular tissues
• Perforation of the root
• Over instrumentation during shaping and
cleaning of root canals

12. SYMPTOMS
• Pain and tenderness of the tooth
• Tooth may be slightly sore, sometimes only when it
is percussed in a certain direction, or the soreness
may be severe.
• The tooth may feel extruded and the patient may
have pain on closure and mastication.

13. DIAGNOSIS
• Pain on percussion or slight pressure
• Overlying mucosa may or not be tender to
percussion
• Radiographic changes
Non vital tooth-slight widening of apical
periodontal space and loss of apical lamina
dura of involved pulpless tooth
Vital tooth-no radiographic changes with
normal periradicular structures

14. Radiographic features of symptomatic apical periodontitis.
“High” amalgam restoration was placed on the occlusal
surface of a second mandibular molar. The periodontal ligament
space is widened at the apex

15. DIFFERENTIAL DIAGNOSIS
• Acute alveolar abscess
TREATMENT
• Determining the cause and relieving the symptoms
• Adjustment of high points in hyper-occlusion cases
• Removal of irritants in case of non vital infected
pulp
• When the acute phase has subsided, the tooth is
treated by conservative means

16. ACUTE ALVEOLAR ABSCESS
(ACUTE ABSCESS/ACUTE APICAL ABSCESS/ACUTE
DENTOALVEOLAR ABSCESS/ACUTE PERIAPICAL
ABSCESS/ACUTE RADICULAR ABSCESS)
An acute alveolar abscess is an inflammatory reaction to
pulpal infection and necrosis characterised by rapid onset,
spontaneous pain, tenderness of the tooth to pressure, pus
formation, and eventual swelling of associated tissues.

17. CAUSES
• Bacterial invasion of dead pulp tissue
• Trauma
• Chemical or mechanical irritation
SYMPTOMS
• Tenderness of the tooth that may be relieved by
continued slight pressure on the extruded tooth to
push it back into the alveolus.
• Later, the patient has severe, throbbing pain, with
attendant swelling of the overlying soft tissue.
• Tooth becomes more painful, elongated and
mobile.

18. • At times, the pain may subside or cease entirely
while the adjacent tissue continues to swell.
• If left unattended, the infection may progress to
chronic apical abscess wherein the contained pus
may break through to form a sinus tract, usually
opening in the labial or buccal mucosa.
• Patient may appear pale, irritable, & weakened
from pain and loss of sleep, as well as from
absorption of septic products.

19. • Patients in mild cases may only have a slight rise
in temperature whereas those in severe cases may
reach several degrees above normal.
• Intestinal stasis may occur, manifesting itself
orally by a coated tongue and foul breath.
• Patient may complain of headache and malaise.

20. DIAGNOSIS
• Clinical examination.
• Presence of diffuse & annoying pain.
• Extrusion of the tooth.
• Radiographically, a cavity, a defective restoration, or
slight widening of the apical PDL space.
• Diagnosis is confirmed by means of electric pulp and
thermal testing.
• The affected pulp is necrotic and does not respond to
electric current or application of cold.
• The tooth may be tender to percussion, or the patient may
state that it hurts to chew.

21. Intraoral labial sinus opening
in relation to the carious
maxillary lateral incisor
Intraoral palatal sinus opening in
relation to the carious maxillary central
incisor
Extraoral sinus opening

22. Radiographic features of
symptomatic apical
abscess A. Localized abscess resulting from an
incomplete root canal treatment on a
maxillary lateral incisor.
B. Cellulitis caused by a maxillary first
molar with necrotic pulp.

23. DIFFERENTIAL DIAGNOSIS
• Periodontal abscess
TREATMENT
• Establishing drainage and controlling systemic
reaction.

24. ACUTE EXACERBATION OF
ASYMPTOMATIC APICAL
PERIODONTITIS
(PHOENIX ABSCESS/EXACERBATING APICAL
PERIODONTITIS)
This condition is an acute inflammatory reaction
superimposed on an existing asymptomatic apical
periodontitis.

25. CAUSES
• When chronic periradicular diseases, such as
asymptomatic apical periodontitis are in a state of
equilibrium, the periradicular tissues are
asymptomatic. Sometimes, noxious stimulus from a
diseased pulp can cause acute inflammatory
response in these dormant lesions.
• Lowering of body defences due to influx of
bacterial toxins from the root canal or irritation
during root canal instrumentation may also trigger
acute inflammatory response.

