Oral Pathology Periapical Disease

Front 1

Does a periapical abscess result from acute or chronic periapical inflammation?

Back 1

Periapical abscess = Acute

Front 2

Does a periapical granuloma result from acute or chronic periapical inflammation?

Back 2

Periapical granuloma = Chronic inflammation

Front 3

What are some complications if a Periapical Abscess enters the blood stream?

Back 3

Bacteremia
Cavernous sinus thrombosis

Front 4

What are some complications from Periapical Abscess penetration?

Back 4

Penetration of the:
Mucosal sinus
Skin sinus

Front 5

What are some complications if a Periapical Abscess Spreads to Soft Tissues?

Back 5

Abscess
Cellulitis

Front 6

What are some complications if a Periapical Abscess Spreads through the jaw?

Back 6

Osteomyelitis
Periosteitis

Front 7

What are some complications if a Periapical Abscess becomes chronic?

Back 7

Chronic abscess
Chronic osteomyelitis

Front 8

What condition arises as a result of a periapical granuloma?

Back 8

Periapical (Radicular) Cyst

Front 9

What is a mass of chronically inflamed granulation tissue at the apex of a non-vital tooth?

Back 9

Periapical Granuloma (Chronic apical Periodontitis)

Front 10

What are the Clinical Features of a Periapical Granuloma?

Back 10

1. Asymptomatic but pain with acute exacerbation
2. Tooth shows No mobility or sensitivity to percussion
3. Tooth is NON-VITAL so it does Not respond to pulp testing

Front 11

What are the Radiographic features of a Periapical Granuloma?

Back 11

1. Circumscribed or ill-defined radiolucency
2. Loss of apical Lamina Dura
3. Root Resorption possible
4. Cannot differentiate a periapical granuloma from a cyst based on size and radiographic appearance

Front 12

How is a Periapical Granuloma Treated?

Back 12

1. Root canal (if tooth is restorable)
2. Extract tooth and curettage of all apical soft tissue for microscopic examination (Non-Restorable tooth)
3. Follow restored asymptomatic teeth at 1 & 2 year intervals

Front 13

What are some of the possible sources of epithelium to create a Periapical Cyst? (radicular cyst, apical periodontal cyst)

Back 13

Sources of epithelium include:
1. Rests of Malassez (most common)
2. Crevicular epithelium
3. Sinus lining
4. Sinus tract epithelium

Front 14

What are the clinical features of a Periapical Cyst?

Back 14

1. Asymptomatic unless there is an acute exacerbation
2. Swelling and sensitivity from large cysts
3. Mobility of adjacent teeth as cyst enlargens
4. Non-Vital tooth (does not respond to pulp testing)

Front 15

What malignancy has been rarely reported in a periapical cyst?

Back 15

Squamous Cell Carcinoma

Front 16

What is the accumulation of acute inflammatory cells at the apex of a non-vital tooth?

Back 16

Periapical abscess

Front 17

What are two situations that would lead to periapical abscess?

Back 17

1. de novo
2. acute exacerbation of a chronic periapical lesion

Front 18

What are the clinical features of Periapical Abscess?

Back 18

1. Acute vs Chronic
2. Symptomatic vs Asymptomatic
2a. Symptomatic: pain, sensitivity to percussion, extruded tooth, and swelling
3. No response to Cold or Electric pulp testing
4. Headache, chills, fever, and malaise

Front 19

What are the radiographic features of a Periapical Abscess?

Back 19

1. PDL may appear thickened or an ill-defined radiolucency
2. May not appear on radiograph if little bone destruction has occurred

Front 20

How is a periapical abscess treated?

Back 20

1. Drain and eliminate the focus of the infection
2. Source of infection removed using endodontics or extraction
3. Analgesics & antibiotics are needed in severe cases

Front 21

What should you do if a periapical abscess progresses to a parulis?

Back 21

It may subside after endo or extraction. If not it is surgically removed along with curettage of the sinus tract

Front 22

What is a mass of subacutely inflamed granulation tissue at the opening of the intraoral sinus tract?

Back 22

Parulis (gum boil)

Front 23

What are the clinical features of a parulis?

