LOCAL AND GENERAL TREATMENT OF ACUTE AND CHRONIC

EXACERBATED APICAL PERIODONTITIS. PRINCIPLES. TECHNIQUES

AND METHODS

ENGL
Lecture 3,
Year 4 , Semester 7
© 2020 V.Nicolaiciuc
 LOCAL AND GENERAL TREATMENT OF ACUTE AND
CHRONIC EXACERBATED APICAL PERIODONTITIS.
PRINCIPLES. TECHNIQUES AND METHODS
Treatment given for acute periodontitis, is designed to reduce
pain, stopping inflammation and preventing the spread of
inflammation to the surrounding tissue.
Acute periodontitis conducted taking into account the stage of
the inflammatory process. The first priority is to remove the
channel from the inflamed and necrotic pulp, and if the tooth is
exposed to early treatment, then the filling material.
INDICATION AND CONTRAINDICATION
Acute apical periodontitis.
Exacerbation of chronic fibrotic periodontitis.
Exacerbation of chronic granulating periodontitis.
Exacerbation of chronic granulomatous periodontitis (granuloma).
Cysto granulema.
Radicular cyst the size of 1.5-2 cm (diameter).
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 Absolute contraindications for medical treatment of
periodontitis are cases where there are:
The growth effects of inflammation, general septic reaction
despite the disclosure of the tooth cavity, cut along the crease
of the transition, and in the absence of the effect of
antibiotics.
Radicular cyst greater than 2 cm in diameter and cysts
germinated in the maxillary sinus (cavity).
The shattered teeth with mobility III degree.
Teeth, about which there is significant atrophy of alveolar
jaw and pathological gingival pocket depth achieves apical
inflammatory focus.

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 Relative contraindications:
Repeatedly exacerbation of chronic periodontitis in multi-
rooted teeth with narrow curved channels.
The sharp curvature of the root single rooted tooth,
eliminating passability of root channel.
The presence of debris of endodontic instruments in the
root canal.
Teeth with early filling root channels with phosphate
cement is not up to the top (2/3, ½, 4/5 length).
A perforated bottom of the cavity of the tooth or root walls.
Contra-indication called relative, because a certain
percentage of cases, the teeth can be saved, if more apply
long-term and complicate methods of treatment.

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 ACUTE MEDICAMENTOUS (TOXIC) PERIODONTITIS IN STAGE
OF INTOXICATION
This form of periodontitis, as a rule, is the result of a
long stay in the cavity of the tooth arsenious pastes or
overdose in treatment of pulpitis by devitalization. The success
of treatment with this form of periodontitis is provided
primarily the rapid removal of the coronal and root pulp.
Root canals should be cleaned with an antiseptic
solution (1-2% solution of bleach, 3% solution of hydrogen
peroxide, solution furatsilin at a dilution of 1:5000 Frc) or
enzymes (trypsin, chymotrypsin).
Then, in the root canal should be kept for 1-2
days. turundae or swab with the drug, is an antidote to arsenic
(5% solution unitiola, 1% solution iodinol). In multi-rooted
teeth appropriate to use electrophoresis solution potassium
iodide.
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 If periodontal irritation appeared as a result of the
potent (toxic) drug, treatment begins with the removal of
them. The goal of treatment of acute medicamentous in stage
of intoxication and exudation in periodontium, which is
achieved by using antidotes and drugs with pronounced
aniexudative action (furagin 1:3000, 1:25,000 furazolidone,
hydrocortisone).
In the cavity of a tooth under hermetic bandage ​of
artificial dentin leave the same drugs. Patients were dosed
warm oral baths, as well as non-narcotic analgesics
(aminopyrine, Analgin, etc.).
As a result of therapeutic measures, pain usually
subsides and during the second visit, usually after the second
sterilization of root canal one of the above antiseptics or
enzymes it is dried and sealed hardening of the material at
the level of the apical opening.

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 If treatment is not carried out led to the elimination
of periodontal tissue irritation and the acute medical
periodontitis is delayed, then the second visit advisable to
galvanization isotonic sodium chloride solution from the
anode (anode electroplating) or with a saturated solution of
potassium iodide (for incisors, canines and premolar teeth).
For relief of acute process rather 1-2 procedures, and then
the pain goes away.
After galvanization and electrophoresis tooth cavity
closed with bandage of artificial dentin, and under it is left
sterile cotton swab. In 1-2 days. a third visit to the absence of
pain tooth should be sealed. If in the medicamentous
periodontitis inflammatory response increases (increasing
pain, swelling of the gums appear at the crease transition
arches of the mouth, the expression infiltration), it means
the offensive pronounced exudative phase of acute
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inflammation, which requires other treatment measures. 7
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 ACUTE INFECTIOUS PERIODONTITIS

Acute apical periodontitis of infectious origin is also

made in relation to the phase of acute inflammation.
In the stage of intoxication when exudative manifestations are
mild, then delete the contents of the root canal (necrotic
tissue) anesthetic or antiseptic solution introduced into the
channel and the tooth tightly closed with bandage for 1 - 2
days.
In the midst of an acute inflammation of the
periodontal (pronounced exudative stage of the process) in
order to relieve pain and prevent further spread of the
inflammatory process in the other departments of
maxillofacial region, and a tooth for a few days should be left
open to create an outflow of exudates over the root canal.