26. SYMPTOMS
• Initially, tooth may be tender on palpation.
• As inflammation progresses, tooth gets elevated
from its socket and becomes sensitive.
• The mucosa over the radicular area may appear red
and swollen and is sensitive to palpation.

27. DIAGNOSIS
• The radiograph shows a well-defined periradicular
lesion.
• The patient gives a history of trauma that lead to
discolouring of the tooth over a period of time or a
post operative pain that subsided until then.
• Lack of response to vitality tests diagnoses a
necrotic pulp.
• On rare occasions, a tooth may respond to the
electric pulp test because of fluid in the root canal
or in a multirooted tooth.

28. A, Radiograph of lower anterior teeth with periapical lucency.
B, Upon opening the central incisors, copious amounts of pus drained
through the canals. The diagnosis is phoenix abscess.

29. DIFFERENTIAL DIAGNOSIS
• Acute alveolar abscess
TREATMENT
• Establishing drainage and controlling systemic
reaction.

30. ASYMPTOMATIC PERIRADICULAR DISEASES
ASYMPTOMATIC APICAL
PERIODONTITIS
(PREVIOUSLY KNOWN AS CHRONIC APICAL
PERIODONTITIS)
Asymptomatic apical periodontitis is the
symptomless sequelae of symptomatic apical
periodontitis and is characterised
radiographically by periradicular radiolucent
changes and histologically by the lesion
dominated with macrophages, lymphocytes and
plasma cells.

31. CAUSES
• It may be seen as a chronic, low grade defensive
reaction of the alveolar bone to the irritation from
the root canal.
• Develops only some time after the pulp has died.
• Asymptomatic apical periodontitis is a cell
mediated response to pulpal bacterial products.
SYMPTOMS
• May not produce any subjective reaction, except in
rare cases when it breaks down and undergoes
suppuration.

33. DIAGNOSIS
• Discovered by routine radiographic examination. The
area of rarefaction is well defined, with lack of continuity
of the lamina dura.
• An exact diagnosis can be made only by microscopic
examination.
• Mucosa over the root may or may not be tender to
palpation.
• Tooth does not respond to thermal or electric pulp tests.
• Patient may give a history of pulpalgia that subsided.

34. Chronic apical periodontitis in an
asymptomatic poorly obturated
mandibular molar
Radiographic appearance of
asymptomatic apical
periodontitis.
Two distinct lesions are present
at the periradicular
regions of a mandibular first
molar with necrotic pulp.

35. DIFFERENTIAL DIAGNOSIS
• Cannot be differentiated from other periradicular
diseases unless the tissue is examined histologically.
TREATMENT
• Root canal therapy
• Removal of the cause of inflammation is usually
followed by resorption of the granulomatous tissue
and repair with trabeculated bone.

36. CHRONIC ALVEOLAR ABSCESS
(CHRONIC SUPPURATIVE APICAL
PERIODONTITIS/SUPPURATIVE PERIRADICULAR
PERIODONTITIS/CHRONIC APICAL
ABSCESS/CHRONIC PERIRADICULAR
ABSCESS/CHRONIC PERIAPICAL ABSCESS)
A chronic alveolar abscess is a long standing, low
grade infection of the periradicular alveolar bone
generally symptomless and characterised by the
presence of an abscess draining through a sinus
tract.

37. CAUSES
• Source of infection is in the root canal
• It is a natural sequelae of death of the pulp with
extension of the infective process periapically or it
may result from a pre existing acute abscess.
SYMPTOMS
• Generally asymptomatic or only mildly painful.
• At times detected only during routine radiographic
examination or because of the presence of sinus
tract which can either be intraoral or extraoral.

38. DIAGNOSIS
• The first sign of osseous breakdown is
radiographic evidence seen during routine
examination or discoloration of the crown of the
tooth.
• A radiograph taken after the insertion of a gutta
percha cone into the sinus tract often shows the
involved tooth by tracing the sinus tract to its
origin.
• When an open cavity is present in the tooth,
drainage may occur by way of root canal.
• The PDL is thickened.