Back 23

1. red tumescence (or yellow if pus filled)
2. Buccal gingiva
3. Children and young adults
4. Asymptomatic

Front 24

What is the cause of a parulis?

Back 24

Parulis is caused by inflammation arising from a periodontal or periapical abscess

Front 25

What is the significance regarding drainage of a parulis?

Back 25

Cyclical drainage occurs until the underlying condition is resolved

Front 26

What is a diffuse inflammation of soft tissues, which is not circumscribed or confinded to one area, but which in contradistinction to an abscess, tends to spread through tissue spaces and along fascial planes?

Back 26

Cellulits

Front 27

What are the two dangerous forms of cellulitis that are of interest to dentists?

Back 27

Ludwig Angina
Cavernous Sinous Thrombosis

Front 28

What are the Clinical features of Ludwig Angina?

Back 28

1. Swelling of floor of mouth, tongue and submandibular region
2. Sublingual space involvement causes posterior enlargement, elevation and protrusion of the tongue (woody tongue)
3. Submandibular space enlargement causes enlargement and tenderness of the neck about the hyoid bone (bull neck)
4. Initially unilateral but progresses to bilateral
5. Pain in neck and floor of mouth
6. Dysphagia, dysphonia, dysarthria, drooling, sore throat and restricted neck movement may occur
7. Involvement of lateral pharyngeal space can cause respiratory obstruction
8. Tachypnea, dyspnea, tachycardia, stridor and restlessness
9. Fever, chills, leukocytosis and elevated SED rate is common

Front 29

What is the treatment of Ludwig Angina?

Back 29

1. Maintenance of the airway
2. Antibiotic therapy
3. Surgical drainage

Front 30

What is the prognosis for Ludwig angina?

Back 30

With appropriate therapy, the incidence of mortality is 8%

Front 31

What are the clinical features for Cavernous Sinus Thrombosis?

Back 31

1. Swelling around the eye with enlargement of the eyelids and conjunctiva
2. Protrusion and fixation of the eyeball may occur
3. Induration and swelling of forehead and nose is common
4. Lacrimation, photophobia, pupil dilation and loss of vision
5. Pain over the eye and along the opthalmic and maxillary branches of the trigeminal nerve occurs
6. Fever, chills, sweating, tachycardia, nausea and vomiting
7. CNS involvement includes tachycardia, tachypnea, irregular breathing, stiff neck, stupor and delirium
8. Brain abscess possible

Front 32

What is the treatment for Cavernous Sinus Thrombosis?

Back 32

1. Extract tooth
2. Establish drainage
3. High dose antibiotics
4. Corticosteroids to decrease inflammation and prevent vascular collapse
5. Anticoagulant may or may not help. One theory is they prevent thrombosis and septic emboli, but some say their usage increases vascular complications.

Front 33

What is an acute or chronic inflammatory process in the medullary spaces or cortical surfaces of bone that extends away from the intitial site of involvement. In the oral region, it is usually a bacterial infection.

Back 33

Osteomyelitis

Front 34

What are some predisposing factors of osteomyelitis?

Back 34

1. Alcohol & tobacco use
2. IV drug use
3 Diabetes mellitus
4. Malaria
5. Anemia
6. Malnutrition
7. Malignancy
8. AIDS
9. Radiation, osteopetrosis, osteitis deformans (Paget disease) and late stage cemento-osseous dysplasia may result in hypovascularized bone

Front 35

What are the demographics for Acute Osteomyelitis?

Back 35

1. All ages may be affected
2. Men mostly
3. Mandible primarily involved

Front 36

What are some of the clinical manifestations of Acute Osteomyelitis?

Back 36

Fever, leukocytosis, lymphadenopathy, significant sensitivitym pain or paresthesia may occur. Soft tissue swelling and redness may be present.

Front 37

How does Acute Osteomyelitis appear radiographically?

Back 37

1. Radiographs may be unremarkable or demonstrate an ill-defined radiolucency
2. Fragments of necrotic bone may separate from vital bone and be exfoliated (sequestrum)

Front 38

How is Acute Osteomyelitis treated?

Back 38

Antibiotics and drainage
Most of the time this is sufficient and does not need surgery

Front 39

What are some clinical manifestations of Chronic Osteomyelitis?

