Dental sequalae of Pulpitis DC DC with

pulpitisDefensive reaction-Periapical Granuloma or Periapical cyst

Bone reaction-Osteomyelitis

Soft tissue reaction-Cellulitis

Blood reaction-Septicemia

Pathway of Pulpitis

Pulpitis

Acute Pathway

Periapical abscess

Osteomyelitis

Cellulitis

Chronic Pathway

Chronic Apical Periodontitis

Periapical Granuloma

Periapical cyst

Acute PathwayPeriapical Abscess

Requires a non-vital tooth

It is an accumultaion of Acute inflammatory cells(PMNs) at the apex of a non-vital tooth

May arise as an exacerbation of a chronic lesion-Phoenix abscess

Mostly symptomatic with acutely painful periapicalregionbut maybe unsymptomatic if there is a path of drainage of purulent material

Drainage Pathways of acute periapical infection Surface of gingiva-Parulis(Gum boil)

Palate-Palatal abscess

Maxillary sinus-Psuedocyst

Soft tissue spaces-Cellulitis

Floor of the mouth-Ludwigs Angina

Parulis(Gum boil) Associated with acute periapical inflammation

Purulent material perforates through boneperiosteumsoft tissue and epitheliumdrainsthrough intraoral sinus tract

Consists of Fluctuant mass of inflamed granulation tissue leading to an epithelialised sinus tract

Cutaneous Sinus tract An abscess that drains on its ownextraorallythrough

the overlying skin(Draining sinus tract)

Extra oral abscess Localised collection of pus that has

accumulated(consolidated) in a tissue cavityproducing fluctuance

Can serve as a nidus for sacrophytic bacterial growth

Antibiotics cant reach center of large abscessesbecause blood supply is along the peripherytherefore draining is very important for effective antibiotic treatment

Cellulitis Diffuse spread of an acute inflammatory process

through the fascial planes of soft tissueproducingerythemaoedemawarmth and pain

It is a board-likediffusehard swelling

Trismus is a common secondary to cellulitis due to loss of function of muscles of mastication

Requires immediate antibiotics and drain placement

Ludwigs angina Aggressiverapidly spreading cellulitis involving

multiple anatomic spacessubmentalsublingualsubmandibular

Produces massive swelling of the neck that may extend close to the clavicles and cause airway obstruction(bullneck)

Causes elevation of the floor of the mouth and protrusion of tomgue(woody tongue)

Can be fatal due to airway obstructionmust establish an airwaydrain and give IV antibiotics

Cavernous sinus thrombosis Maybe associated with spread of infection from

maxillary teeth(classic canine space infection)

It is the formation of a blood clot within the cavernous sinus

Life threatening infection cause the cavernous sinus holds the pituitary gland and sella turcicaCranialnerves-346

Proliferative Periostitis Form of chronic osteomyelitis with proliferative

periostitis

Periosteal reaction in which layers of reactive vital bone are formedproducing cortical expansion(onion skinning) The periosteum is not destroyedbut lifted upwhen bone is formed beneath its layers

Chronic focal sclerosingosteomyelitis AKA Condensing osteitis Localised area of bone sclerosis associated with apices

of non-vital teeth

Most frequent in children and young adults involving mandibular molarspremolars

No cortical expansion

Differential diagnosisOsseous Dysplasia and idiopathic osseosclerosis

Osteomyelitis Bacterial infection of bone secondary to

A)Odontogenic infection

B)Traumatic injury

C)Necrotising Ulcerative GingivitisNoma or cancrumoris

Predisposition to decreased vascularity of bone-PagetrsquosOsteopetrosisflorid cemento-osseous dysplasia

Chronic PathwayPeriapical granuloma

It is a misnomerit is not a granulomatous reaction

Mass of chronically inflamed granulation tissue at apex of non-vital teethdesigned to wall off bacterial invasion at apex

Associated with chronic apical periodontitis

Periapical cyst AKA apical periodontal cystradicular cyst

Inflammatory odontogenic cystinduced by cell rests of malassez(Hertwigs Epithelial Root Sheath remnants) proliferation

Radiolucency at periapex of non-vital teeth

To differentiate from a granulomait must be tested histologically

Management of apical lesions Non-surgical management Periapical lesions develop as

sequelae to pulp disease They often occur without any episode of acute pain and are discovered on routine radiographic examination It is accepted that all inflammatory periapicallesions should be initially treated with conservative nonsurgical procedures

Methods1The conservative root canal treatment

2decompression technique3active nonsurgical decompression technique4aspiration-irrigation technique

5 method using calcium hydroxide6 Lesion Sterilization and Repair Therapy and7the Apexum procedure

Case selectionThe current philosophy in the management of periapical lesions includes the initial use of nonsurgical methods When this treatment approach is not successful a surgical approach may be adoptedThe following factors must be considered while deciding on the management approach

Diagnosis of the lesionMany bone destroying lesions closely resemble endodontically related periapicallesions on radiographs Some of these nonendodontic lesions include ameloblastoma central fibroma giant cell lesions fibrous dysplasia central hemangioma primary malignancies metastatic neoplasms and inflammatory bone diseases

Proximity of the periapical lesion to adjacent vital teethWhen in proximity to a vital toothadopting a surgical approach may result in injury to the blood vessels and nerves of the adjacent teeth thereby compromising their vitality

Encroachment on anatomical structuresSurgery increases the risk of damage to the anatomic structures such as mental foramen inferior alveolar nerve Also the aspirationndashirrigation technique a nonsurgical method is not recommended where adjacent tissue spaces or sinus cavities are involved

Patient cooperation

Considerable pain or discomfort can be experienced by the patient during or after a surgical procedure A nonsurgical approach would be recommended for apprehensive and uncooperative patients

Obstructions in the root canal system

Ledges calcified canals separated instruments may prevent access to the apical foramen and may warrant a surgical approach in managing periapical lesions related to such teeth

Time involved for treatment

Enhanced healing kinetics are observed after performing apical surgery in teeth with periapical lesions

Cases refractory to nonsurgical management methods

Inflammatory apical true cysts and the presence of cholesterol crystals have been suggested as possible causes that prevent healing of periapical lesionsSurgery is recommended for such cases

METHODS FOR NONSURGICAL MANAGMENT OF PERIAPICAL LESIONS Conservative root canal treatment without adjunctive therapy

Instrumentation should be carried 1 mm beyond the apical foramen when a periapical lesion is evident on a radiograph This may cause transitory inflammation and ulceration of the epithelial lining resulting in resolution of the cyst

Decompression technique

The decompression technique involves placement of a drain into the lesion regular irrigation periodic length adjustment and maintenance of the drain for various periods of time

Active nonsurgical decompression technique

This technique uses the Endo-eze vacuum system to create a negative pressure which results in the decompression of large periapical lesions The high-volume suction aspirator is connected to a micro 22-gauge needle which is inserted in the root canal and activated for 20 minutes creating a negative pressure which results in aspiration of the exudate When the drainage partially stops the access cavity is closed with temporary cement which helps in maintaining bacterial control

Aspiration and irrigation technique

Hoen et al suggested aspiration of the cystic fluid from the periapcial lesion using a buccal palatal approach In this technique an 18-gauge needle attached to a 20 ml syringe is used to penetrate the buccal mucosa and aspirate the cystic fluid A second syringe filled with saline is then used to rinse the bony lesion The new needle is inserted through the buccal wound and passed out through the palatal tissue creating a pathway for the escape of the irrigant

Aspiration through the root canal technique

In this technique aspiration of the cystic fluid is done through the root canal by passing the aspirating needle through the apical foramen This technique eliminates the creation of buccal and palatal wounds as in the traditional aspirationndashirrigation technique This minimizes the discomfort that the patient may experience

However it is advisable not to use either aspirationndashirrigation or aspiration through the root canal techniques where adjacent tissue spaces or sinus cavities are involved when there is no fluid aspiration from the lesion or in infected periapicallesions

Method using calcium hydroxide

Calcium hydroxide is a widely used material in endodontic treatment because of its bactericidal effectsIt is thought to create favorable conditions for periapical repair and stimulate hard tissue formationSouza et al suggested that the action of calcium hydroxide beyond the apex may be four-fold (a) anti-inflammatory activity (b) neutralization of acid products (c) activation of the alkaline phosphatase and (d) antibacterial action

Lesion sterilization and repair therapy

lsquoLesion Sterilization and Tissue Repair (LSTR)rsquo therapy that uses a triple antibiotic paste of ciprofloxacin metronidazole and minocycline for disinfection of oral infectious lesions including dentinal pulpal and periradicular lesions Repair of damaged tissues can be expected if lesions are disinfectedMetronidazole is the first choice because it has a wide antibacterial spectrum against anaerobesHowever some bacteria are resistant to metronidazole and hence ciprofloxacin and minocycline are added to the mix

Apexum procedure

Surgical removal of the periapical chronically inflamed tissue allows a fresh blood clot to form thereby converting a chronic inflammatory lesion into a new granulation tissue where healing might proceed much fasterThe Apexumprocedure uses two sequential rotary devices the Apexum NiTi Ablator and Apexum PGA Ablator (Apexum Ltd Or Yehuda Israel) designed to extend beyond the apex and mince the periapical tissues on rotation in a low-speed handpiece followed by washing out the minced tissue

Surgical management of Apical lesions Apical lesions maybe managed surgically to reduce

healing and recovery time

Indicated for emergency cases

Incision and drainagewith antibiotic therapy of the lesionfollowed by RCT with apisectomy is the usual modality of surgical treatment of apical lesions

Medical Management of apical lesions Antibiotic therapy is used to treat minor apical

lesionsin order to relieve the symptomsThis enables easier surgical or non0surgical management of the lesionThus medical management of apical lesions is used in conjunction with Surgical or non surgical management of apical lesions

Cellulitis-Cefazolin 1g iv Q8H7-10 days or cloxacillin500-1000mg po Q6H7-10 days

Acute osteomyelitis-Cefazolin 2g iv Q8H

Ludwigs angina-Clindamycin 600mg iv Q8H2-3 weeks

References J Conserv Dent 2010 Oct-Dec 13(4) 240-

245doi 1041030972070773384PMCID PMC3010029Nonsurgical management of periapical lesions Marina Fernandes and Ida de Ataide

Manual in maxillofacial surgery for senior house officers-Dental 2cmcvellore

Pathway of Pulpitis

Pulpitis

Acute Pathway

Periapical abscess

Osteomyelitis

Cellulitis

Chronic Pathway

Chronic Apical Periodontitis

Periapical Granuloma

Periapical cyst

Acute PathwayPeriapical Abscess

Requires a non-vital tooth

It is an accumultaion of Acute inflammatory cells(PMNs) at the apex of a non-vital tooth

May arise as an exacerbation of a chronic lesion-Phoenix abscess

Mostly symptomatic with acutely painful periapicalregionbut maybe unsymptomatic if there is a path of drainage of purulent material

Drainage Pathways of acute periapical infection Surface of gingiva-Parulis(Gum boil)

