Periodontal And Periapical Diseases

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Periodontal And Periapical Diseases
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Periodontal Disease
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Usefulness of Radiographs

• Amount of bone present
• Condition of alveolar crest
• Bone loss in furcation areas
• Width of periodontal ligament
• Local factors calculus, overhanging restorations
• Crown/root ratio

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Limitations of Radiographs

• No indication of morphology of bony defects
• No indication of successful management
• No indication of hard/soft tissue relationship,
  i.e., depth of pockets

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Normal Alveolar Crest

• 1.0-1.5 mm apical to cemento-enamel junction
• Parallel to line joining the CEJ of adjoining
  teeth
• Smooth
• Continuation of lamina dura, has the same
  radiopacity

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Evidence of Early Periodontitis

• Localized erosion of crest of bone
• Blunting of crest- anterior teeth
• Loss of sharp angle between lamina dura and crest
• Widening of PDL near crest

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Local Factors

• Calculus
• Overhanging restorations
• Poor restoration contours

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Calculus
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Overhanging Restoration
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Buccal VS Lingual Bone Loss
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Direction Of Bone Loss

• Horizontal Bone Loss
  Crest of bone is parallel to CEJ line between
  adjoining teeth. The remaining bone is still
  horizontal but may be positioned apically.

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Direction Of Bone Loss

• Vertical bone loss
• Crest of remaining bone is not parallel to the
  CEJ line between adjoining teeth (displays an
  oblique angulation to the CEJ line )

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Bone Loss In Bifurcation/trifurcation Areas
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Bitewing Radiographs Most Reliable For Crestal
Bone Evaluation
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Generalized Periodontal Disease
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Juvenile Periodontitis(Early-onset
Periodontitis, Rapidly Progressing Periodontitis)

• Occurs in healthy individuals between puberty and
  age 25
• Amount of bone loss is not consistent with local
  factors and oral Hygiene habits. Rate of bone
  loss is 3-4 times faster than in typical
  periodontitis

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Juvenile Periodontitis(cont.)

• Typically affects crestal bone of first molars
  and incisors. Eventually affects greater of
  teeth.
• Bone loss is progressive and frequently
  bilaterally symmetrical. Many teeth show vertical
  bone loss.
• Host neutrophil dysfunction has been demonstrated
  by several investigators.

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Papillon-Lefevre Syndrome

• Autosomal recessive trait
• Hyperkeratosis of palms and soles
• Occasional keratosis of other skin surfaces
• Calcification in falx cerebri
• Severe destruction of alveolar bone involving all
  deciduous and perm. teeth
• Exfoliation of teeth

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Langerhans Cell Histiocytosis (Histiocytosis X)

• Complex of three diseases
• Eosinophilic granuloma (usually solitary)
• Hand-Schuller-Christian disease (chronic)
• Letterer-Siwe disease (acute)
• Due to abnormal proliferation of Langerhans
  cells or their precursors

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Eosinophilic Granuloma of Bone

• Most common in children and young adults
• Usually single radiolucency
• Skull, mandible, vertebra and long bones commonly
  involved
• Painful, mobile teeth and gingival lesions

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Hand-Schuller-Christian Disease

• Most cases reported in children under 10 years.
  Has been reported in older individuals
• Skeletal and soft tissues may be involved
• Classic triad of symptoms
• punched out destructive bone lesions
• unilateral or bilateral exophthalmos
• diabetes insipidus
• Complete triad occurs in 25 of patients

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Hand-Schuller-Christian (Cont.)

• Oral manifestations include
• loose teeth
• exfoliated teeth
• gingivitis
• loss of alveolar bone / advanced
  periodontitis
• Sharply outlined multiple radiolucent lesions in
  skull, jaws and other bones

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Letterer-Siwe Disease

• Acute, disseminated form of disease
• Usually occurs before age 3. Most patients die
• Involves several bones and organs
• Skin rash
• Intermittent fever, enlargement of liver and
  spleen, lymphadenopathy common
• Destructive radiolucencies in jaws
• Loosening and premature loss of teeth

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Hand-Schuller-Christian Disease
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Hand-Schuller-Christian Disease
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Skull lesions of Histiocytosis X
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Other Diseases Influencing Course Of Periodontal
Disease

• Diabetes mellitus
• Leukemia

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Leukemia
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Leukemia
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Periapical Inflammatory Lesions

• Bone destruction around apex of tooth, mostly
  secondary to pulp exposure due to caries or
  trauma.
• Bacterial invasion of pulp produces toxic
  metabolites which escape to the periapical bone
  through apical foramen and cause inflammation.