39. • The rarefied area may be so diffuse as to fade indistinctly
into normal bone.
• When asked, the patient may remember a sudden sharp
pain that subsided and has not recurred, or he or she may
relate a history of traumatic injury.
• Clinical examination may show a cavity, a composite or a
metallic restoration, or a full coverage crown under which
the pulp may have died without causing symptoms.
• In other cases the patient may complain of slight pain in
relation to the tooth, particularly during mastication.
• Tooth does not react to electric pulp tests.

40. DIFFERENTIAL DIAGNOSIS
• Abscess due to presence of a diffuse area
• Asymptomatic apical periodontitis due to a
circumscribed area
• Cyst due to a sclerotic bony outline
• Cannot be differentiated from other periradicular
diseases unless the tissue is examined histologically.
TREATMENT
• Elimination of infection in root canal.
• Once this end is accomplished and the root canal is
filled, repair of the periradicular tissues generally
take place.

41. RADICULAR CYST
(CYSTIC APICAL PERIODONTITIS)
Cyst is a closed cavity or sac internally lined with
epithelium, the centre of which is filled with fluid or
semisolid material.
Cysts of the jaws are divided into:
• ODONTOGENIC CYSTS arise from odontogenic
epithelium and are classified as follicular, arising
from the enamel organ or follicle, and radicular
arising from the cell rests of mallasez.

42. •NON ODONTOGENIC CYSTS are classified as
either fissural, arising from epithelial remnants
entrapped in the fusion of the facial processes, or
nasopalatine, arising from the remnants of
nasopalatine duct.
•PSEUDOCYSTS or NON EPITHELIAL CYSTS
are bony cavities that are not lined with epithelium
and therefore, are not truly cysts. They are divided
into traumatic cysts, idiopathic bone cavities, and
aneurysmal bone cysts.

44. CAUSES
A radicular cyst presupposes physical, chemical,
or bacterial injury resulting in death of the pulp,
followed by stimulation of the epithelial rests of
mallasez, which are normally present in the PDL.
Two distinct categories of radicular cysts were
described by Nair:
a) periapical pocket cyst
b) periapical true cyst

45. • PERIAPICAL POCKET CYST-The cyst contains
an epithelial lined cavity that is open towards
the root canal of the affected tooth. It was
originally designated as bay cyst and is now
redesignated as the periapical pocket cyst.
• PERIAPICAL TRUE CYST-The cyst is
characterised by cavities that are completely
enclosed in epithelial lining and are totally
independent of the root canal of the affected
tooth.

46. SYMPTOMS
No symptoms are
associated with the
development of a cyst,
except incidental to
necrosis of the pulp.
The pressure of the
cyst may be sufficient
to cause movement of
the affected teeth,
owing to accumulation
of cystic fluid.in such
cases, the root apices
of the involved tooth
becomes spread
apart,so the crowns
are forced out of
alignment. The teeth
may also become
mobile.
If left untreated,a cyst
may continue to grow
at the expense of the
maxilla or mandible.

47. DIAGNOSIS
• Tooth does not react to electrical or thermal stimuli,and
results of other clinical tests are negative,except the
radiograph.
• Radiographically, one sees loss of continuity of the lamina
dura with an area of rarefaction.
• The radiolucent area is generally round in outline,except
when it approximates adjacent teeth, in which case it may
be flattened and may have an oval shape.
• The radiolucent area may be larger than a chronic apical
abscess and may include more than one tooth.

49. DIFFERENTIAL DIAGNOSIS
• Asymptomatic apical periodontitis
• Normal bone cavity such as an incisive foramen
• Globulomaxillary cyst
• Traumatic bone cyst
• Lateral periodontal cyst
TREATMENT
• The treatment of choice is non surgical root canal
therapy alone,followed by periodic observation.
• Surgical teatment is indicated if a lesion fails to
resolve or if symptoms develop.

50. CONDENSING OSTEITIS
Condensing osteitis is a diffuse radiopaque lesion
believed to represent a localised bony reaction to
a low grade inflammatory stimulus, usually seen
at the apex of a tooth in which there has been a
long standing pulpal pathosis.

51. CAUSES
• It is a mild irritation from pulpal disease that stimulates
osteoblastic activity in the alveolar bone.
SYMPTOMS
• Usually asymptomatic
• Discovered during routine radiographic examination
DIAGNOSIS
• Made from radiographs
• Appears as a localised area of radiopacity surrounding the
affected root.