Palate-Palatal abscess

Maxillary sinus-Psuedocyst

Soft tissue spaces-Cellulitis

Floor of the mouth-Ludwigs Angina

Parulis(Gum boil) Associated with acute periapical inflammation

Purulent material perforates through boneperiosteumsoft tissue and epitheliumdrainsthrough intraoral sinus tract

Consists of Fluctuant mass of inflamed granulation tissue leading to an epithelialised sinus tract

Cutaneous Sinus tract An abscess that drains on its ownextraorallythrough

the overlying skin(Draining sinus tract)

Extra oral abscess Localised collection of pus that has

accumulated(consolidated) in a tissue cavityproducing fluctuance

Can serve as a nidus for sacrophytic bacterial growth

Antibiotics cant reach center of large abscessesbecause blood supply is along the peripherytherefore draining is very important for effective antibiotic treatment

Cellulitis Diffuse spread of an acute inflammatory process

through the fascial planes of soft tissueproducingerythemaoedemawarmth and pain

It is a board-likediffusehard swelling

Trismus is a common secondary to cellulitis due to loss of function of muscles of mastication

Requires immediate antibiotics and drain placement

Ludwigs angina Aggressiverapidly spreading cellulitis involving

multiple anatomic spacessubmentalsublingualsubmandibular

Produces massive swelling of the neck that may extend close to the clavicles and cause airway obstruction(bullneck)

Causes elevation of the floor of the mouth and protrusion of tomgue(woody tongue)

Can be fatal due to airway obstructionmust establish an airwaydrain and give IV antibiotics

Cavernous sinus thrombosis Maybe associated with spread of infection from

maxillary teeth(classic canine space infection)

It is the formation of a blood clot within the cavernous sinus

Life threatening infection cause the cavernous sinus holds the pituitary gland and sella turcicaCranialnerves-346

Proliferative Periostitis Form of chronic osteomyelitis with proliferative

periostitis

Periosteal reaction in which layers of reactive vital bone are formedproducing cortical expansion(onion skinning) The periosteum is not destroyedbut lifted upwhen bone is formed beneath its layers

Chronic focal sclerosingosteomyelitis AKA Condensing osteitis Localised area of bone sclerosis associated with apices

of non-vital teeth

Most frequent in children and young adults involving mandibular molarspremolars

No cortical expansion

Differential diagnosisOsseous Dysplasia and idiopathic osseosclerosis

Osteomyelitis Bacterial infection of bone secondary to

A)Odontogenic infection

B)Traumatic injury

C)Necrotising Ulcerative GingivitisNoma or cancrumoris

Predisposition to decreased vascularity of bone-PagetrsquosOsteopetrosisflorid cemento-osseous dysplasia

Chronic PathwayPeriapical granuloma

It is a misnomerit is not a granulomatous reaction

Mass of chronically inflamed granulation tissue at apex of non-vital teethdesigned to wall off bacterial invasion at apex

Associated with chronic apical periodontitis

Periapical cyst AKA apical periodontal cystradicular cyst

Inflammatory odontogenic cystinduced by cell rests of malassez(Hertwigs Epithelial Root Sheath remnants) proliferation

Radiolucency at periapex of non-vital teeth

To differentiate from a granulomait must be tested histologically

Management of apical lesions Non-surgical management Periapical lesions develop as

sequelae to pulp disease They often occur without any episode of acute pain and are discovered on routine radiographic examination It is accepted that all inflammatory periapicallesions should be initially treated with conservative nonsurgical procedures

Methods1The conservative root canal treatment

2decompression technique3active nonsurgical decompression technique4aspiration-irrigation technique

5 method using calcium hydroxide6 Lesion Sterilization and Repair Therapy and7the Apexum procedure

Case selectionThe current philosophy in the management of periapical lesions includes the initial use of nonsurgical methods When this treatment approach is not successful a surgical approach may be adoptedThe following factors must be considered while deciding on the management approach

Diagnosis of the lesionMany bone destroying lesions closely resemble endodontically related periapicallesions on radiographs Some of these nonendodontic lesions include ameloblastoma central fibroma giant cell lesions fibrous dysplasia central hemangioma primary malignancies metastatic neoplasms and inflammatory bone diseases

Proximity of the periapical lesion to adjacent vital teethWhen in proximity to a vital toothadopting a surgical approach may result in injury to the blood vessels and nerves of the adjacent teeth thereby compromising their vitality

Encroachment on anatomical structuresSurgery increases the risk of damage to the anatomic structures such as mental foramen inferior alveolar nerve Also the aspirationndashirrigation technique a nonsurgical method is not recommended where adjacent tissue spaces or sinus cavities are involved

Patient cooperation

Considerable pain or discomfort can be experienced by the patient during or after a surgical procedure A nonsurgical approach would be recommended for apprehensive and uncooperative patients

Obstructions in the root canal system

Ledges calcified canals separated instruments may prevent access to the apical foramen and may warrant a surgical approach in managing periapical lesions related to such teeth

Time involved for treatment

Enhanced healing kinetics are observed after performing apical surgery in teeth with periapical lesions

Cases refractory to nonsurgical management methods

Inflammatory apical true cysts and the presence of cholesterol crystals have been suggested as possible causes that prevent healing of periapical lesionsSurgery is recommended for such cases

METHODS FOR NONSURGICAL MANAGMENT OF PERIAPICAL LESIONS Conservative root canal treatment without adjunctive therapy

Instrumentation should be carried 1 mm beyond the apical foramen when a periapical lesion is evident on a radiograph This may cause transitory inflammation and ulceration of the epithelial lining resulting in resolution of the cyst

Decompression technique

The decompression technique involves placement of a drain into the lesion regular irrigation periodic length adjustment and maintenance of the drain for various periods of time

Active nonsurgical decompression technique

This technique uses the Endo-eze vacuum system to create a negative pressure which results in the decompression of large periapical lesions The high-volume suction aspirator is connected to a micro 22-gauge needle which is inserted in the root canal and activated for 20 minutes creating a negative pressure which results in aspiration of the exudate When the drainage partially stops the access cavity is closed with temporary cement which helps in maintaining bacterial control

Aspiration and irrigation technique

Hoen et al suggested aspiration of the cystic fluid from the periapcial lesion using a buccal palatal approach In this technique an 18-gauge needle attached to a 20 ml syringe is used to penetrate the buccal mucosa and aspirate the cystic fluid A second syringe filled with saline is then used to rinse the bony lesion The new needle is inserted through the buccal wound and passed out through the palatal tissue creating a pathway for the escape of the irrigant

Aspiration through the root canal technique

In this technique aspiration of the cystic fluid is done through the root canal by passing the aspirating needle through the apical foramen This technique eliminates the creation of buccal and palatal wounds as in the traditional aspirationndashirrigation technique This minimizes the discomfort that the patient may experience

However it is advisable not to use either aspirationndashirrigation or aspiration through the root canal techniques where adjacent tissue spaces or sinus cavities are involved when there is no fluid aspiration from the lesion or in infected periapicallesions

Method using calcium hydroxide

Calcium hydroxide is a widely used material in endodontic treatment because of its bactericidal effectsIt is thought to create favorable conditions for periapical repair and stimulate hard tissue formationSouza et al suggested that the action of calcium hydroxide beyond the apex may be four-fold (a) anti-inflammatory activity (b) neutralization of acid products (c) activation of the alkaline phosphatase and (d) antibacterial action

Lesion sterilization and repair therapy

lsquoLesion Sterilization and Tissue Repair (LSTR)rsquo therapy that uses a triple antibiotic paste of ciprofloxacin metronidazole and minocycline for disinfection of oral infectious lesions including dentinal pulpal and periradicular lesions Repair of damaged tissues can be expected if lesions are disinfectedMetronidazole is the first choice because it has a wide antibacterial spectrum against anaerobesHowever some bacteria are resistant to metronidazole and hence ciprofloxacin and minocycline are added to the mix

Apexum procedure

Surgical removal of the periapical chronically inflamed tissue allows a fresh blood clot to form thereby converting a chronic inflammatory lesion into a new granulation tissue where healing might proceed much fasterThe Apexumprocedure uses two sequential rotary devices the Apexum NiTi Ablator and Apexum PGA Ablator (Apexum Ltd Or Yehuda Israel) designed to extend beyond the apex and mince the periapical tissues on rotation in a low-speed handpiece followed by washing out the minced tissue

Surgical management of Apical lesions Apical lesions maybe managed surgically to reduce

healing and recovery time

Indicated for emergency cases

Incision and drainagewith antibiotic therapy of the lesionfollowed by RCT with apisectomy is the usual modality of surgical treatment of apical lesions

Medical Management of apical lesions Antibiotic therapy is used to treat minor apical

lesionsin order to relieve the symptomsThis enables easier surgical or non0surgical management of the lesionThus medical management of apical lesions is used in conjunction with Surgical or non surgical management of apical lesions

Cellulitis-Cefazolin 1g iv Q8H7-10 days or cloxacillin500-1000mg po Q6H7-10 days

Acute osteomyelitis-Cefazolin 2g iv Q8H

Ludwigs angina-Clindamycin 600mg iv Q8H2-3 weeks

References J Conserv Dent 2010 Oct-Dec 13(4) 240-

245doi 1041030972070773384PMCID PMC3010029Nonsurgical management of periapical lesions Marina Fernandes and Ida de Ataide

Manual in maxillofacial surgery for senior house officers-Dental 2cmcvellore

Acute PathwayPeriapical Abscess

Requires a non-vital tooth

It is an accumultaion of Acute inflammatory cells(PMNs) at the apex of a non-vital tooth

May arise as an exacerbation of a chronic lesion-Phoenix abscess

Mostly symptomatic with acutely painful periapicalregionbut maybe unsymptomatic if there is a path of drainage of purulent material

Drainage Pathways of acute periapical infection Surface of gingiva-Parulis(Gum boil)

Palate-Palatal abscess

Maxillary sinus-Psuedocyst

Soft tissue spaces-Cellulitis

Floor of the mouth-Ludwigs Angina

Parulis(Gum boil) Associated with acute periapical inflammation

Purulent material perforates through boneperiosteumsoft tissue and epitheliumdrainsthrough intraoral sinus tract

Consists of Fluctuant mass of inflamed granulation tissue leading to an epithelialised sinus tract

Cutaneous Sinus tract An abscess that drains on its ownextraorallythrough

the overlying skin(Draining sinus tract)

Extra oral abscess Localised collection of pus that has

accumulated(consolidated) in a tissue cavityproducing fluctuance

Can serve as a nidus for sacrophytic bacterial growth

Antibiotics cant reach center of large abscessesbecause blood supply is along the peripherytherefore draining is very important for effective antibiotic treatment

Cellulitis Diffuse spread of an acute inflammatory process

through the fascial planes of soft tissueproducingerythemaoedemawarmth and pain

It is a board-likediffusehard swelling

Trismus is a common secondary to cellulitis due to loss of function of muscles of mastication

Requires immediate antibiotics and drain placement

Ludwigs angina Aggressiverapidly spreading cellulitis involving

multiple anatomic spacessubmentalsublingualsubmandibular

Produces massive swelling of the neck that may extend close to the clavicles and cause airway obstruction(bullneck)

