[Overview]
Chronic periapical periodontitis is a secondary disease of pulp disease. It is a chronic inflammatory reaction of periapical tissue caused by long-term irritants in root canal, which is manifested by the formation of inflammatory granulation tissue and the destruction of alveolar bone. In addition, acute periapical periodontitis can be transformed into chronic periodontitis if it is not thoroughly treated.
Chronic periapical periodontitis generally has no obvious pain symptoms. According to its pathological changes, it can be divided into apical granuloma, chronic apical abscess, apical cyst and apical compact osteitis.
[Diagnostic Points]
1. Most of the medical history features have no obvious symptoms, but they have weakness in occlusion, discomfort in percussion or strange feeling. At the time of examination, most of the teeth had deep holes, and the teeth were dark gray, and the pulp vitality test was unresponsive.
2. There may be sinus formation in the mucosa or skin of the root tip of the tooth.
3.x-ray film shows the image of bone destruction in the apical area of the affected tooth as a diagnostic basis. Diffuse bone sparse area can be seen in apical abscess; Apex granuloma is characterized by sparse bone area being round or oval, with obvious boundary with normal bone and small lesion area. Apical cyst has dense bone white line outside the circular or elliptical bone sparse area.
[Differential diagnosis and its basis]
Pay attention to the differentiation from non-odontogenic jaw cysts and other tumors. The pulp vitality of the latter is normal, and the periodontal ligament space is a continuous and regular transmission image.
[therapeutic principle]
1. Thoroughly remove irritants in root canals, eliminate infection sources that cause periapical periodontitis, promote periapical tissue healing and restore health.
2. Differentiate different types and make different treatment plans. Generally, root canal therapy or pulp plasticization can be selected, but large-scale apical granuloma and apical cyst often need to be supplemented by root canal surgery.
3. The teeth suffering from periapical compact osteitis generally have no discomfort symptoms and do not need treatment.
[Case study]
Patient, male, 45 years old. Self-reported recurrent pus 1 week in the left lower posterior teeth.
Examination: the occlusal surface of the left lower 6 teeth was exposed to deep caries, the crown turned black, the bottom of the cavity was not sensitive, and the percussion was uncomfortable; There is a millet-shaped gingival sinus at the root tip of the affected tooth, which is crowded with pus. There was no obvious loosening of teeth and no response to cold and hot diagnosis.
X-ray film shows that there is a transmission shadow area with large area, irregular shape and blurred edge at the apex of the left lower 6 heart.
Accordingly, please: ① Make a diagnosis. ② Briefly describe the pathogenesis. ③ Draw up a treatment plan. 1. Diagnose chronic periapical periodontitis (chronic periapical abscess) in the lower left 6.
Diagnostic basis: the teeth are dead pulp teeth with deep caries and gingival sulcus at the apex; More importantly, the X-ray shows that there is a large, irregular and blurred transmission shadow area at the apex of the heart.
2. Pathogenesis 6. Deep caries caused pulpitis, and the infected pulp was not treated in time, which led to pulp necrosis and became the source of root canal infection; Due to the role of pathogenic irritants in root canal, the normal periodontal ligament tissue structure of root tip is destroyed and inflammatory granulation tissue is formed. With the development of the lesion, the inflammatory granulation tissue increases, and the blood supply is difficult to reach the granulation center. The cells in the center of the lesion are necrotic and liquefied, eventually forming pus, which stays in the pus cavity of the apical part and becomes chronic apical abscess, also known as chronic alveolar abscess.
3. Treatment plan
(1) selective root canal therapy. Gingival sinus root canal therapy can be closed after 1-2 weeks, generally without additional treatment.
(2) Regular postoperative review. If the sinus does not disappear and the shadow does not shrink after 3 months of follow-up, it means that root canal treatment has failed, and the lesion can be cured after root canal treatment or root tip curettage.
[Thinking]
1. On the diagnostic points of chronic periapical periodontitis.
2. Please describe the diagnosis points of periapical cyst and non-odontogenic intramaxillary cyst.
3. Please describe the treatment principle of chronic periapical periodontitis.