Back 39

1. Swelling, pain, sinus formation, purulent discharge, sequestrum formation, tooth loss or pathologic fracture may occur.
2. During quiescent periods, the lesions may be asymptomatic or present minimal discomfort

Front 40

What does Chronic Osteomyelitis look like radiographically?

Back 40

Patchy, ragged, and ill-defined radiolucency often containing sclerotic foci. This is often referred to as a Moth-Eaten pattern

Front 41

How is Chronic Osteomyelitis treated?

Back 41

1. Antibiotics administered Intravenously in High Doses
2. Surgical removal of all infected tissue
3. Scintigraphic techniques
4. Hyperbaric oxygen
5. Direct delivery of antibiotics via antibiotic-impregnated polymethyl-methacrylate beads

Front 42

What diagnosis encompasses a group of presentations that are characterized by pain, inflammation and varying degrees of gnathic periosteal hyperplasia, sclerosis and lucency?

Back 42

Diffuse Sclerosing Osteomyelitis

Front 43

What are three categories that Diffuse Sclerosing Osteomyelitis is discussed?

Back 43

1. Diffuse sclerosing osteomyelitis
2) Chronic Tendoperiostitis
3) SAPHO syndrome

Front 44

When is the term Diffuse Sclerosing Osteomyelitis allowed?

Back 44

Only in cases where the infectious process is Directly (not secondarily, ie florid cemento-osseous dysplasia with superimposed inflammation) responsible for the bony sclerosis

Front 45

What is a residual area of condensing osteitis that remains after resolution of the inflammatory focus?

Back 45

Bone Scar

Front 46

What is characterized as localized areas of bone sclerosis associated with the apices of teeth with pulpitis or pulpal necrosis?

Back 46

Condensing Osteitis

Front 47

What is another term for condensing osteitis?

Back 47

Focal Sclerosing Osteomyelitis = Condensing Osteitis

Front 48

What are some other terms for Osteomyelitis w/Proliferative Periostitis?

Back 48

Osteomyelitis w/Proliferative Periostitis = Periostitis Ossificans = Garre's Osteomyelitis

Front 49

If bony destruction is seen in association with the cortical surface or new periosteal bone, then one should consider the possibility of a neoplastic process like Ewing sarcoma. What condition is this associated with?

Back 49

Proliferative periostitis

Front 50

What are the other terms for Alveolar Osteitis?

Back 50

Dry Socket = Fibrinolytic Alveolitis = Alveolar Osteitis

Front 51

What develops as a result of destruction of the blood clot which naturally occurs following tooth extraction, preventing normal healing?

Back 51

Alveolar Osteitis

Front 52

Local trauma, estrogens and bacterial pyrogens are known to stimulate _______ which can destroy the clots. This is Alveolar Osteitis.

Back 52

Fibrinolysins

Front 53

What is the frequency of Alveolar Osteitis related to extrations?

Back 53

25-30% of impacted mandibular 3rd molar extractions
1-3% of all extractions overall

Front 54

How long does it take to develop dry socket and once established, how long until it resolves?

Back 54

3-4 days develop
10-40 days resolve

Front 55

Which patients are high risk for Alveolar Osteitis?

Back 55

1. Taking oral contraceptives
2. Smokers
3. Existing pericoronitis
4. alveolar osteitis Hx
5. more traumatic extractions

Front 56

Which patients are high risk for Alveolar Osteitis?

Back 56

1. Taking oral contraceptives
2. Smokers
3. Existing pericoronitis
4. alveolar osteitis Hx
5. more traumatic extractions

Front 57

How does Acute Osteomyelitis Present Radiographically?

Back 57

Unremarkable or have an ill-defined radiolucency
Necrotic bone separates,forming sequestrum

Front 58

Which condition presents clinically as Fever, leukocytosis, lymphadenopathy, significant sensitivity, pain or paresthesia, soft tissue swelling and redness?

Back 58

Acute Osteomyelitis

Front 59

How is Acute Osteomyelitis treated?

Back 59

Antibiotics and Drainage
Rarely need surgery

Front 60

How does Chronic Osteomyelitis present radiographically?