Causes elevation of the floor of the mouth and protrusion of tomgue(woody tongue)

Can be fatal due to airway obstructionmust establish an airwaydrain and give IV antibiotics

Cavernous sinus thrombosis Maybe associated with spread of infection from

maxillary teeth(classic canine space infection)

It is the formation of a blood clot within the cavernous sinus

Life threatening infection cause the cavernous sinus holds the pituitary gland and sella turcicaCranialnerves-346

Proliferative Periostitis Form of chronic osteomyelitis with proliferative

periostitis

Periosteal reaction in which layers of reactive vital bone are formedproducing cortical expansion(onion skinning) The periosteum is not destroyedbut lifted upwhen bone is formed beneath its layers

Chronic focal sclerosingosteomyelitis AKA Condensing osteitis Localised area of bone sclerosis associated with apices

of non-vital teeth

Most frequent in children and young adults involving mandibular molarspremolars

No cortical expansion

Differential diagnosisOsseous Dysplasia and idiopathic osseosclerosis

Osteomyelitis Bacterial infection of bone secondary to

A)Odontogenic infection

B)Traumatic injury

C)Necrotising Ulcerative GingivitisNoma or cancrumoris

Predisposition to decreased vascularity of bone-PagetrsquosOsteopetrosisflorid cemento-osseous dysplasia

Chronic PathwayPeriapical granuloma

It is a misnomerit is not a granulomatous reaction

Mass of chronically inflamed granulation tissue at apex of non-vital teethdesigned to wall off bacterial invasion at apex

Associated with chronic apical periodontitis

Periapical cyst AKA apical periodontal cystradicular cyst

Inflammatory odontogenic cystinduced by cell rests of malassez(Hertwigs Epithelial Root Sheath remnants) proliferation

Radiolucency at periapex of non-vital teeth

To differentiate from a granulomait must be tested histologically

Management of apical lesions Non-surgical management Periapical lesions develop as

sequelae to pulp disease They often occur without any episode of acute pain and are discovered on routine radiographic examination It is accepted that all inflammatory periapicallesions should be initially treated with conservative nonsurgical procedures

Methods1The conservative root canal treatment

2decompression technique3active nonsurgical decompression technique4aspiration-irrigation technique

5 method using calcium hydroxide6 Lesion Sterilization and Repair Therapy and7the Apexum procedure

Case selectionThe current philosophy in the management of periapical lesions includes the initial use of nonsurgical methods When this treatment approach is not successful a surgical approach may be adoptedThe following factors must be considered while deciding on the management approach

Diagnosis of the lesionMany bone destroying lesions closely resemble endodontically related periapicallesions on radiographs Some of these nonendodontic lesions include ameloblastoma central fibroma giant cell lesions fibrous dysplasia central hemangioma primary malignancies metastatic neoplasms and inflammatory bone diseases

Proximity of the periapical lesion to adjacent vital teethWhen in proximity to a vital toothadopting a surgical approach may result in injury to the blood vessels and nerves of the adjacent teeth thereby compromising their vitality

Encroachment on anatomical structuresSurgery increases the risk of damage to the anatomic structures such as mental foramen inferior alveolar nerve Also the aspirationndashirrigation technique a nonsurgical method is not recommended where adjacent tissue spaces or sinus cavities are involved

Patient cooperation

Considerable pain or discomfort can be experienced by the patient during or after a surgical procedure A nonsurgical approach would be recommended for apprehensive and uncooperative patients

Obstructions in the root canal system

Ledges calcified canals separated instruments may prevent access to the apical foramen and may warrant a surgical approach in managing periapical lesions related to such teeth

Time involved for treatment

Enhanced healing kinetics are observed after performing apical surgery in teeth with periapical lesions

Cases refractory to nonsurgical management methods

Inflammatory apical true cysts and the presence of cholesterol crystals have been suggested as possible causes that prevent healing of periapical lesionsSurgery is recommended for such cases

METHODS FOR NONSURGICAL MANAGMENT OF PERIAPICAL LESIONS Conservative root canal treatment without adjunctive therapy

Instrumentation should be carried 1 mm beyond the apical foramen when a periapical lesion is evident on a radiograph This may cause transitory inflammation and ulceration of the epithelial lining resulting in resolution of the cyst

Decompression technique

The decompression technique involves placement of a drain into the lesion regular irrigation periodic length adjustment and maintenance of the drain for various periods of time

Active nonsurgical decompression technique

This technique uses the Endo-eze vacuum system to create a negative pressure which results in the decompression of large periapical lesions The high-volume suction aspirator is connected to a micro 22-gauge needle which is inserted in the root canal and activated for 20 minutes creating a negative pressure which results in aspiration of the exudate When the drainage partially stops the access cavity is closed with temporary cement which helps in maintaining bacterial control

Aspiration and irrigation technique

Hoen et al suggested aspiration of the cystic fluid from the periapcial lesion using a buccal palatal approach In this technique an 18-gauge needle attached to a 20 ml syringe is used to penetrate the buccal mucosa and aspirate the cystic fluid A second syringe filled with saline is then used to rinse the bony lesion The new needle is inserted through the buccal wound and passed out through the palatal tissue creating a pathway for the escape of the irrigant

Aspiration through the root canal technique

In this technique aspiration of the cystic fluid is done through the root canal by passing the aspirating needle through the apical foramen This technique eliminates the creation of buccal and palatal wounds as in the traditional aspirationndashirrigation technique This minimizes the discomfort that the patient may experience

However it is advisable not to use either aspirationndashirrigation or aspiration through the root canal techniques where adjacent tissue spaces or sinus cavities are involved when there is no fluid aspiration from the lesion or in infected periapicallesions

Method using calcium hydroxide

Calcium hydroxide is a widely used material in endodontic treatment because of its bactericidal effectsIt is thought to create favorable conditions for periapical repair and stimulate hard tissue formationSouza et al suggested that the action of calcium hydroxide beyond the apex may be four-fold (a) anti-inflammatory activity (b) neutralization of acid products (c) activation of the alkaline phosphatase and (d) antibacterial action

Lesion sterilization and repair therapy

lsquoLesion Sterilization and Tissue Repair (LSTR)rsquo therapy that uses a triple antibiotic paste of ciprofloxacin metronidazole and minocycline for disinfection of oral infectious lesions including dentinal pulpal and periradicular lesions Repair of damaged tissues can be expected if lesions are disinfectedMetronidazole is the first choice because it has a wide antibacterial spectrum against anaerobesHowever some bacteria are resistant to metronidazole and hence ciprofloxacin and minocycline are added to the mix

Apexum procedure

Surgical removal of the periapical chronically inflamed tissue allows a fresh blood clot to form thereby converting a chronic inflammatory lesion into a new granulation tissue where healing might proceed much fasterThe Apexumprocedure uses two sequential rotary devices the Apexum NiTi Ablator and Apexum PGA Ablator (Apexum Ltd Or Yehuda Israel) designed to extend beyond the apex and mince the periapical tissues on rotation in a low-speed handpiece followed by washing out the minced tissue

Surgical management of Apical lesions Apical lesions maybe managed surgically to reduce

healing and recovery time

Indicated for emergency cases

Incision and drainagewith antibiotic therapy of the lesionfollowed by RCT with apisectomy is the usual modality of surgical treatment of apical lesions

Medical Management of apical lesions Antibiotic therapy is used to treat minor apical

lesionsin order to relieve the symptomsThis enables easier surgical or non0surgical management of the lesionThus medical management of apical lesions is used in conjunction with Surgical or non surgical management of apical lesions

Cellulitis-Cefazolin 1g iv Q8H7-10 days or cloxacillin500-1000mg po Q6H7-10 days

Acute osteomyelitis-Cefazolin 2g iv Q8H

Ludwigs angina-Clindamycin 600mg iv Q8H2-3 weeks

References J Conserv Dent 2010 Oct-Dec 13(4) 240-

245doi 1041030972070773384PMCID PMC3010029Nonsurgical management of periapical lesions Marina Fernandes and Ida de Ataide

Manual in maxillofacial surgery for senior house officers-Dental 2cmcvellore

Drainage Pathways of acute periapical infection Surface of gingiva-Parulis(Gum boil)

Palate-Palatal abscess

Maxillary sinus-Psuedocyst

Soft tissue spaces-Cellulitis

Floor of the mouth-Ludwigs Angina

Parulis(Gum boil) Associated with acute periapical inflammation

Purulent material perforates through boneperiosteumsoft tissue and epitheliumdrainsthrough intraoral sinus tract

Consists of Fluctuant mass of inflamed granulation tissue leading to an epithelialised sinus tract

Cutaneous Sinus tract An abscess that drains on its ownextraorallythrough

the overlying skin(Draining sinus tract)

Extra oral abscess Localised collection of pus that has

accumulated(consolidated) in a tissue cavityproducing fluctuance

Can serve as a nidus for sacrophytic bacterial growth

Antibiotics cant reach center of large abscessesbecause blood supply is along the peripherytherefore draining is very important for effective antibiotic treatment

Cellulitis Diffuse spread of an acute inflammatory process

through the fascial planes of soft tissueproducingerythemaoedemawarmth and pain

It is a board-likediffusehard swelling

Trismus is a common secondary to cellulitis due to loss of function of muscles of mastication

Requires immediate antibiotics and drain placement

Ludwigs angina Aggressiverapidly spreading cellulitis involving

multiple anatomic spacessubmentalsublingualsubmandibular

Produces massive swelling of the neck that may extend close to the clavicles and cause airway obstruction(bullneck)

Causes elevation of the floor of the mouth and protrusion of tomgue(woody tongue)

Can be fatal due to airway obstructionmust establish an airwaydrain and give IV antibiotics

Cavernous sinus thrombosis Maybe associated with spread of infection from

maxillary teeth(classic canine space infection)

It is the formation of a blood clot within the cavernous sinus

Life threatening infection cause the cavernous sinus holds the pituitary gland and sella turcicaCranialnerves-346

Proliferative Periostitis Form of chronic osteomyelitis with proliferative

periostitis

Periosteal reaction in which layers of reactive vital bone are formedproducing cortical expansion(onion skinning) The periosteum is not destroyedbut lifted upwhen bone is formed beneath its layers

Chronic focal sclerosingosteomyelitis AKA Condensing osteitis Localised area of bone sclerosis associated with apices

of non-vital teeth

Most frequent in children and young adults involving mandibular molarspremolars

No cortical expansion

Differential diagnosisOsseous Dysplasia and idiopathic osseosclerosis

Osteomyelitis Bacterial infection of bone secondary to

A)Odontogenic infection

B)Traumatic injury

C)Necrotising Ulcerative GingivitisNoma or cancrumoris

Predisposition to decreased vascularity of bone-PagetrsquosOsteopetrosisflorid cemento-osseous dysplasia

Chronic PathwayPeriapical granuloma

It is a misnomerit is not a granulomatous reaction

Mass of chronically inflamed granulation tissue at apex of non-vital teethdesigned to wall off bacterial invasion at apex

