 Hello everyone, welcome back to another session in dentistry and more. Today's topic is various diseases of periapical tissues. It is a very commonly asked question in oral pathology, oral medicine, oral surgery and endodontics. Irrespective of the subject, it is very commonly asked short notes or short essay. So it could be a long essay in diseases of periapical tissues. They are periapical abscess, periapical granuloma, radical assist, phoenix, abscess and condensing austritis. Condensing austritis is commonly asked in oral medicine and radiology. This is asked in endodontics and these are asked in oral pathology or even oral surgery or in oral medicine and radiology. So let's learn about the various diseases of periapical tissues. So the basic pattern of the origin of periapical tissue, the caries which starts from enamel, dentine and pulp, it reaches to the periapical erasure through the apical foramen. So the tooth will be grossly decayed in most of the cases or the caries will not be very wide but it will be a deeper lesion. So the first one in periapical tissue diseases we have periapical abscess. Periapical abscess which is also known as dental alveolar abscess or alveolar abscess which is acute or chronic separative process of dental periapical region, acute or a chronic separative process because there will be pus formation or pus collection at the apical region and it usually arises as a result of infection. So the abscess which developed directly as an acute apical periodontitis following an acute pulpitus. So pulpitus is infection of pulp and periodontitis is infection of periodontia. So this could be developed directly as an acute apical periodontitis after pulpitus. So after pulpitus it leads to periodontitis, after pulpitus it leads to periodontitis. But more commonly it originates in an area of chronic infection. So the clinical features are it present as an acute inflammation of the apical periodontium. Tooth will be extremely painful and it will be slightly extruded from its socket because the socket and the tooth. So tooth there will be infection and there will be abscess. So this creation of abscess will push the tooth little towards the incisal region, towards the crown region. So little away from the bone because of the collection of abscess here. So that is why it is little extruded, normal position will be here, the new position will be here because there will be little extrusion from its socket due to the collection of abscess. And there will be chronic, these abscess which generally present with no clinical features that is chronic lesions will not create any much symptoms. And there will be mild circumscribed area of separation that shows little tendency to spread from local area. So there will be a circumscribed area of pus that shows little tendency to spread. In radiographic features except for slight thickening of periodontal membrane there will not be any radiographic evidence of its presence. So chronic abscess which are developing in a periapacal granuloma we can see a radio loosened area at the apex. So chronic abscess, radio loosened will be black area at the developing in a periapacal granuloma. So this will go to periapacal granuloma. So such cases there will be a radio loosened area at the apex. In histopathological feature this area of separation is composed of chiefly that is integrating leukocytes and there will be dilation of blood vessels. And also there will be serous exudate. This pus will contain serous exudate. And the most common treatment is drainage of the abscess then open the pulp chamber and do the root canal treatment or sometimes we need to extract the tooth. So root canal treatment will give a better prognosis. Once infection is completely removed there will be healing at the periapacal area. So if it is not treated it might leads to space infection like cellulitis, osteomyelitis and there will be chances for fistula formation and bacterium here. So all this could be happen. The second one is periapacal granuloma which is also known as apical prodolditis. So it is one of the most common sequelae of pulpitus which is the most common sequelae of pulpitus and it is a localized mass of chronic granulation tissue. So this will be seen in radiograph periapacal abscess will not be seen. So when this abscess on a longer duration when it is in a chronic nature and it is changing to granuloma that time this will be visible in radiograph. So it is due to again a response to infection. The clinical features include it is a first evidence we get that the spread is beyond the confines of tooth pulp and may be noticeable sensitivity of involved tooth to percussion. So that is the most common thing tendron percussion or sensitivity and mild pain when biting or chewing on solid food and in some cases tooth feels like elongated in its sockets because of this granuloma the granuloma it will be elongated or extruded and also the sensitivity or this TOP it could be due to the edema or inflammation of pedodontal ligament and hyperemia. In radiographic feature this is the earliest evidence of periapacal tissue and there will be thickening of pedodontal ligament at root apex there will be proliferation of granulation tissue and there will be some resorption of the bone resorption of bone and it appear as a radio loosened area of variable size it depends on the chronic nature and it will be attached to the root apex if this is a root apex this will be attached to the root apex and some cases it will be well circumscribed