Back 60

Patchy, ragged, and ill-defined radiolucency, sclerotic foci, Moth Eaten

Front 61

Which condition presents as Swelling, pain, sinus formation, purulent discharge, sequestrum, tooth loss, pathologic fracture?

Back 61

Chronic Osteomyelitis

Front 62

How is Chronic Osteomyelitis treated?

Back 62

IV antibiotics in high doses
Surgical removal of infected tissue
Scintigraphic, Hyperbaric oxygen, Direct delivery of antibiotics

Front 63

What demographic is mostly affected by Diffuse Sclerosing Osteomyelitis?

Back 63

Adults

Front 64

How does Diffuse Sclerosing Osteomyelitis manifest radiographically?

Back 64

Increased radiodensity around sites of chronic infection. Multifocal or entire quadrant.

Front 65

How does Diffuse Sclerosing Osteomyelitis present clinically?

Back 65

No pain or swelling

Front 66

How is Diffuse Sclerosing Osteomyelitis treated?

Back 66

Remove the source of the infection

Front 67

How does Chronic Tendoperiostitis present radiographically?

Back 67

Areas of radiolucency are observed in areas of radiodensity. Sclerosis is limited to one quadrant. Erosion of inferior border of mandible.

Front 68

How does Chronic Tendoperiostitis manifest clinically?

Back 68

Recurrent pain, swelling of cheek and trismus

Front 69

How is Chronic Tendoperiostitis treated?

Back 69

Resolving muscle overuse (relaxation techniques, exercises, splints)

Front 70

What does SAPHO stand for?

Back 70

Synovitis Acne Pustulosis Hyperostosis and Osteitis

Front 71

What demographic is most affected by SAPHO?

Back 71

< 60 years old mostly affected

Front 72

How does SAPHO present radiographically?

Back 72

Diffuse areas of osteolysis with some bony sclerosis

Front 73

What is another term for SAPHO (Synovitis Acne Pustulosis Hyperostosis and Osteitis)?

Back 73

CRMO (Chronic Recurrent Multifocal Osteomyelitis)

Front 74

What is significant regarding clinical manifestation of SAPHO?

Back 74

Bone lesions may present without associated skin involvement

Front 75

How is SAPHO treated?

Back 75

Steroids and NSAIDs
Typically incomplete resolution

Front 76

Who is mostly affected by Condensing or Focal Sclerosing Osteitis?

Back 76

Children in the Mandibular molar/premolar region

Front 77

How does Condensing Osteitis present radiographically?

Back 77

Radiodensity near the apex of the tooth exhibiting a thickened PDL or apical inflammatory lesion
No radiolucent border
Not separated from apex of tooth

Front 78

What causes condensing osteitis?

Back 78

Tooth pulp has pulpitis or necrosis

Front 79

How is Condensing Osteitis treated?

Back 79

Do NOT expand the jaw during diagnosis
Endodontics or extraction
bone scar

Front 80

What age is most affected by Osteomyelitis with proliferative periostitis?

Back 80

mean age of 13
affects the mandibular molar/premolar region and inferior border of the mandible

Front 81

How does Osteomyelitis with proliferative periostitis present radiographically?

Back 81

Radiopaque laminations of bone that roughly parallel each other and the underlying cortical surface

Front 82

How does Osteomyelitis with proliferative periostitis manifest clinically?

Back 82

It is a periosteal reaction to the presence of inflammation from a Carious tooth.
Periosteum forms rows of reactive, vital bone that parallel each other and expand the bone

Front 83

How is Osteomyelitis with proliferative periostitis treated?

Back 83

Endodontics or Extraction
Typically takes 6-12 months to resolve after treatment

Front 84

What age range is most affected by alveolar osteitis?

Back 84

40-45

Front 85

How does alveolar osteitis present clinically?

Back 85

Clot is lost leaving a bare bony socket.
Severe pain and foul odor

Front 86

How is Alveolar Osteitis treated?

Back 86

Irrigate the socket then pack with an obtundent and an antiseptic dressing (iodoform gauze with eugenol)
Change dressing every 24 hours for the first 3 days the every 2-3 days

Front 87

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What are three Periapical conditions that are associated with NON-Vital teeth?
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Back 87

1. Periapical Cyst
2. Periapical Granuloma
3. Periapical Abscess