Associated with chronic apical periodontitis

Periapical cyst AKA apical periodontal cystradicular cyst

Inflammatory odontogenic cystinduced by cell rests of malassez(Hertwigs Epithelial Root Sheath remnants) proliferation

Radiolucency at periapex of non-vital teeth

To differentiate from a granulomait must be tested histologically

Management of apical lesions Non-surgical management Periapical lesions develop as

sequelae to pulp disease They often occur without any episode of acute pain and are discovered on routine radiographic examination It is accepted that all inflammatory periapicallesions should be initially treated with conservative nonsurgical procedures

Methods1The conservative root canal treatment

2decompression technique3active nonsurgical decompression technique4aspiration-irrigation technique

5 method using calcium hydroxide6 Lesion Sterilization and Repair Therapy and7the Apexum procedure

Case selectionThe current philosophy in the management of periapical lesions includes the initial use of nonsurgical methods When this treatment approach is not successful a surgical approach may be adoptedThe following factors must be considered while deciding on the management approach

Diagnosis of the lesionMany bone destroying lesions closely resemble endodontically related periapicallesions on radiographs Some of these nonendodontic lesions include ameloblastoma central fibroma giant cell lesions fibrous dysplasia central hemangioma primary malignancies metastatic neoplasms and inflammatory bone diseases

Proximity of the periapical lesion to adjacent vital teethWhen in proximity to a vital toothadopting a surgical approach may result in injury to the blood vessels and nerves of the adjacent teeth thereby compromising their vitality

Encroachment on anatomical structuresSurgery increases the risk of damage to the anatomic structures such as mental foramen inferior alveolar nerve Also the aspirationndashirrigation technique a nonsurgical method is not recommended where adjacent tissue spaces or sinus cavities are involved

Patient cooperation

Considerable pain or discomfort can be experienced by the patient during or after a surgical procedure A nonsurgical approach would be recommended for apprehensive and uncooperative patients

Obstructions in the root canal system

Ledges calcified canals separated instruments may prevent access to the apical foramen and may warrant a surgical approach in managing periapical lesions related to such teeth

Time involved for treatment

Enhanced healing kinetics are observed after performing apical surgery in teeth with periapical lesions

Cases refractory to nonsurgical management methods

Inflammatory apical true cysts and the presence of cholesterol crystals have been suggested as possible causes that prevent healing of periapical lesionsSurgery is recommended for such cases

METHODS FOR NONSURGICAL MANAGMENT OF PERIAPICAL LESIONS Conservative root canal treatment without adjunctive therapy

Instrumentation should be carried 1 mm beyond the apical foramen when a periapical lesion is evident on a radiograph This may cause transitory inflammation and ulceration of the epithelial lining resulting in resolution of the cyst

Decompression technique

The decompression technique involves placement of a drain into the lesion regular irrigation periodic length adjustment and maintenance of the drain for various periods of time

Active nonsurgical decompression technique

This technique uses the Endo-eze vacuum system to create a negative pressure which results in the decompression of large periapical lesions The high-volume suction aspirator is connected to a micro 22-gauge needle which is inserted in the root canal and activated for 20 minutes creating a negative pressure which results in aspiration of the exudate When the drainage partially stops the access cavity is closed with temporary cement which helps in maintaining bacterial control

Aspiration and irrigation technique

Hoen et al suggested aspiration of the cystic fluid from the periapcial lesion using a buccal palatal approach In this technique an 18-gauge needle attached to a 20 ml syringe is used to penetrate the buccal mucosa and aspirate the cystic fluid A second syringe filled with saline is then used to rinse the bony lesion The new needle is inserted through the buccal wound and passed out through the palatal tissue creating a pathway for the escape of the irrigant

Aspiration through the root canal technique

In this technique aspiration of the cystic fluid is done through the root canal by passing the aspirating needle through the apical foramen This technique eliminates the creation of buccal and palatal wounds as in the traditional aspirationndashirrigation technique This minimizes the discomfort that the patient may experience

However it is advisable not to use either aspirationndashirrigation or aspiration through the root canal techniques where adjacent tissue spaces or sinus cavities are involved when there is no fluid aspiration from the lesion or in infected periapicallesions

Method using calcium hydroxide

Calcium hydroxide is a widely used material in endodontic treatment because of its bactericidal effectsIt is thought to create favorable conditions for periapical repair and stimulate hard tissue formationSouza et al suggested that the action of calcium hydroxide beyond the apex may be four-fold (a) anti-inflammatory activity (b) neutralization of acid products (c) activation of the alkaline phosphatase and (d) antibacterial action

Lesion sterilization and repair therapy

lsquoLesion Sterilization and Tissue Repair (LSTR)rsquo therapy that uses a triple antibiotic paste of ciprofloxacin metronidazole and minocycline for disinfection of oral infectious lesions including dentinal pulpal and periradicular lesions Repair of damaged tissues can be expected if lesions are disinfectedMetronidazole is the first choice because it has a wide antibacterial spectrum against anaerobesHowever some bacteria are resistant to metronidazole and hence ciprofloxacin and minocycline are added to the mix

Apexum procedure

Surgical removal of the periapical chronically inflamed tissue allows a fresh blood clot to form thereby converting a chronic inflammatory lesion into a new granulation tissue where healing might proceed much fasterThe Apexumprocedure uses two sequential rotary devices the Apexum NiTi Ablator and Apexum PGA Ablator (Apexum Ltd Or Yehuda Israel) designed to extend beyond the apex and mince the periapical tissues on rotation in a low-speed handpiece followed by washing out the minced tissue

Surgical management of Apical lesions Apical lesions maybe managed surgically to reduce

healing and recovery time

Indicated for emergency cases

Incision and drainagewith antibiotic therapy of the lesionfollowed by RCT with apisectomy is the usual modality of surgical treatment of apical lesions

Medical Management of apical lesions Antibiotic therapy is used to treat minor apical

lesionsin order to relieve the symptomsThis enables easier surgical or non0surgical management of the lesionThus medical management of apical lesions is used in conjunction with Surgical or non surgical management of apical lesions

Cellulitis-Cefazolin 1g iv Q8H7-10 days or cloxacillin500-1000mg po Q6H7-10 days

Acute osteomyelitis-Cefazolin 2g iv Q8H

Ludwigs angina-Clindamycin 600mg iv Q8H2-3 weeks

References J Conserv Dent 2010 Oct-Dec 13(4) 240-

245doi 1041030972070773384PMCID PMC3010029Nonsurgical management of periapical lesions Marina Fernandes and Ida de Ataide

Manual in maxillofacial surgery for senior house officers-Dental 2cmcvellore

Parulis(Gum boil) Associated with acute periapical inflammation

Purulent material perforates through boneperiosteumsoft tissue and epitheliumdrainsthrough intraoral sinus tract

Consists of Fluctuant mass of inflamed granulation tissue leading to an epithelialised sinus tract

Cutaneous Sinus tract An abscess that drains on its ownextraorallythrough

the overlying skin(Draining sinus tract)

Extra oral abscess Localised collection of pus that has

accumulated(consolidated) in a tissue cavityproducing fluctuance

Can serve as a nidus for sacrophytic bacterial growth

Antibiotics cant reach center of large abscessesbecause blood supply is along the peripherytherefore draining is very important for effective antibiotic treatment

Cellulitis Diffuse spread of an acute inflammatory process

through the fascial planes of soft tissueproducingerythemaoedemawarmth and pain

It is a board-likediffusehard swelling

Trismus is a common secondary to cellulitis due to loss of function of muscles of mastication

Requires immediate antibiotics and drain placement

Ludwigs angina Aggressiverapidly spreading cellulitis involving

multiple anatomic spacessubmentalsublingualsubmandibular

Produces massive swelling of the neck that may extend close to the clavicles and cause airway obstruction(bullneck)

Causes elevation of the floor of the mouth and protrusion of tomgue(woody tongue)

Can be fatal due to airway obstructionmust establish an airwaydrain and give IV antibiotics

Cavernous sinus thrombosis Maybe associated with spread of infection from

maxillary teeth(classic canine space infection)

It is the formation of a blood clot within the cavernous sinus

Life threatening infection cause the cavernous sinus holds the pituitary gland and sella turcicaCranialnerves-346

Proliferative Periostitis Form of chronic osteomyelitis with proliferative

periostitis

Periosteal reaction in which layers of reactive vital bone are formedproducing cortical expansion(onion skinning) The periosteum is not destroyedbut lifted upwhen bone is formed beneath its layers

Chronic focal sclerosingosteomyelitis AKA Condensing osteitis Localised area of bone sclerosis associated with apices

of non-vital teeth

Most frequent in children and young adults involving mandibular molarspremolars

No cortical expansion

Differential diagnosisOsseous Dysplasia and idiopathic osseosclerosis

Osteomyelitis Bacterial infection of bone secondary to

A)Odontogenic infection

B)Traumatic injury

C)Necrotising Ulcerative GingivitisNoma or cancrumoris

Predisposition to decreased vascularity of bone-PagetrsquosOsteopetrosisflorid cemento-osseous dysplasia

Chronic PathwayPeriapical granuloma

It is a misnomerit is not a granulomatous reaction

Mass of chronically inflamed granulation tissue at apex of non-vital teethdesigned to wall off bacterial invasion at apex

Associated with chronic apical periodontitis

Periapical cyst AKA apical periodontal cystradicular cyst

Inflammatory odontogenic cystinduced by cell rests of malassez(Hertwigs Epithelial Root Sheath remnants) proliferation

Radiolucency at periapex of non-vital teeth

To differentiate from a granulomait must be tested histologically

Management of apical lesions Non-surgical management Periapical lesions develop as

sequelae to pulp disease They often occur without any episode of acute pain and are discovered on routine radiographic examination It is accepted that all inflammatory periapicallesions should be initially treated with conservative nonsurgical procedures

Methods1The conservative root canal treatment

2decompression technique3active nonsurgical decompression technique4aspiration-irrigation technique

5 method using calcium hydroxide6 Lesion Sterilization and Repair Therapy and7the Apexum procedure

Case selectionThe current philosophy in the management of periapical lesions includes the initial use of nonsurgical methods When this treatment approach is not successful a surgical approach may be adoptedThe following factors must be considered while deciding on the management approach

Diagnosis of the lesionMany bone destroying lesions closely resemble endodontically related periapicallesions on radiographs Some of these nonendodontic lesions include ameloblastoma central fibroma giant cell lesions fibrous dysplasia central hemangioma primary malignancies metastatic neoplasms and inflammatory bone diseases

Proximity of the periapical lesion to adjacent vital teethWhen in proximity to a vital toothadopting a surgical approach may result in injury to the blood vessels and nerves of the adjacent teeth thereby compromising their vitality

Encroachment on anatomical structuresSurgery increases the risk of damage to the anatomic structures such as mental foramen inferior alveolar nerve Also the aspirationndashirrigation technique a nonsurgical method is not recommended where adjacent tissue spaces or sinus cavities are involved