52. • It is an area of dense bone with reduced
trabecular pattern.
• The mandibular posterior teeth are most
frequently affected.

53. A. Apical condensing osteitis associated with
chronic
pulpitis. Endodontic treatment has just been
completed. Obvious
condensation of alveolar bone (black arrow) is
noticeable around
the mesial root of the first molar. Radiolucent
area is evident at the
apex of the distal root of the same tooth. The
retained primary
molar root tip (open arrow) lies within the
alveolar septum mesial
to the molar.
B, Resolution (arrow) of apical condensing
osteitis
shown in A, 1 year after endodontic treatment.

54. TREATMENT
• Removal of the irritant stimulus
• Endodontic treatment should be initiated if
signs and symptoms of irreversible pulpitis
are diagnosed.

55. EXTERNAL ROOT RESORPTION
External root resorption is a lytic process
occurring in the cementum and dentin of the
roots of teeth.

56. CLASSIFICATION
TOOTH RESORPTION
EXTERNAL INTERNAL
EXTERNAL
SURFACE
RESORPTION
EXTERNAL
INFLAMMATORY ROOT
RESORPTION
EXTERNAL REPLACEMENT
RESORPTION OR ANKYLOSIS

57. CAUSES
Although unknown, the suspected cause is-
• Periradicular inflammation due to trauma
• Excessive forces
• Granuloma
• Cyst
• Central jaw tumors
• Replantation of teeth
• Bleaching of teeth
• Impaction of teeth
• Systemic diseases
• If no cause is evident, the disorder is called idiopathic
resorption

58. SYMPTOMS
• Asymptomatic
• When the root is completely resorbed,the tooth
may become mobile
• If the external root resorption extends into the
crown, it will give appearance of “pink tooth”
seen in internal resorption
• Root resorption of the type called replacement
resorption or ankylosis, in which the root is
gradually replaced by bone, renders the tooth
immobile, in infra occlusion, and with a high
metallic percussion sound.

59. DIAGNOSIS
• Small areas of resorption cannot be seen radiographically
and histologically
• External inflammatory root resorption is usually
diagnosed by radiographs. External resorption appears as
concave or ragged areas on the root surface or as blunting
of the apex.
• Areas of inflammatory resorption caused by the pressure
of a growing granuloma, cyst or tumour have an area of
root resorption adjacent to the area of radiolucency.
• Areas of ankylosis have a resorbed root with no PDL
space and with bone replacing the defects.

60. DIFFERENTIAL DIAGNOSIS
• Internal resorption
• In external resorption the radiograph shows a
blunting of apex,a ragged area, a “scooped
out” area on the side of the root.
• In internal resorption one sees a root canal
with a well demarcated, enlarged
“ballooning” area of resorption.

61. TREATMENT
• Root canal therapy if caused by extension of
pulpal disease
• By reducing the excessive forces if caused by
orthodontic appliance
• In cases of external cervical root resorption,
intervention in the form of surgical exposure of
the defect and restoration with a suitable
restorative material is the treatment of choice
before the resorptive defect invades the pulp
tissue.

62. PERSISTANT APICAL
PERIODONTITS
It is a post treatment apical periodontitis in an
endodontically treated tooth.
CAUSES
• Apical periodontitis may persist basically because of
anatomical complexity of pulp space system with
regions that cannot be reached with instruments or
with irrigants or intracanal medicaments.
• Nair had highlighted certain extra radicular factors
that contribute to persistent apical periodontitis.
These are-
-apical biofilms or periapical plaque
-actinomycotic infection

63. -Cholesterol crystals
-Foreign body reaction to gutta percha
-Cellulose granuloma
-Periapical scar tissue

64. CONCLUSION
The periapical diseases are a result of the
noxious stimuli in pulp which may be
mechanical, thermal, physical or
chemical. A tooth affected by periapical
diseases should always be treated, it
cannot just be ignored. There are two
available treatment options, namely to
extract the tooth or to perform
endodontic treatment and retain the
tooth.

65. REFERENCES
• Grossman’s Endodontic Practice (13th Edition)
• Textbook of Oral Pathology by Shafer, Hine & Levy
(4th Edition).
• Textbook of Endodontics- Nisha Garg. (3rd Edition)