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Chronic apical
( parodontitis apicalis
chronica )
Etiology, classification,
clinical features, dg.,
diff. Dg.
Classified as:
– Acute Apical Periodonitis
– Acute Apical Abscess
– Chronic Apical Periodontitis
(Diffuse, Suppurative Apical Periodontitis with sinus
tract, Apical cyst)
– Condensing Osteitis
• The fundamental lesion of chronic
periapical inflammation is known as
´´chronic apical periodontitis´´
• While this designation is the preferred
one, most dentists know it by the term
´´dental granuloma´´
• The lesion is not a granuloma at all
because it is not composed of
granulomatous chronic inflammation.
• The etiology of apical periodontitis is an
infection of the tissues in the root canal
system and of the surrounding dentin, in
some cases also of tissues outside the
apical foramen or other portals of entry
• Typically,the lesion is located at the root
apex, but communications may exist at
various levels along the root surface,and
lesions may develop at lateral and furcal
• One or more of the clinical symptoms pain, swelling,
redness, increased temperature and impaired
function»characterize acute apical periodontitis.
• Chronic apical periodontitis shows replacement
of adjacent tissue with an inflammatory cell
infiltrate. Due to the encasement of the root in bone
and the relatively greater resistance of the root to
resorption, the production of an inflammatory
infiltrate usually occurs at the expense of the
surrounding bone.
• The changes in mineralization and structure of the
bone adjacent to the site of inflammation form the
basis of radiographic diagnostic procedures for the
detection and monitoring of chronic apical
• Apical periodontitis develops as a response to
infection and in the chronic form a granuloma is
formed with characteristics peculiar to the
location and anatomy.
• In addition to the inflammatory cells, it typically
contains fibrous tissue and often cholesterol
crystals, as well as proliferating strands of
epithelium derived from the cells of Malassez. It
may or may not develop a cyst cavity, which is
lined in part or in full by epithelium. If the lumen
of this radicular cyst is continuous with the
infectious source at the pulpal entry, it may not
be self-sustained (a ‘bay’ or ‘pocket’ cyst) and
will heal following elimination of the infectious
• On the other hand, if the cyst is
completely encased by epithelium and
removed from the source of infection, it
may be self-sustained (a‘true’ cyst) and
refractory to treatment except by surgical
• The stages in development and also in
healing of chronic apical periodontitis,
granulomas and cyst are to a degree,
reflected by changes in the radiographic
appearance of the periapical area
• These changes are of decisive
importance in diagnosis and choice of
Chronic apical periodontitis
• The lesion is present over long time
of periode
• Mild state of symptoms
• Histologic picture of chronic
• 1) Diffuse type:
- small, recurrent amount of tissue damage
- cellular infilltration with lymphocytes,
plasma cells, phagocytic mononuclear
cells, fibroblasts which produce
granulation tissues for repair of damaged
GRANULOMA: formation of large nodule of
granulation tissue that is slowly increase in size
Resorption of hard tissue, granulation tissue
around apex (outlined by capsule of fibrous
• 2) Chronic suppurative periodontitis
- central cavity which is accompanied
with fistula and stroma
- its known as chronic apical abscess
( chronic alveolar abscess)
• 3) Apical cyst
- true cyst: pathologic cavity which
contain fluid or semi-fluid substance
that is lined by epithelium and
surrounded by connective tissue
Clinical features
• CAP is generally without symptoms that
may stay in the mouth with no-pain untill
its revealed by x-ray
• The patient may rarely complain
symptoms, slight pain, some amount of
swelling, a sinus may be found in buccal
sulcus or in skin
( fistula ) mucosa over swelling may be
• CAP is usually associated with long
standing restorations such as prosthetic
crowns, extensive bridge work, composite
or amalgam filling
Vitality test – no response of pulp
Percussion- slightly tender to percussion
X-ray – diffuse or demarcated
radiolucency around the apex of the tooth,
root resorption, loss of bone, granuloma
or cyst→ with sclerotic margin to the bone
Diff. Dg.
• Chronic Pulpitis
Case 1,fig.1a
21-years old woman-non
successful endodontic treatment
tooth N.22,apical clear
radiolucency confirming an
established lesion bigger than
3mm,it shows features of lamina
dura disruption and bone
structural changes
Case 1,fig.1b
Measurement of the tooth canal length
Case 1,fig.1c
Final endodontic treatment Foredent
and gutapercha
Case 1,fig.1d
5 months after the endodontic treatment
without any surgical procedure,intraoral
x-ray shows chronic apical periodontitis,
partial restitution of the periapical region
Case 2,fig.2a
Orthopantogram image,unsuccessful endodontic treatment d.N.22,
Cystis radicularis D.N.22
Case 2,fig.2b
Intraoral image D.22-Cystis radicularis
processus alveolaris maxillae reg.frontalis
Case 2,fig.2c
3months after the therapyCystectomio sec.PARTSCH II.
et resectio apicis dentis N.22
Retrograde root canal
endodontic therapy with
Granuloma periapicalis and
infection transmission paths
Chronic apical periodontitis. Extensive tissue
destruction in the periapical region of a mandibular
first molar occurred as a result of pulpal necrosis.
Lack of symptoms together with presence of a
radiographic lesion is diagnostic.
Periapical radiolucencies associated with
mandibular incisors. These teeth were
vital, and a diagnosis of cemental
dysplasia was made.
Periodontitis chronica
circumscripta d.41