Patient cooperation

Considerable pain or discomfort can be experienced by the patient during or after a surgical procedure A nonsurgical approach would be recommended for apprehensive and uncooperative patients

Obstructions in the root canal system

Ledges calcified canals separated instruments may prevent access to the apical foramen and may warrant a surgical approach in managing periapical lesions related to such teeth

Time involved for treatment

Enhanced healing kinetics are observed after performing apical surgery in teeth with periapical lesions

Cases refractory to nonsurgical management methods

Inflammatory apical true cysts and the presence of cholesterol crystals have been suggested as possible causes that prevent healing of periapical lesionsSurgery is recommended for such cases

METHODS FOR NONSURGICAL MANAGMENT OF PERIAPICAL LESIONS Conservative root canal treatment without adjunctive therapy

Instrumentation should be carried 1 mm beyond the apical foramen when a periapical lesion is evident on a radiograph This may cause transitory inflammation and ulceration of the epithelial lining resulting in resolution of the cyst

Decompression technique

The decompression technique involves placement of a drain into the lesion regular irrigation periodic length adjustment and maintenance of the drain for various periods of time

Active nonsurgical decompression technique

This technique uses the Endo-eze vacuum system to create a negative pressure which results in the decompression of large periapical lesions The high-volume suction aspirator is connected to a micro 22-gauge needle which is inserted in the root canal and activated for 20 minutes creating a negative pressure which results in aspiration of the exudate When the drainage partially stops the access cavity is closed with temporary cement which helps in maintaining bacterial control

Aspiration and irrigation technique

Hoen et al suggested aspiration of the cystic fluid from the periapcial lesion using a buccal palatal approach In this technique an 18-gauge needle attached to a 20 ml syringe is used to penetrate the buccal mucosa and aspirate the cystic fluid A second syringe filled with saline is then used to rinse the bony lesion The new needle is inserted through the buccal wound and passed out through the palatal tissue creating a pathway for the escape of the irrigant

Aspiration through the root canal technique

In this technique aspiration of the cystic fluid is done through the root canal by passing the aspirating needle through the apical foramen This technique eliminates the creation of buccal and palatal wounds as in the traditional aspirationndashirrigation technique This minimizes the discomfort that the patient may experience

However it is advisable not to use either aspirationndashirrigation or aspiration through the root canal techniques where adjacent tissue spaces or sinus cavities are involved when there is no fluid aspiration from the lesion or in infected periapicallesions

Method using calcium hydroxide

Calcium hydroxide is a widely used material in endodontic treatment because of its bactericidal effectsIt is thought to create favorable conditions for periapical repair and stimulate hard tissue formationSouza et al suggested that the action of calcium hydroxide beyond the apex may be four-fold (a) anti-inflammatory activity (b) neutralization of acid products (c) activation of the alkaline phosphatase and (d) antibacterial action

Lesion sterilization and repair therapy

lsquoLesion Sterilization and Tissue Repair (LSTR)rsquo therapy that uses a triple antibiotic paste of ciprofloxacin metronidazole and minocycline for disinfection of oral infectious lesions including dentinal pulpal and periradicular lesions Repair of damaged tissues can be expected if lesions are disinfectedMetronidazole is the first choice because it has a wide antibacterial spectrum against anaerobesHowever some bacteria are resistant to metronidazole and hence ciprofloxacin and minocycline are added to the mix

Apexum procedure

Surgical removal of the periapical chronically inflamed tissue allows a fresh blood clot to form thereby converting a chronic inflammatory lesion into a new granulation tissue where healing might proceed much fasterThe Apexumprocedure uses two sequential rotary devices the Apexum NiTi Ablator and Apexum PGA Ablator (Apexum Ltd Or Yehuda Israel) designed to extend beyond the apex and mince the periapical tissues on rotation in a low-speed handpiece followed by washing out the minced tissue

Surgical management of Apical lesions Apical lesions maybe managed surgically to reduce

healing and recovery time

Indicated for emergency cases

Incision and drainagewith antibiotic therapy of the lesionfollowed by RCT with apisectomy is the usual modality of surgical treatment of apical lesions

Medical Management of apical lesions Antibiotic therapy is used to treat minor apical

lesionsin order to relieve the symptomsThis enables easier surgical or non0surgical management of the lesionThus medical management of apical lesions is used in conjunction with Surgical or non surgical management of apical lesions

Cellulitis-Cefazolin 1g iv Q8H7-10 days or cloxacillin500-1000mg po Q6H7-10 days

Acute osteomyelitis-Cefazolin 2g iv Q8H

Ludwigs angina-Clindamycin 600mg iv Q8H2-3 weeks

References J Conserv Dent 2010 Oct-Dec 13(4) 240-

245doi 1041030972070773384PMCID PMC3010029Nonsurgical management of periapical lesions Marina Fernandes and Ida de Ataide

Manual in maxillofacial surgery for senior house officers-Dental 2cmcvellore

Cutaneous Sinus tract An abscess that drains on its ownextraorallythrough

the overlying skin(Draining sinus tract)

Extra oral abscess Localised collection of pus that has

accumulated(consolidated) in a tissue cavityproducing fluctuance

Can serve as a nidus for sacrophytic bacterial growth

Antibiotics cant reach center of large abscessesbecause blood supply is along the peripherytherefore draining is very important for effective antibiotic treatment

Cellulitis Diffuse spread of an acute inflammatory process

through the fascial planes of soft tissueproducingerythemaoedemawarmth and pain

It is a board-likediffusehard swelling

Trismus is a common secondary to cellulitis due to loss of function of muscles of mastication

Requires immediate antibiotics and drain placement

Ludwigs angina Aggressiverapidly spreading cellulitis involving

multiple anatomic spacessubmentalsublingualsubmandibular

Produces massive swelling of the neck that may extend close to the clavicles and cause airway obstruction(bullneck)

Causes elevation of the floor of the mouth and protrusion of tomgue(woody tongue)

Can be fatal due to airway obstructionmust establish an airwaydrain and give IV antibiotics

Cavernous sinus thrombosis Maybe associated with spread of infection from

maxillary teeth(classic canine space infection)

It is the formation of a blood clot within the cavernous sinus

Life threatening infection cause the cavernous sinus holds the pituitary gland and sella turcicaCranialnerves-346

Proliferative Periostitis Form of chronic osteomyelitis with proliferative

periostitis

Periosteal reaction in which layers of reactive vital bone are formedproducing cortical expansion(onion skinning) The periosteum is not destroyedbut lifted upwhen bone is formed beneath its layers

Chronic focal sclerosingosteomyelitis AKA Condensing osteitis Localised area of bone sclerosis associated with apices

of non-vital teeth

Most frequent in children and young adults involving mandibular molarspremolars

No cortical expansion

Differential diagnosisOsseous Dysplasia and idiopathic osseosclerosis

Osteomyelitis Bacterial infection of bone secondary to

A)Odontogenic infection

B)Traumatic injury

C)Necrotising Ulcerative GingivitisNoma or cancrumoris

Predisposition to decreased vascularity of bone-PagetrsquosOsteopetrosisflorid cemento-osseous dysplasia

Chronic PathwayPeriapical granuloma

It is a misnomerit is not a granulomatous reaction

Mass of chronically inflamed granulation tissue at apex of non-vital teethdesigned to wall off bacterial invasion at apex

Associated with chronic apical periodontitis

Periapical cyst AKA apical periodontal cystradicular cyst

Inflammatory odontogenic cystinduced by cell rests of malassez(Hertwigs Epithelial Root Sheath remnants) proliferation

Radiolucency at periapex of non-vital teeth

To differentiate from a granulomait must be tested histologically

Management of apical lesions Non-surgical management Periapical lesions develop as

sequelae to pulp disease They often occur without any episode of acute pain and are discovered on routine radiographic examination It is accepted that all inflammatory periapicallesions should be initially treated with conservative nonsurgical procedures

Methods1The conservative root canal treatment

2decompression technique3active nonsurgical decompression technique4aspiration-irrigation technique

5 method using calcium hydroxide6 Lesion Sterilization and Repair Therapy and7the Apexum procedure

Case selectionThe current philosophy in the management of periapical lesions includes the initial use of nonsurgical methods When this treatment approach is not successful a surgical approach may be adoptedThe following factors must be considered while deciding on the management approach

Diagnosis of the lesionMany bone destroying lesions closely resemble endodontically related periapicallesions on radiographs Some of these nonendodontic lesions include ameloblastoma central fibroma giant cell lesions fibrous dysplasia central hemangioma primary malignancies metastatic neoplasms and inflammatory bone diseases

Proximity of the periapical lesion to adjacent vital teethWhen in proximity to a vital toothadopting a surgical approach may result in injury to the blood vessels and nerves of the adjacent teeth thereby compromising their vitality

Encroachment on anatomical structuresSurgery increases the risk of damage to the anatomic structures such as mental foramen inferior alveolar nerve Also the aspirationndashirrigation technique a nonsurgical method is not recommended where adjacent tissue spaces or sinus cavities are involved

Patient cooperation

Considerable pain or discomfort can be experienced by the patient during or after a surgical procedure A nonsurgical approach would be recommended for apprehensive and uncooperative patients

Obstructions in the root canal system

Ledges calcified canals separated instruments may prevent access to the apical foramen and may warrant a surgical approach in managing periapical lesions related to such teeth

Time involved for treatment

Enhanced healing kinetics are observed after performing apical surgery in teeth with periapical lesions

Cases refractory to nonsurgical management methods

Inflammatory apical true cysts and the presence of cholesterol crystals have been suggested as possible causes that prevent healing of periapical lesionsSurgery is recommended for such cases

METHODS FOR NONSURGICAL MANAGMENT OF PERIAPICAL LESIONS Conservative root canal treatment without adjunctive therapy

Instrumentation should be carried 1 mm beyond the apical foramen when a periapical lesion is evident on a radiograph This may cause transitory inflammation and ulceration of the epithelial lining resulting in resolution of the cyst

Decompression technique

The decompression technique involves placement of a drain into the lesion regular irrigation periodic length adjustment and maintenance of the drain for various periods of time

Active nonsurgical decompression technique

This technique uses the Endo-eze vacuum system to create a negative pressure which results in the decompression of large periapical lesions The high-volume suction aspirator is connected to a micro 22-gauge needle which is inserted in the root canal and activated for 20 minutes creating a negative pressure which results in aspiration of the exudate When the drainage partially stops the access cavity is closed with temporary cement which helps in maintaining bacterial control

Aspiration and irrigation technique

Hoen et al suggested aspiration of the cystic fluid from the periapcial lesion using a buccal palatal approach In this technique an 18-gauge needle attached to a 20 ml syringe is used to penetrate the buccal mucosa and aspirate the cystic fluid A second syringe filled with saline is then used to rinse the bony lesion The new needle is inserted through the buccal wound and passed out through the palatal tissue creating a pathway for the escape of the irrigant

Aspiration through the root canal technique

In this technique aspiration of the cystic fluid is done through the root canal by passing the aspirating needle through the apical foramen This technique eliminates the creation of buccal and palatal wounds as in the traditional aspirationndashirrigation technique This minimizes the discomfort that the patient may experience