it will be well circumscribed the borders will be very clear and it does not pass through an acute face it is mostly a chronic nature there will not be any acute face granuloma formation takes a lot of time so this will be a chronic nature and in histologic feature we know that it is starting as a hyperemia or edema of pedodontal ligament with infiltration of all those inflammatory cells mainly lymphocytes and plasma cells and there will be increased vascularity at this particular site there will be increased vascularity and it also induce resorption of the supporting bone so there will be proliferation of fibroblast and formation of more tiny vascular channels and there will be numerous delicate connective tissue fibres and the treatment it is mostly extraction sometimes we can go for root canal therapy with subsequent apisectomy so apisectomy also indicated after root canal therapy so periapical granuloma if it is not treated it may undergo transformation into periapical cyst so radical cyst we have already discussed in detail anyway let's look into the main points which is also known as apical pedodontal cyst periapical cyst or root n cyst which is the most common cyst of tautorogen and there will be it could be due to bacterial infection necrosis of dental pulp and this involvement of caries tooth so there will be proliferation of epithelial rest in the periapical area involved by granuloma and the epithelial proliferation follows an irregular pattern of growth the clinical features include it is commonly asymptomatic this is asymptomatic these two are symptomatic whereas radical cyst is asymptomatic which present no clinical evidence of their presence seldom painful or even sensitive to percussion so it represent chronic inflammatory process which develops only over a very longer period of time so cyst formation this will be like cyst okay so this is a granuloma this will be cyst with fluid cavity inside so it develops over a very longer period of time so this coagulase enzyme which promotes virulence by inhibiting phagocytosis so clinical features are when palpated clinically there will be superficial abscess which is fluctuate in nature and the tooth is definitely will be carious and sometimes mobile and symptoms of acute inflammation swirling and fever will be there so the treatment commonly involves the enterotic therapy or the RCT should be repeated with much better debridement sometimes we need to go for tooth extraction and we should put on antibiotics antibiotics is important to control the spit of inflection and the last one is condensing austritis which is also known as chronic focal sclerosing osteomirates which is a very unusual reaction of bone which occurs in instances of extremely high tissue resistance or in cases of very low-grade infection so low-grade infection low-grade infection is the main cause of condensing austritis which occurs in almost young persons before the age of 20 years old and commonly affected is mantibular first molar with large carouselation so the mantibular first molar with large carouselation is the most commonly affected tooth and the other features are which is associated with non-vital teeth or teeth which is undergoing process of degeneration tooth will be definitely asymptomatic but some cases very rare cases pain or tenderness will be there on percation and palpation radiographic feature there will be well circumscribed radio opaque mass of sclerotic bone surrounding okay so it will be a radio opaque not radio loosened radio opaque mass with this sclerotic bone surrounding which extend below the apex of one or more roots of this mantibular molar and in histologic features it has dense mass of bony trabeculae with little interstitial marrow tissue and there will be dense mass of and there will be inflammatory cells such as plasma cell lymphocytes so in treatment part we follow the same regimen just like how we were doing in all these periapical tissue problems that is endodontic treatment extraction so in treatment side we follow the same regimen what we were following for all the periapical tissues it is like root canal treatment or surgical removal of the tooth so that is all about the five lesions or the five diseases of periapical tissues so it is in a ascending order we can say abscess leads to granuloma which leads to cyst so the radiographic appearance starts from here granuloma cyst and abscess phoenix abscess is a peculiar abscess which commonly seen after the root canal treatment due to the improper debridement so the post root canal treatment abscess is a phoenix abscess so it was not there but just the cause of the abscess is root canal treatment and condensing of status due to the low grade infection there will be a sclerotic bone of the radio opacity seen in only condensing of status rest these three are radioleusin area this is not visible in radiograph it is known as apical periodontitis then to alveolar abscess or alveolar abscess that is chronic focal sclerosing osteomyelitis so this is a very commonly asked five questions in many of the subjects endodontics oral surgery oral pathology oral medicine and radiology so I hope you understood the difference between these five and the treatment part is almost same for everything rct, rarct, epistectomy or extraction and the duration is chronic nature from periapical granuloma onwards this is very acute nature so I will come up with a new topic in the industry and more so hope you understood this concept of diseases of periapical tissues thank you