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 To do this, it is important to expand the apical
foramen of the root of the tooth. Expansion of terminal holes
in the treatment of acute periodontium is important. This
creates access to the apical periodontium and the outflow of
exudates from pathologic focus.
Methods of expansion of the apical foramen. To
expand the use of the apical foramen use: triangular root
needle, Rimmer, or K-file. Selected endodontic instruments
are inserted into the root canal to stop and spend the
rotational motion using the fingertips (not a machine). At the
same time produce a small pressure.
At the opening of the apical foramen doctor feels the
failure of instrument, and the patient - a little pain. To reduce
the effect of pain - tooth to be followed by finger.
Confirmation of the opening of the apical opening is
exudate in the root canal and a sense of relief to the patient.
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 Given that touching the tooth with acute
periodontitis sharply painful, these manipulations, especially
the crown of the tooth trepanation, removal of seals, etc., to
produce a turbine installation with acute boron and fix
causative tooth fingertips without pressure tool on the tooth.
Sometimes it is possible to resort to injecting
anesthesia.
For patient prescribed per ores: fenkarol, tavegil,
diazolin, suprastin, diphenhydramine, pipolfen in standard
dosages. The patient is also advised to take into drugs acting
on the anaerobic microflora (Bactrim, biseptol etc.).
During this period shows physiotherapy: UHF (ultra
high frequency), electromagnetic field, microwaves, etc.
With symptoms of intoxication (persistent headache,
fever, weakness, changes in blood counts, etc.) must be
assigned to the patient oral antibiotics (100 000-200 000 IU
erythromycin 4-6 times a day, or intramuscularly, 200 000-
11.11.2020300 000 units penicillin *three times
V.Nicolaiciuc - a day). 10
 If the prescription of antibiotics after 24 h did not
cause improvement in general condition, it must be assumed
that the microflora of the patient is resistant to the chosen
antibiotic and should be replaced by another, better
semisynthetic (methicillin, oxacillin). If this does not improve
the condition of the patient, then resorted to the removal of
a tooth.
With contraindications to the prescription of
antibiotics must be assigned to the patient sulfa drugs of 1.0
g 4 times a day in combination with non-narcotic analgesics.
In the acute stage of severe periodontitis complicated by
periostitis, efficient injection of anesthetic into the transition
lap of a sick tooth, followed by a horizontal section of
subperiosteal abscess or infiltrate (prior to symptom
fluctuation). Incision is made of at least 2 cm incision
required jaw periosteum (preferably until the pus).

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 Treatment of acute periodontitis is terminated, usually
during the second visit, after 5-7 days the elimination of pain,
discontinuation of exudates elimination from the root canal,
in the presence of a painless tooth percussion and palpation
of gingiva mucosa.
In this visit make instrument and medicamentous,
processing of root canals, (used proteolytic enzymes iodinol,
hydrogen peroxide, chloramine, drugs nitro furan series) and
filling at the level of apical foramen (anatomical apex).
Filling the root canal can be at:
•Elimination of pain (no complaints from the patient);
•Discontinuation of exudate and odor of the root canal. In
acute and chronic periodontitis escalating it occurs 5-7 days
after expansion of the apical foramen;
•Painless percussion and palpation of the gums;
•Turundae of the root canal must be dry (not wet);
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 •Turundae of the root canal should be odorless;
•Turundae of the root canal should be white. Filling is done
to block the opening of the tooth apex, isolating apical tissue
from infected macro-and micro-channels of the tooth. This is
a crucial stage of treatment. On the quality of his
performance depends largely on the fate of the tooth and
the effectiveness of the hard work carried out previously.
Channel filling with the hardening materials with
modern techniques (lateral condensation, vertical
condensation, thermophilic) using fillers and sealers.
If you have pain after filling, then resort to the use of
physiotherapy treatments (fluctorization), and when
indicated - to a wide section to transition lap near the tooth.
To prevent complications immediately after filling the
channel transition lap in the projection of the apex can
introduce solution 0.2-0.5 ml hydrocortisone or
deksometazona.
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 In multi-rooted teeth with poorly permeable channels, the
number of visits will depend on the possibility of going
through all the root canals. If after a few visits can conduct
mechanical and antiseptic preparation of all channels, their
filling with hardening pastes or pins.
If all channels are permeability, we can apply the combined
method of treatment: permeable channels filling to the
apical foramen; the roots of the teeth, which channels are
not possible to be filled to the top, are treated surgically. In
molars of the upper jaw can be made root amputation, but at
the molars of the lower jaw – hemisection, and for frontal
(monoradicular) tooth – resection of apical part of root.