However it is advisable not to use either aspirationndashirrigation or aspiration through the root canal techniques where adjacent tissue spaces or sinus cavities are involved when there is no fluid aspiration from the lesion or in infected periapicallesions

Method using calcium hydroxide

Calcium hydroxide is a widely used material in endodontic treatment because of its bactericidal effectsIt is thought to create favorable conditions for periapical repair and stimulate hard tissue formationSouza et al suggested that the action of calcium hydroxide beyond the apex may be four-fold (a) anti-inflammatory activity (b) neutralization of acid products (c) activation of the alkaline phosphatase and (d) antibacterial action

Lesion sterilization and repair therapy

lsquoLesion Sterilization and Tissue Repair (LSTR)rsquo therapy that uses a triple antibiotic paste of ciprofloxacin metronidazole and minocycline for disinfection of oral infectious lesions including dentinal pulpal and periradicular lesions Repair of damaged tissues can be expected if lesions are disinfectedMetronidazole is the first choice because it has a wide antibacterial spectrum against anaerobesHowever some bacteria are resistant to metronidazole and hence ciprofloxacin and minocycline are added to the mix

Apexum procedure

Surgical removal of the periapical chronically inflamed tissue allows a fresh blood clot to form thereby converting a chronic inflammatory lesion into a new granulation tissue where healing might proceed much fasterThe Apexumprocedure uses two sequential rotary devices the Apexum NiTi Ablator and Apexum PGA Ablator (Apexum Ltd Or Yehuda Israel) designed to extend beyond the apex and mince the periapical tissues on rotation in a low-speed handpiece followed by washing out the minced tissue

Surgical management of Apical lesions Apical lesions maybe managed surgically to reduce

healing and recovery time

Indicated for emergency cases

Incision and drainagewith antibiotic therapy of the lesionfollowed by RCT with apisectomy is the usual modality of surgical treatment of apical lesions

Medical Management of apical lesions Antibiotic therapy is used to treat minor apical

lesionsin order to relieve the symptomsThis enables easier surgical or non0surgical management of the lesionThus medical management of apical lesions is used in conjunction with Surgical or non surgical management of apical lesions

Cellulitis-Cefazolin 1g iv Q8H7-10 days or cloxacillin500-1000mg po Q6H7-10 days

Acute osteomyelitis-Cefazolin 2g iv Q8H

Ludwigs angina-Clindamycin 600mg iv Q8H2-3 weeks

References J Conserv Dent 2010 Oct-Dec 13(4) 240-

245doi 1041030972070773384PMCID PMC3010029Nonsurgical management of periapical lesions Marina Fernandes and Ida de Ataide

Manual in maxillofacial surgery for senior house officers-Dental 2cmcvellore

Extra oral abscess Localised collection of pus that has

accumulated(consolidated) in a tissue cavityproducing fluctuance

Can serve as a nidus for sacrophytic bacterial growth

Antibiotics cant reach center of large abscessesbecause blood supply is along the peripherytherefore draining is very important for effective antibiotic treatment

Cellulitis Diffuse spread of an acute inflammatory process

through the fascial planes of soft tissueproducingerythemaoedemawarmth and pain

It is a board-likediffusehard swelling

Trismus is a common secondary to cellulitis due to loss of function of muscles of mastication

Requires immediate antibiotics and drain placement

Ludwigs angina Aggressiverapidly spreading cellulitis involving

multiple anatomic spacessubmentalsublingualsubmandibular

Produces massive swelling of the neck that may extend close to the clavicles and cause airway obstruction(bullneck)

Causes elevation of the floor of the mouth and protrusion of tomgue(woody tongue)

Can be fatal due to airway obstructionmust establish an airwaydrain and give IV antibiotics

Cavernous sinus thrombosis Maybe associated with spread of infection from

maxillary teeth(classic canine space infection)

It is the formation of a blood clot within the cavernous sinus

Life threatening infection cause the cavernous sinus holds the pituitary gland and sella turcicaCranialnerves-346

Proliferative Periostitis Form of chronic osteomyelitis with proliferative

periostitis

Periosteal reaction in which layers of reactive vital bone are formedproducing cortical expansion(onion skinning) The periosteum is not destroyedbut lifted upwhen bone is formed beneath its layers

Chronic focal sclerosingosteomyelitis AKA Condensing osteitis Localised area of bone sclerosis associated with apices

of non-vital teeth

Most frequent in children and young adults involving mandibular molarspremolars

No cortical expansion

Differential diagnosisOsseous Dysplasia and idiopathic osseosclerosis

Osteomyelitis Bacterial infection of bone secondary to

A)Odontogenic infection

B)Traumatic injury

C)Necrotising Ulcerative GingivitisNoma or cancrumoris

Predisposition to decreased vascularity of bone-PagetrsquosOsteopetrosisflorid cemento-osseous dysplasia

Chronic PathwayPeriapical granuloma

It is a misnomerit is not a granulomatous reaction

Mass of chronically inflamed granulation tissue at apex of non-vital teethdesigned to wall off bacterial invasion at apex

Associated with chronic apical periodontitis

Periapical cyst AKA apical periodontal cystradicular cyst

Inflammatory odontogenic cystinduced by cell rests of malassez(Hertwigs Epithelial Root Sheath remnants) proliferation

Radiolucency at periapex of non-vital teeth

To differentiate from a granulomait must be tested histologically

Management of apical lesions Non-surgical management Periapical lesions develop as

sequelae to pulp disease They often occur without any episode of acute pain and are discovered on routine radiographic examination It is accepted that all inflammatory periapicallesions should be initially treated with conservative nonsurgical procedures

Methods1The conservative root canal treatment

2decompression technique3active nonsurgical decompression technique4aspiration-irrigation technique

5 method using calcium hydroxide6 Lesion Sterilization and Repair Therapy and7the Apexum procedure

Case selectionThe current philosophy in the management of periapical lesions includes the initial use of nonsurgical methods When this treatment approach is not successful a surgical approach may be adoptedThe following factors must be considered while deciding on the management approach

Diagnosis of the lesionMany bone destroying lesions closely resemble endodontically related periapicallesions on radiographs Some of these nonendodontic lesions include ameloblastoma central fibroma giant cell lesions fibrous dysplasia central hemangioma primary malignancies metastatic neoplasms and inflammatory bone diseases

Proximity of the periapical lesion to adjacent vital teethWhen in proximity to a vital toothadopting a surgical approach may result in injury to the blood vessels and nerves of the adjacent teeth thereby compromising their vitality

Encroachment on anatomical structuresSurgery increases the risk of damage to the anatomic structures such as mental foramen inferior alveolar nerve Also the aspirationndashirrigation technique a nonsurgical method is not recommended where adjacent tissue spaces or sinus cavities are involved

Patient cooperation

Considerable pain or discomfort can be experienced by the patient during or after a surgical procedure A nonsurgical approach would be recommended for apprehensive and uncooperative patients

Obstructions in the root canal system

Ledges calcified canals separated instruments may prevent access to the apical foramen and may warrant a surgical approach in managing periapical lesions related to such teeth

Time involved for treatment

Enhanced healing kinetics are observed after performing apical surgery in teeth with periapical lesions

Cases refractory to nonsurgical management methods

Inflammatory apical true cysts and the presence of cholesterol crystals have been suggested as possible causes that prevent healing of periapical lesionsSurgery is recommended for such cases

METHODS FOR NONSURGICAL MANAGMENT OF PERIAPICAL LESIONS Conservative root canal treatment without adjunctive therapy

Instrumentation should be carried 1 mm beyond the apical foramen when a periapical lesion is evident on a radiograph This may cause transitory inflammation and ulceration of the epithelial lining resulting in resolution of the cyst

Decompression technique

The decompression technique involves placement of a drain into the lesion regular irrigation periodic length adjustment and maintenance of the drain for various periods of time

Active nonsurgical decompression technique

This technique uses the Endo-eze vacuum system to create a negative pressure which results in the decompression of large periapical lesions The high-volume suction aspirator is connected to a micro 22-gauge needle which is inserted in the root canal and activated for 20 minutes creating a negative pressure which results in aspiration of the exudate When the drainage partially stops the access cavity is closed with temporary cement which helps in maintaining bacterial control

Aspiration and irrigation technique

Hoen et al suggested aspiration of the cystic fluid from the periapcial lesion using a buccal palatal approach In this technique an 18-gauge needle attached to a 20 ml syringe is used to penetrate the buccal mucosa and aspirate the cystic fluid A second syringe filled with saline is then used to rinse the bony lesion The new needle is inserted through the buccal wound and passed out through the palatal tissue creating a pathway for the escape of the irrigant

Aspiration through the root canal technique

In this technique aspiration of the cystic fluid is done through the root canal by passing the aspirating needle through the apical foramen This technique eliminates the creation of buccal and palatal wounds as in the traditional aspirationndashirrigation technique This minimizes the discomfort that the patient may experience

However it is advisable not to use either aspirationndashirrigation or aspiration through the root canal techniques where adjacent tissue spaces or sinus cavities are involved when there is no fluid aspiration from the lesion or in infected periapicallesions

Method using calcium hydroxide

Calcium hydroxide is a widely used material in endodontic treatment because of its bactericidal effectsIt is thought to create favorable conditions for periapical repair and stimulate hard tissue formationSouza et al suggested that the action of calcium hydroxide beyond the apex may be four-fold (a) anti-inflammatory activity (b) neutralization of acid products (c) activation of the alkaline phosphatase and (d) antibacterial action

Lesion sterilization and repair therapy

lsquoLesion Sterilization and Tissue Repair (LSTR)rsquo therapy that uses a triple antibiotic paste of ciprofloxacin metronidazole and minocycline for disinfection of oral infectious lesions including dentinal pulpal and periradicular lesions Repair of damaged tissues can be expected if lesions are disinfectedMetronidazole is the first choice because it has a wide antibacterial spectrum against anaerobesHowever some bacteria are resistant to metronidazole and hence ciprofloxacin and minocycline are added to the mix

Apexum procedure

Surgical removal of the periapical chronically inflamed tissue allows a fresh blood clot to form thereby converting a chronic inflammatory lesion into a new granulation tissue where healing might proceed much fasterThe Apexumprocedure uses two sequential rotary devices the Apexum NiTi Ablator and Apexum PGA Ablator (Apexum Ltd Or Yehuda Israel) designed to extend beyond the apex and mince the periapical tissues on rotation in a low-speed handpiece followed by washing out the minced tissue

Surgical management of Apical lesions Apical lesions maybe managed surgically to reduce

healing and recovery time

Indicated for emergency cases

Incision and drainagewith antibiotic therapy of the lesionfollowed by RCT with apisectomy is the usual modality of surgical treatment of apical lesions

Medical Management of apical lesions Antibiotic therapy is used to treat minor apical

lesionsin order to relieve the symptomsThis enables easier surgical or non0surgical management of the lesionThus medical management of apical lesions is used in conjunction with Surgical or non surgical management of apical lesions

