Acute Suppurations

• Pulp diagnosis


  Evaluation of the condition of the dental pulp
• Periapical diagnosis


  Evaluation of the condition of the tissues around the root tip of a tooth
• Pulp diagnosis


  • Normal pulp
  • Reversible pulpitis
  • Irreversible pulpitis
  • Pulp Necrosis
  • Endodontically treated
  • Ongoing RCT
• Periapical diagnosis


  • Normal periapical tissue
  • Acute Periapical Periodontitis
  • Acute Periapical Abscess
  • Chronic Apical Periodontitis
  • Dental Granuloma
  • Periapical Cyst
  • Chronic Periapical Abscess
• Endodontist way of identifying the patient's case is to include both pulpal and periapical condition even if normal
• If you are going to do your diagnosis based on endodontist classification, you have to write both pulpal dx and periapical dx
• Example 1


  • Pulp dx: Pulp tissue is normal
  • Periapical dx: Acute Traumatic Apical Periodontitis
• Example 2


  • Pulp dx: Pulp Necrosis
  • Periapical dx: Chronic Apical Periodontitis
• Example 3


  • Proximal caries #16 MO
  • Pulp dx: no symptoms; normal
• Example 4


  • Proximal caries #16 MO
  • Pulp dx: sensitivity to cold water but disappears immediately
• Complications of suppuration


  • Acute → chronic → acute (if not treated)
  • Always look for areas to spread and affect the surrounding tissues
  • If a balance is established between the irritant and host defense, the abscess becomes CHRONIC and remains localized
  • If increase hydrostatic pressure within an abscess occur with progressive suppuration, pus spreads along the LEAST RESISTANCE
  • Last is spread in bloodstream → worst case → brain → death
• Gumboil


  • Accumulation of pus in the gingival connective tissue
  • May be periodontal or pulpal in origin
  • If it is periodontal in origin → no periapical RL → no management just scaling
  • If it is pulpal in origin → periapical lesions (RL) → endo/exo
  • Gutta percha test - GP stick is inserted → radiograph → will lead to the origin of the fistula
  • The field is filled with neutrophils which are characteristic of acute inflammation and of suppuration (pus)
• Directions of pus exits

  • Pulp cavity
  • Gingival Sulcus
  • Palate
  • Sinus
  • Vestibule
  • Skin
  • Sublingual space
  • Submandibular/submaxillary space
  • Submental area
• Fistula


  • The result of an abscess burrowing its way towards the surface in an attempt to drain itself
  • Follows the path of least resistance through bone and soft tissue
  • May drain intraorally, or extraorally depending on muscle attachment, thickness of bone, and direction of roots
• Muscle attachment


  • Buccinator
  • Mylohyoid muscle
• Thickness of bone


  • Most dental related abscess perforate buccally because bone is thinner in the buccal plate except with lateral incisors and palatal roots of molars
  • Mostly, the teeth are near the buccal/labial → gumboil are more on the buccal/labial (sometimes are asymptomatic)
• Direction of roots


  • Abscesses related to the palatal root of maxillary molars → palatal abscess
  • Abscesses related to posterior maxillary teeth are very close to the floor of the maxillary sinus → pus discharge into the sinus leading to sinusitis
  • Abscesses related to anterior maxillary teeth may perforate the labial bone above the attachment of the levator anguli oris muscle reaching the inner canthus of the eyelid
• Osteomyelitis


  • Inflammation/infection of medullary portion of the bone (maxilla or mandible) induced by pyogenic microorganisms
  • The inflammatory process is widespread tending to involve the entire marrow cavity
  • The process is very destructive (causing bone resorption) with extensive secondary necrosis of the bone
  • Sequestrum - pieces of dead bone
  • Involucrum - zone of granulation tissue separating dead bone from normal bone
• Classification of osteomyelitis


  • Acute / Subacute osteomyelitis
  • Secondary chronic osteomyelitis
  • Primary chronic osteomyelitis
  • Suppurative osteomyelitis
  • Non-suppurative osteomyelitis
• Acute osteomyelitis (AO)


  Symptomatic; first 4 weeks
• Secondary chronic osteomyelitis (SCO)

  Gone beyond 4 weeks
• Etiology of osteomyelitis


  • Neonatal, tooth germ associated
  • Trauma related
  • Odontogenic
  • Foreign body, transplant/implant inducer
  • As a complication of suppuration
• Suppurative osteomyelitis


  • Acute suppurative osteomyelitis
  • Chronic suppurative osteomyelitis
• Non-suppurative osteomyelitis


  • Chronic sclerosing osteomyelitis (hardening, bone becomes denser)
  • Garre's sclerosing osteomyelitis
  • Radiation osteomyelitis and necrosis (osteoradionecrosis) - cancer patient receiving radiotherapy
• Difference between AO and SCO

  Time period
• Arbitrary time limit of 4 weeks after onset of disease
• Pathological-anatomical onset corresponds to deep bacterial invasion into the medullary and cortical bone
• Etiology


  • Neonatal, tooth germ associated
  • Trauma related
  • Odontogenic
  • Foreign body, transplant/implant inducer
  • Associated with bone pathology and systemic diseases (diabetic)
• Subacute Osteomyelitis


  • Condition somewhat in between acute and chronic osteomyelitis with relatively moderate symptoms
  • Transitional stage within the time frame of AO corresponding to the 3rd and 4th week after onset of symptoms
  • Not usually used
• Primary factors in the establishment of osteomyelitis

  • Number of pathogens
  • Virulence of pathogens
  • Local and systemic host immunity
  • Local tissue perfusion - blood supply is compromised
• From acute periapical abscess → marrow spaces → osteomyelitis
• Microbiology (multimicrobial)


  • Staphylococcus aureus
  • Staphylococcus epidermidis
  • Actinomyces group
  • Polymicrobic infection
• Systemic factors altering host immunity

  • Location
  • Gender
  • Mean age
• Why is maxilla not often affected?

  • Blood supply is more extensive
  • Thin cortical plates and the paucity of medullary tissues preclude confinement of infections within the bone
  • Permits dissipation of edema and pus into soft tissues of the midface and paranasal sinuses
• Why is mandible often affected?

  • Less blood supply
  • Clear distinction of a medullary cavity, dense/thick cortical plates and a well-defined periosteum → confinement of infection

  
• Between the two chunks of bone are many lymphocytes and plasma cells (chronic inflammation)
• Chronic Focal Sclerosing Osteomyelitis (Condensing osteitis)


  • Occurs exclusively in young persons
  • Mandibular 1st molar with large caries
  • Instead of bone resorption, there is more bone deposition → sclerosing (hardening) → radiopacity
  • Local
  • Non-vital tooth
• Chronic Diffuse Sclerosing Osteomyelitis

  • Portal of entry is through diffuse periodontal disease
  • Occurs mostly in older persons
  • Widespread radiopacity
• Garre's Osteomyelitis


  • Focal overgrowth of the outer surface of the bone cortex
  • Radiograph: "onion-skin" appearance
• Cellulitis


  • Diffuse inflammation of soft tissue
  • Streptococcus
  • May become facial abscess with pointing
  • During the first stage of inflammation, it can turn into a pus formation → facial abscess