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Pulp and Periapical

Chapter 3
Also notes from biopsy techniques

Teeth are non-vital

Condensing Osteitis

Two periapical films showing well defined radiopacity at apex of Mn 1st


molar, exibits root tip absorption and loss of lamina dura and some
widening of the PDL space. Both lesions are present on teeth with
crown or extensive caries
Differential
Condensing osteitis--look for large carious lesion or crown
(this is correct for previous 2 radiographs)
Idiopathic osteosclerosis (bone scar) (because the tooth is nonvital you can rule this out--Also note that the PDL space is rarely
obliterated with bone scars
Osteoma (a smaller lesion)--look for multiple impacted
supernumerary teeth and odontomas--can tip you off to Garnders
Periapical cemento-osseous dysplasia-- if pt. was female and
african and pulp vital! (so this can be ruled out)
Cementoblastoma--these can be differentiated by a thin
radiolucent border and they generally show fusion to the root from
which it arose

Treatment
Root canal therapy

Patient reports severe


pain to heat extremes
Spontaneous pain
Response to Electric pulp
test is erractic
Onset has been about a
week

Irreversable Pulpitis
Occlusal view and periapical radiograph of tooth #14
showing enlarged pulp and occlusal mass protruding
through the dentin
Differential
Irreversible pulpitis
Periapical abcess-remember if you see a cyst at the apex it
means that a cyst was there before the abcess--abcess is
acute--it dosent have enough time to wear through the bone
and make a well-defined radiolucency

Treatment
Endo
extraction

Sensitive to heat
extremes
Pain goes away when
thermal stimulus
removed
No spontaneous pain
Responds at lower
currents to electric
pulp testing

Reversible Pulpitis
Differential Reversible pulpitis
Recurrent caries

Treatment
Remove agent that is causing the inflammation

Note the white


arrow

Radiograph of
same tooth

Periapical Abscess
Tooth #3 has widened PDL on DB root, parulis (a result of
purulent drainage) has collected near the apex of the DB root
tip. No distinct radiolucency noted and pt reports acute onset
Differential
Scleroderma (systemic sclerosis) generalized widening of
PDL
Sarcoma or carcinoma
Treatment
Root canal therapy

If the teeth are VITAL and you see any


radioLUCENCY in the jaw you must biopsy!!

Teeth are vital

Idiopathic (focal) Osteosclerosis


Differential
Cemento-osseous dysplasia
Complex odontoma

Treatment
None b/c its a radiopacity

African woman, vital teeth

Periapical cemento-osseous dysplasia

Differential
Complex odontoma
Idiopathic osteosclerosis

Treatment
None, you dont worry about a biopsy b/c
african and anterior MN

Pt has history of
infected MN molar
and/or root
fracture & airway
obstruction

Ludwigs Angina
Swelling of the submandibular, submental and
sublingual spaces with resulting airway obstruction
Differential
Thyroid gland enlargement, Thyroglossal duct cyst, dermoid
cyst

Treatment
Aggressive use of antibiotics, drainage, in some pts may
need to perform tracheostomy

Cavernous Sinus Thrombosis


Grave concern is raised when the infection
encroaches on the eyelid or affects vision,
because the ophthalmic (angular) veins lack
valves and spread of infection to the brain is
possible

Treatment
drainage, antibiotics, high mortality rate

Teeth are vital

Periapical cyst or Granuloma


Loss of lamina dura around effected roots
Differential
Impossible to tell difference b/w cyst or granuloma from
radiograph alone--need biopsy (cysts are the result of cell
rests of Malassez being in the area of inflammation)
Periapical scar-radiolucency will persist if scar is formed
If on the side of root (not at apex) then lateral radicular cyst
Treatment
Root canal therapy with follow up to make sure the lesion
has healed

Biopsy techniques

Get normal tissue with abnormal tissue


If surface lesion--dont need to go too deep
If swelling or mass--the deeper the better
Dont biopsy the middle of an ulcer
Lasso technique
Mark with sutures
Punch biopsy--5mm minimum
Include picture and differential with as much clinical
info as possible--this is very important
Contact the pt right away with results!!

Traumatic (simple) bone cyst


Not a true cyst; posterior mandible; asymptomatic or painless
swelling
X-ray: well-defined unilocular radiolucency; scalloped
appearance in multiple teeth involvement
Histo: fibrovascular CT & trabecular bone; cyst may be empty
Tx: surgical exploration & tissue submission; good prognosis,
rapid new bone formation
DD: periapical granuloma, periapical cyst, periapical cementoosseous dysplasia, periapical scar, dentin dysplasia type 1
(page 804)

Granular Cell Tumor


-no diff. diagnosis in book
-nodular mass under skin or mucosa
-tongue and buccal muscoa
-schwann cell origin or neuroendocrine cells
tx: local excision

Allergic Stomatitis Dentifrice Stomatitis


-pseudomembranous candidiasis, morsicatio, sloughing traumatic lesion, mouthwash,
chemical burn
-burning, slight redness to brilliant erythematous lesion, edema possible, superficial aphthous
ulcerations possible, stinging tingling, *superficial epithelial sloughing
-located at site of contact
-dentifrice, medications, lip stick, metals
-tx: remove allergen, antihistamines if necessary

Angioedema
-no diff. Dx listed in book
-diffuse edematous swelling of soft tissue, nontender, solitary or multiple
-face, lips, tongue, pharynx, larynx, hands, arms, legs, genitals, buttocks
-cause: mast cell degranulation which leads to histamine release and typical IgE
hypersensitivity reaction from drugs, foods, plants, dust, heat cold, stress, complement
cascade is common in hereditary andioedema
-tx: oral antihistamines, intramuscular epi,