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Diseases of the Periapical Tissue



After the pulp dies, the inflammatory process will frequently extend through the apical or lateral foramina into the adjacent tissues. Among the resulting diseases are acute periapical inflammation, periapical granuloma, radicular cyst, and periapical abscess. Extensions of infections originating in teeth may lead to such conditions as osteomyelitis and Ludwig's angina.


Acute inflammation of the periapical tissue usually represents an extension of acute pulpal inflammation. The periapical tissues become inflamed and the tooth is usually very tender when used in mastication. No pathology is seen in the bone on a radiograph. The treatment consists of either root canal therapy or extraction.


A chronic inflammatory condition may occur and cause little or no pain. It may persist for a long time and pathology is usually seen in the bone on a radiograph. There may also be a sinus track present in the gingiva adjacent to the tooth.


The inflammation in the periapical tissues is very severe resulting in swelling, fever, and sharp pain. An incision and drainage may be necessary to relieve the pain and drain the pus. There is generally no pathology seen in the bone on a radiograph. (This abscess is nearly always the result of a change from an existing chronic infection.)


The symptoms and treatment are the same as those for the acute apical abscess. However, pathology can be seen in the surrounding bone on the radiograph.


Periapical Granuloma. Periapical (or radicular) granuloma is a common result of pulpitis. It is a mass of granulation tissue that forms at the apical/lateral foramen in response to chronic inflammation caused by necrosis of the pulp tissue. It is composed of capillaries, inflammatory cells, fibroblasts, collagen, and macrophages. It is this type of tissue that fills the bony defect seen on radiographs.

Periapical Cyst (Radicular Cyst) (Figures 1-2 and 1-3). A periapical cyst (or radicular cyst) often forms from proliferation of islands of odontogenic (tooth origin) epithelium present within a radicular granuloma. The cystic lesion consists of a fluid-filled cavity that is lined with epithelium. The cyst generally develops from a long-standing periapical granuloma.

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Figure 1-2. Periapical cyst, bone destruction.

NOTE: This radiograph shows extensive destruction of bone in the periapical region of the mandibular incisor teeth. Note the extensive carious involvement of these teeth. A biopsy is necessary to determine whether a cyst or a granuloma has developed. Both have a similar appearance on a radiograph.


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Figure 1-3. Periapical cyst, excised.

NOTE: This cyst was removed from the root area of a patient's tooth.


Ludwig's angina is a profound infection clinically characterized by a firm swelling of the floor of the mouth and elevation of the tongue. Swelling may spread into the tissues of the neck that can cause swelling of the tissues and airway obstruction that can cause death. This condition is relatively rare but very dangerous. It is commonly accompanied by fever, pain, and serious interference with breathing. Extensions of infection from carious teeth, extraction sites, or tonsils may cause this disease. Treatment includes establishing an airway, administering antibiotics to control infection, and establishing drainage through incision. Referral to an oral and maxillofacial surgeon is usually required.

David L. Heiserman, Editor

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Revised: June 06, 2015