ACUTE APICAL TRAUMATIC PERIODONTITIS

It is important in treatment to eliminate the cause (eg.
grinding excess previously filling) and holding the symptomatic
treatment - purpose analgesics (analgin, amidopyrine, etc.) inside
and physiotherapy procedures.* V.Nicolaiciuc -
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 With significant trauma, accompanied by a shift of the
tooth, and suspect any of the neurovascular bundle, check
electroexitability of tooth and hold X-rays to rule out a
possible fracture of the root.
Repeated studies of the pulp and periodontal status
should be held not earlier than 3-4 weeks after injury. With
further sharp decline electroexitability or appearance of the
inflammatory focus near apical conduct appropriate
treatment of the tooth.
Outcome of acute periodontitis may be clinical
recovery. Periodontium is not restored to normal as it was
before the disease, its structure is changed due to the
emergence of more rough scar tissue. However, the functions
of such periodontal performs satisfactorily.
Less favorable outcome is the transition of acute to
chronic inflammation process. The most severe outcome of
acute periodontitis - go to the periostitis or osteomyelitis of
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the jaw.
 Treatment of acute and exacerbated chronic periodontitis
will be successful if his conduct and a strict sequence:
1. Rentgenografiya of causal tooth.
2. Anesthesia.
3. Preparation of caries cavity.
4. Unroofing tooth cavity.
5. Removing necrotic tissue of the coronal pulp.
6. Expansion of the mouths of root canals.
7. Evacuation of the necrotic tissue of the root canal on the
third (1/3, ½, 2/3, etc.).
8. Excision of abnormal tissue from the walls of the root
canal and its medicamentous treatment.
9. Expansion of apical holes.

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 The above steps are carried out in the first visit.
Second Visit – after 6-7 days. At the second visit by thorough
medical and tooling root canal with a predetermined length
of the root canal. Seal the root canal can be at:
discontinuation of exudate, odor termination of root canal
painless percussion and palpation, turundes of root canal
should be dry, odorless, white.
Next, hold the control radiography and impose a
permanent filling. The patient should be put on a dispensary
registration and warn of the need in the case of pain after
filling to visit a doctor. Patient can not warm the area of the
tooth after treatment (packs, heating pads, etc.).

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 Management of acute apical periodontitis

• Endodontic therapy should be initiated on the affected

tooth at the earliest
• To control postoperative pain following initial endodontic
therapy, analgesics are prescribed
• Use of antibiotics, either alone or in conjunction with root
canal therapy is not recommended
• If tooth is in hyperocclusion, relieve the occlusion
• For some patients and in certain situations, extraction is
an alternative to endodontic therapy.

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 Fig. Management of acute apical periodontitis
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 Management of an Acute Apical Abscess

• Drainage of the abscess should be initiated as early as

possible. This may include:
a. Non-surgical endodontic treatment (Root canal
therapy)
b. Incision and drainage
c. Extraction
• Considerations regarding the treatment should be
dependent on certain factors:
a. Prognosis of the tooth
b. Patient preference
c. Strategic value of the tooth
d. Economic status of the patient
• In case of localized infections, systemic antibiotics provide
no additional benefit over drainage of the abscess
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 • In the case of systemic complications such as fever,
lymphadenopathy, cellulitis or patient who is
immunocompromised, antibiotics should be given in
addition to drainage of the tooth
• Relieve the tooth out of occlusion in hyperocclusion cases
• To control postoperative pain following endodontic
therapy, nonsteroidal anti-inflammatory drugs should be
given.

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Fig. Management of periapical abscess
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 Management of an Acute Exacerbation of a Chronic Lesion
PHOENIX ABSCESS/RECRUDESCENT ABSCESS
Phoenix abscess is defined as an acute inflammatory
reaction superimposed on an existing chronic lesion, such
as a cyst or granuloma; acute exacerbation of a chronic
lesion.
Treatment
• Establishment of drainage
• Once symptoms subside—complete root canal treatment.

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 PERIAPICAL GRANULOMA

Fig. Periapical granuloma

present at the apex of
nonvital tooth

Treatment and Prognosis

Main objective in treatment is to reduce and eliminate offending
organisms and irritants from the periapical area.
• In restorable tooth, root canal therapy is preferred
• In non-restorable tooth, extraction followed by curettage of all
apical soft tissue.
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 RADICULAR CYST

Fig. Radiographic picture of a

periapical cyst

Treatment
Different options for management of residual cyst are:
• Endodontic treatment
• Apicoectomy
• Extraction (severe bone loss)
• Enucleation with primary closure
• Marsupilization (in case* of
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large cysts).
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