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Periapical Inflammatory Lesions

• Periapical granuloma Localized mass of chronic
  granulation tissue containing PMNs, lymphocytes,
  plasma cells.

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Periapical Granuloma

• Radiographically, widening of PDL or variable
  size of periapical radiolucency may be present

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Periapical Granuloma
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Periapical Granuloma
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Periapical Abscess

• Periapical abscess When pus forms in the area.
  It may develop directly as an acute process or
  develop in a pre-existing granuloma.
  Radiographically, appears identical to granuloma.
  

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Periapical Granuloma Or Abscess

• Can one differentiate between the two on the
  basis of radiographs alone?

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Periapical Inflammatory Lesions

• Radicular cyst (periapical cyst) Cell rests of
  Mallasez (remnants of epithelial root sheath of
  Hertwig) proliferate due to inflammatory stimulus
  of a granuloma or an abscess and provide the
  epithelial lining.
• A cyst is an epithelium lined cavity which is
  filled with fluid or semi-solid material.
• Radicular cyst is the ONLY cyst related to
  non-vital pulp.

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Periapical Inflammatory Lesions

• Can you definitively differentiate between a
  periapical granuloma, abscess or radicular cyst
  on the basis of radiograph alone?

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Periapical Inflammatory Lesions

• Sclerosing osteitis (chronic sclerosing
  osteomyelitis). Occasionally, the reaction to
  periapical inflammation is predominantly
  osteoblastic, i.e., more sclerotic bone is formed
  (radiopaque mass).
• Usually occurs in children or young adults when
  the resistance is high.
• Most common location is mandibular 1st molar.

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Sclerosing Osteitis
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(Idiopathic) Osteosclerosis
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Osteosclerosis

• How do you differentiate between osteosclerosis
  and condensing osteitis?
• In osteosclerosis, the pulp is vital. There are
  no clinical signs or symptoms. No treatment is
  necessary.
• Sclerosing osteitis is secondary to pulp
  exposure. Patient is symptomatic. Endodontic
  treatment or extraction is indicated.

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Calcific Degeneration(Calcific Metamorphosis)

• Secondary to Trauma to the Tooth

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Calcific Degeneration
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Calcific Degeneration
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Radiographic Evidence Of Non-vital Teeth

• Widening of apical PDL or periapical radiolucency
  ( associated with indication of pulp exposure)
• Discontinuity of lamina dura
• Displacement of lamina dura
• Sclerosing osteitis
• Calcific degeneration (metamorphosis)
• Radiographic indication of pulp exposure

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Periapical Cemental Dysplasia

• Also called Cementoma. Localized alteration in
  periapical area. Osseous structure is replaced by
  fibrous tissue, cementum-like material, abnormal
  bone or combination of these.
• Pulp is vital. Patient is asymptomatic. There are
  no clinical signs.
• No treatment is required.
• Mean age is 39 years.

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Periapical Cemental Dysplasia

• 85 patients are females.
• 3 times more common in African-americans.
• Most commonly seen in mandibular anterior areas.
• May be multiple.
• May be bilateral.
• Well-defined radiolucency, opacity or mixed.

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Periapical Cemental Dysplasia

• Stage I ( Osteolytic stage )
• Stage II ( Osteo or cementoblastic stage)
• Stage III ( mature stage )

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Stage II
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Stage III
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Multiple
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Apical Scar (Fibrous Scar )

• Variation in healing process. Normally surgical
  site fills with blood clot which organizes and
  eventually mineralizes and remodels like
  surrounding bone.
• Occasionally, normal mineralization and
  remodeling fails to occur.
• Patient is asymptomatic and no treatment is
  required.

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Apical Scar (Fibrous Scar )
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Apical Scar (Fibrous Scar )
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Apical Scar (Fibrous Scar )
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Periapical Lesions (Bhaskar)

• Periapical granuloma 48
• Radicular cyst 43
• Periapical abscess 1.1
• Residual cyst 3.5
• Apical scar 3.0
• Periapical cemental dysplasia 1.7
• Rare lesions 1.0

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Rare Periapical Lesions (Bhaskar)

• Central giant cell granuloma
• Traumatic (simple) bone cyst
• Hyperparathyroidism

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Periapical Lesions(LaLonde and Leubke)

• Periapical granuloma 45.2
• Radicular cyst 43.8
• Periapical abscess 3.0
• Other periapical lesions 8.0