Cellulitis-Cefazolin 1g iv Q8H7-10 days or cloxacillin500-1000mg po Q6H7-10 days

Acute osteomyelitis-Cefazolin 2g iv Q8H

Ludwigs angina-Clindamycin 600mg iv Q8H2-3 weeks

References J Conserv Dent 2010 Oct-Dec 13(4) 240-

245doi 1041030972070773384PMCID PMC3010029Nonsurgical management of periapical lesions Marina Fernandes and Ida de Ataide

Manual in maxillofacial surgery for senior house officers-Dental 2cmcvellore

Cellulitis Diffuse spread of an acute inflammatory process

through the fascial planes of soft tissueproducingerythemaoedemawarmth and pain

It is a board-likediffusehard swelling

Trismus is a common secondary to cellulitis due to loss of function of muscles of mastication

Requires immediate antibiotics and drain placement

Ludwigs angina Aggressiverapidly spreading cellulitis involving

multiple anatomic spacessubmentalsublingualsubmandibular

Produces massive swelling of the neck that may extend close to the clavicles and cause airway obstruction(bullneck)

Causes elevation of the floor of the mouth and protrusion of tomgue(woody tongue)

Can be fatal due to airway obstructionmust establish an airwaydrain and give IV antibiotics

Cavernous sinus thrombosis Maybe associated with spread of infection from

maxillary teeth(classic canine space infection)

It is the formation of a blood clot within the cavernous sinus

Life threatening infection cause the cavernous sinus holds the pituitary gland and sella turcicaCranialnerves-346

Proliferative Periostitis Form of chronic osteomyelitis with proliferative

periostitis

Periosteal reaction in which layers of reactive vital bone are formedproducing cortical expansion(onion skinning) The periosteum is not destroyedbut lifted upwhen bone is formed beneath its layers

Chronic focal sclerosingosteomyelitis AKA Condensing osteitis Localised area of bone sclerosis associated with apices

of non-vital teeth

Most frequent in children and young adults involving mandibular molarspremolars

No cortical expansion

Differential diagnosisOsseous Dysplasia and idiopathic osseosclerosis

Osteomyelitis Bacterial infection of bone secondary to

A)Odontogenic infection

B)Traumatic injury

C)Necrotising Ulcerative GingivitisNoma or cancrumoris

Predisposition to decreased vascularity of bone-PagetrsquosOsteopetrosisflorid cemento-osseous dysplasia

Chronic PathwayPeriapical granuloma

It is a misnomerit is not a granulomatous reaction

Mass of chronically inflamed granulation tissue at apex of non-vital teethdesigned to wall off bacterial invasion at apex

Associated with chronic apical periodontitis

Periapical cyst AKA apical periodontal cystradicular cyst

Inflammatory odontogenic cystinduced by cell rests of malassez(Hertwigs Epithelial Root Sheath remnants) proliferation

Radiolucency at periapex of non-vital teeth

To differentiate from a granulomait must be tested histologically

Management of apical lesions Non-surgical management Periapical lesions develop as

sequelae to pulp disease They often occur without any episode of acute pain and are discovered on routine radiographic examination It is accepted that all inflammatory periapicallesions should be initially treated with conservative nonsurgical procedures

Methods1The conservative root canal treatment

2decompression technique3active nonsurgical decompression technique4aspiration-irrigation technique

5 method using calcium hydroxide6 Lesion Sterilization and Repair Therapy and7the Apexum procedure

Case selectionThe current philosophy in the management of periapical lesions includes the initial use of nonsurgical methods When this treatment approach is not successful a surgical approach may be adoptedThe following factors must be considered while deciding on the management approach

Diagnosis of the lesionMany bone destroying lesions closely resemble endodontically related periapicallesions on radiographs Some of these nonendodontic lesions include ameloblastoma central fibroma giant cell lesions fibrous dysplasia central hemangioma primary malignancies metastatic neoplasms and inflammatory bone diseases

Proximity of the periapical lesion to adjacent vital teethWhen in proximity to a vital toothadopting a surgical approach may result in injury to the blood vessels and nerves of the adjacent teeth thereby compromising their vitality

Encroachment on anatomical structuresSurgery increases the risk of damage to the anatomic structures such as mental foramen inferior alveolar nerve Also the aspirationndashirrigation technique a nonsurgical method is not recommended where adjacent tissue spaces or sinus cavities are involved

Patient cooperation

Considerable pain or discomfort can be experienced by the patient during or after a surgical procedure A nonsurgical approach would be recommended for apprehensive and uncooperative patients

Obstructions in the root canal system

Ledges calcified canals separated instruments may prevent access to the apical foramen and may warrant a surgical approach in managing periapical lesions related to such teeth

Time involved for treatment

Enhanced healing kinetics are observed after performing apical surgery in teeth with periapical lesions

Cases refractory to nonsurgical management methods

Inflammatory apical true cysts and the presence of cholesterol crystals have been suggested as possible causes that prevent healing of periapical lesionsSurgery is recommended for such cases

METHODS FOR NONSURGICAL MANAGMENT OF PERIAPICAL LESIONS Conservative root canal treatment without adjunctive therapy

Instrumentation should be carried 1 mm beyond the apical foramen when a periapical lesion is evident on a radiograph This may cause transitory inflammation and ulceration of the epithelial lining resulting in resolution of the cyst

Decompression technique

The decompression technique involves placement of a drain into the lesion regular irrigation periodic length adjustment and maintenance of the drain for various periods of time

Active nonsurgical decompression technique

This technique uses the Endo-eze vacuum system to create a negative pressure which results in the decompression of large periapical lesions The high-volume suction aspirator is connected to a micro 22-gauge needle which is inserted in the root canal and activated for 20 minutes creating a negative pressure which results in aspiration of the exudate When the drainage partially stops the access cavity is closed with temporary cement which helps in maintaining bacterial control

Aspiration and irrigation technique

Hoen et al suggested aspiration of the cystic fluid from the periapcial lesion using a buccal palatal approach In this technique an 18-gauge needle attached to a 20 ml syringe is used to penetrate the buccal mucosa and aspirate the cystic fluid A second syringe filled with saline is then used to rinse the bony lesion The new needle is inserted through the buccal wound and passed out through the palatal tissue creating a pathway for the escape of the irrigant

Aspiration through the root canal technique

In this technique aspiration of the cystic fluid is done through the root canal by passing the aspirating needle through the apical foramen This technique eliminates the creation of buccal and palatal wounds as in the traditional aspirationndashirrigation technique This minimizes the discomfort that the patient may experience

However it is advisable not to use either aspirationndashirrigation or aspiration through the root canal techniques where adjacent tissue spaces or sinus cavities are involved when there is no fluid aspiration from the lesion or in infected periapicallesions

Method using calcium hydroxide

Calcium hydroxide is a widely used material in endodontic treatment because of its bactericidal effectsIt is thought to create favorable conditions for periapical repair and stimulate hard tissue formationSouza et al suggested that the action of calcium hydroxide beyond the apex may be four-fold (a) anti-inflammatory activity (b) neutralization of acid products (c) activation of the alkaline phosphatase and (d) antibacterial action

Lesion sterilization and repair therapy

lsquoLesion Sterilization and Tissue Repair (LSTR)rsquo therapy that uses a triple antibiotic paste of ciprofloxacin metronidazole and minocycline for disinfection of oral infectious lesions including dentinal pulpal and periradicular lesions Repair of damaged tissues can be expected if lesions are disinfectedMetronidazole is the first choice because it has a wide antibacterial spectrum against anaerobesHowever some bacteria are resistant to metronidazole and hence ciprofloxacin and minocycline are added to the mix

Apexum procedure

Surgical removal of the periapical chronically inflamed tissue allows a fresh blood clot to form thereby converting a chronic inflammatory lesion into a new granulation tissue where healing might proceed much fasterThe Apexumprocedure uses two sequential rotary devices the Apexum NiTi Ablator and Apexum PGA Ablator (Apexum Ltd Or Yehuda Israel) designed to extend beyond the apex and mince the periapical tissues on rotation in a low-speed handpiece followed by washing out the minced tissue

Surgical management of Apical lesions Apical lesions maybe managed surgically to reduce

healing and recovery time

Indicated for emergency cases

Incision and drainagewith antibiotic therapy of the lesionfollowed by RCT with apisectomy is the usual modality of surgical treatment of apical lesions

Medical Management of apical lesions Antibiotic therapy is used to treat minor apical

lesionsin order to relieve the symptomsThis enables easier surgical or non0surgical management of the lesionThus medical management of apical lesions is used in conjunction with Surgical or non surgical management of apical lesions

Cellulitis-Cefazolin 1g iv Q8H7-10 days or cloxacillin500-1000mg po Q6H7-10 days

Acute osteomyelitis-Cefazolin 2g iv Q8H

Ludwigs angina-Clindamycin 600mg iv Q8H2-3 weeks

References J Conserv Dent 2010 Oct-Dec 13(4) 240-

245doi 1041030972070773384PMCID PMC3010029Nonsurgical management of periapical lesions Marina Fernandes and Ida de Ataide

Manual in maxillofacial surgery for senior house officers-Dental 2cmcvellore

Ludwigs angina Aggressiverapidly spreading cellulitis involving

multiple anatomic spacessubmentalsublingualsubmandibular

Produces massive swelling of the neck that may extend close to the clavicles and cause airway obstruction(bullneck)

Causes elevation of the floor of the mouth and protrusion of tomgue(woody tongue)

Can be fatal due to airway obstructionmust establish an airwaydrain and give IV antibiotics

Cavernous sinus thrombosis Maybe associated with spread of infection from

maxillary teeth(classic canine space infection)

It is the formation of a blood clot within the cavernous sinus

Life threatening infection cause the cavernous sinus holds the pituitary gland and sella turcicaCranialnerves-346

Proliferative Periostitis Form of chronic osteomyelitis with proliferative

periostitis

Periosteal reaction in which layers of reactive vital bone are formedproducing cortical expansion(onion skinning) The periosteum is not destroyedbut lifted upwhen bone is formed beneath its layers

Chronic focal sclerosingosteomyelitis AKA Condensing osteitis Localised area of bone sclerosis associated with apices

of non-vital teeth

Most frequent in children and young adults involving mandibular molarspremolars

No cortical expansion

Differential diagnosisOsseous Dysplasia and idiopathic osseosclerosis

Osteomyelitis Bacterial infection of bone secondary to

A)Odontogenic infection

B)Traumatic injury

C)Necrotising Ulcerative GingivitisNoma or cancrumoris

Predisposition to decreased vascularity of bone-PagetrsquosOsteopetrosisflorid cemento-osseous dysplasia

Chronic PathwayPeriapical granuloma

It is a misnomerit is not a granulomatous reaction

Mass of chronically inflamed granulation tissue at apex of non-vital teethdesigned to wall off bacterial invasion at apex

Associated with chronic apical periodontitis

Periapical cyst AKA apical periodontal cystradicular cyst

Inflammatory odontogenic cystinduced by cell rests of malassez(Hertwigs Epithelial Root Sheath remnants) proliferation

Radiolucency at periapex of non-vital teeth

To differentiate from a granulomait must be tested histologically

Management of apical lesions Non-surgical management Periapical lesions develop as

sequelae to pulp disease They often occur without any episode of acute pain and are discovered on routine radiographic examination It is accepted that all inflammatory periapicallesions should be initially treated with conservative nonsurgical procedures

Methods1The conservative root canal treatment

2decompression technique3active nonsurgical decompression technique4aspiration-irrigation technique

5 method using calcium hydroxide6 Lesion Sterilization and Repair Therapy and7the Apexum procedure

Case selectionThe current philosophy in the management of periapical lesions includes the initial use of nonsurgical methods When this treatment approach is not successful a surgical approach may be adoptedThe following factors must be considered while deciding on the management approach

Diagnosis of the lesionMany bone destroying lesions closely resemble endodontically related periapicallesions on radiographs Some of these nonendodontic lesions include ameloblastoma central fibroma giant cell lesions fibrous dysplasia central hemangioma primary malignancies metastatic neoplasms and inflammatory bone diseases

Proximity of the periapical lesion to adjacent vital teethWhen in proximity to a vital toothadopting a surgical approach may result in injury to the blood vessels and nerves of the adjacent teeth thereby compromising their vitality

Encroachment on anatomical structuresSurgery increases the risk of damage to the anatomic structures such as mental foramen inferior alveolar nerve Also the aspirationndashirrigation technique a nonsurgical method is not recommended where adjacent tissue spaces or sinus cavities are involved

Patient cooperation

Considerable pain or discomfort can be experienced by the patient during or after a surgical procedure A nonsurgical approach would be recommended for apprehensive and uncooperative patients

Obstructions in the root canal system

Ledges calcified canals separated instruments may prevent access to the apical foramen and may warrant a surgical approach in managing periapical lesions related to such teeth

Time involved for treatment

Enhanced healing kinetics are observed after performing apical surgery in teeth with periapical lesions

Cases refractory to nonsurgical management methods

Inflammatory apical true cysts and the presence of cholesterol crystals have been suggested as possible causes that prevent healing of periapical lesionsSurgery is recommended for such cases

METHODS FOR NONSURGICAL MANAGMENT OF PERIAPICAL LESIONS Conservative root canal treatment without adjunctive therapy

Instrumentation should be carried 1 mm beyond the apical foramen when a periapical lesion is evident on a radiograph This may cause transitory inflammation and ulceration of the epithelial lining resulting in resolution of the cyst

Decompression technique

The decompression technique involves placement of a drain into the lesion regular irrigation periodic length adjustment and maintenance of the drain for various periods of time

Active nonsurgical decompression technique

This technique uses the Endo-eze vacuum system to create a negative pressure which results in the decompression of large periapical lesions The high-volume suction aspirator is connected to a micro 22-gauge needle which is inserted in the root canal and activated for 20 minutes creating a negative pressure which results in aspiration of the exudate When the drainage partially stops the access cavity is closed with temporary cement which helps in maintaining bacterial control

Aspiration and irrigation technique

Hoen et al suggested aspiration of the cystic fluid from the periapcial lesion using a buccal palatal approach In this technique an 18-gauge needle attached to a 20 ml syringe is used to penetrate the buccal mucosa and aspirate the cystic fluid A second syringe filled with saline is then used to rinse the bony lesion The new needle is inserted through the buccal wound and passed out through the palatal tissue creating a pathway for the escape of the irrigant

Aspiration through the root canal technique

In this technique aspiration of the cystic fluid is done through the root canal by passing the aspirating needle through the apical foramen This technique eliminates the creation of buccal and palatal wounds as in the traditional aspirationndashirrigation technique This minimizes the discomfort that the patient may experience

However it is advisable not to use either aspirationndashirrigation or aspiration through the root canal techniques where adjacent tissue spaces or sinus cavities are involved when there is no fluid aspiration from the lesion or in infected periapicallesions

Method using calcium hydroxide

Calcium hydroxide is a widely used material in endodontic treatment because of its bactericidal effectsIt is thought to create favorable conditions for periapical repair and stimulate hard tissue formationSouza et al suggested that the action of calcium hydroxide beyond the apex may be four-fold (a) anti-inflammatory activity (b) neutralization of acid products (c) activation of the alkaline phosphatase and (d) antibacterial action

Lesion sterilization and repair therapy

lsquoLesion Sterilization and Tissue Repair (LSTR)rsquo therapy that uses a triple antibiotic paste of ciprofloxacin metronidazole and minocycline for disinfection of oral infectious lesions including dentinal pulpal and periradicular lesions Repair of damaged tissues can be expected if lesions are disinfectedMetronidazole is the first choice because it has a wide antibacterial spectrum against anaerobesHowever some bacteria are resistant to metronidazole and hence ciprofloxacin and minocycline are added to the mix

Apexum procedure

Surgical removal of the periapical chronically inflamed tissue allows a fresh blood clot to form thereby converting a chronic inflammatory lesion into a new granulation tissue where healing might proceed much fasterThe Apexumprocedure uses two sequential rotary devices the Apexum NiTi Ablator and Apexum PGA Ablator (Apexum Ltd Or Yehuda Israel) designed to extend beyond the apex and mince the periapical tissues on rotation in a low-speed handpiece followed by washing out the minced tissue

Surgical management of Apical lesions Apical lesions maybe managed surgically to reduce

healing and recovery time

Indicated for emergency cases

Incision and drainagewith antibiotic therapy of the lesionfollowed by RCT with apisectomy is the usual modality of surgical treatment of apical lesions

Medical Management of apical lesions Antibiotic therapy is used to treat minor apical

lesionsin order to relieve the symptomsThis enables easier surgical or non0surgical management of the lesionThus medical management of apical lesions is used in conjunction with Surgical or non surgical management of apical lesions

Cellulitis-Cefazolin 1g iv Q8H7-10 days or cloxacillin500-1000mg po Q6H7-10 days

Acute osteomyelitis-Cefazolin 2g iv Q8H

Ludwigs angina-Clindamycin 600mg iv Q8H2-3 weeks

References J Conserv Dent 2010 Oct-Dec 13(4) 240-

245doi 1041030972070773384PMCID PMC3010029Nonsurgical management of periapical lesions Marina Fernandes and Ida de Ataide

Manual in maxillofacial surgery for senior house officers-Dental 2cmcvellore

Cavernous sinus thrombosis Maybe associated with spread of infection from

maxillary teeth(classic canine space infection)

It is the formation of a blood clot within the cavernous sinus

Life threatening infection cause the cavernous sinus holds the pituitary gland and sella turcicaCranialnerves-346

Proliferative Periostitis Form of chronic osteomyelitis with proliferative

periostitis

Periosteal reaction in which layers of reactive vital bone are formedproducing cortical expansion(onion skinning) The periosteum is not destroyedbut lifted upwhen bone is formed beneath its layers

Chronic focal sclerosingosteomyelitis AKA Condensing osteitis Localised area of bone sclerosis associated with apices

of non-vital teeth

Most frequent in children and young adults involving mandibular molarspremolars

No cortical expansion

Differential diagnosisOsseous Dysplasia and idiopathic osseosclerosis

Osteomyelitis Bacterial infection of bone secondary to

A)Odontogenic infection

B)Traumatic injury

C)Necrotising Ulcerative GingivitisNoma or cancrumoris

Predisposition to decreased vascularity of bone-PagetrsquosOsteopetrosisflorid cemento-osseous dysplasia

Chronic PathwayPeriapical granuloma

It is a misnomerit is not a granulomatous reaction

Mass of chronically inflamed granulation tissue at apex of non-vital teethdesigned to wall off bacterial invasion at apex

Associated with chronic apical periodontitis

Periapical cyst AKA apical periodontal cystradicular cyst

Inflammatory odontogenic cystinduced by cell rests of malassez(Hertwigs Epithelial Root Sheath remnants) proliferation

Radiolucency at periapex of non-vital teeth

To differentiate from a granulomait must be tested histologically

Management of apical lesions Non-surgical management Periapical lesions develop as

sequelae to pulp disease They often occur without any episode of acute pain and are discovered on routine radiographic examination It is accepted that all inflammatory periapicallesions should be initially treated with conservative nonsurgical procedures

Methods1The conservative root canal treatment

2decompression technique3active nonsurgical decompression technique4aspiration-irrigation technique

5 method using calcium hydroxide6 Lesion Sterilization and Repair Therapy and7the Apexum procedure

Case selectionThe current philosophy in the management of periapical lesions includes the initial use of nonsurgical methods When this treatment approach is not successful a surgical approach may be adoptedThe following factors must be considered while deciding on the management approach

Diagnosis of the lesionMany bone destroying lesions closely resemble endodontically related periapicallesions on radiographs Some of these nonendodontic lesions include ameloblastoma central fibroma giant cell lesions fibrous dysplasia central hemangioma primary malignancies metastatic neoplasms and inflammatory bone diseases

Proximity of the periapical lesion to adjacent vital teethWhen in proximity to a vital toothadopting a surgical approach may result in injury to the blood vessels and nerves of the adjacent teeth thereby compromising their vitality

Encroachment on anatomical structuresSurgery increases the risk of damage to the anatomic structures such as mental foramen inferior alveolar nerve Also the aspirationndashirrigation technique a nonsurgical method is not recommended where adjacent tissue spaces or sinus cavities are involved

Patient cooperation

Considerable pain or discomfort can be experienced by the patient during or after a surgical procedure A nonsurgical approach would be recommended for apprehensive and uncooperative patients

Obstructions in the root canal system

Ledges calcified canals separated instruments may prevent access to the apical foramen and may warrant a surgical approach in managing periapical lesions related to such teeth

Time involved for treatment

Enhanced healing kinetics are observed after performing apical surgery in teeth with periapical lesions

Cases refractory to nonsurgical management methods

Inflammatory apical true cysts and the presence of cholesterol crystals have been suggested as possible causes that prevent healing of periapical lesionsSurgery is recommended for such cases

METHODS FOR NONSURGICAL MANAGMENT OF PERIAPICAL LESIONS Conservative root canal treatment without adjunctive therapy

Instrumentation should be carried 1 mm beyond the apical foramen when a periapical lesion is evident on a radiograph This may cause transitory inflammation and ulceration of the epithelial lining resulting in resolution of the cyst

Decompression technique

The decompression technique involves placement of a drain into the lesion regular irrigation periodic length adjustment and maintenance of the drain for various periods of time

Active nonsurgical decompression technique

This technique uses the Endo-eze vacuum system to create a negative pressure which results in the decompression of large periapical lesions The high-volume suction aspirator is connected to a micro 22-gauge needle which is inserted in the root canal and activated for 20 minutes creating a negative pressure which results in aspiration of the exudate When the drainage partially stops the access cavity is closed with temporary cement which helps in maintaining bacterial control

Aspiration and irrigation technique

Hoen et al suggested aspiration of the cystic fluid from the periapcial lesion using a buccal palatal approach In this technique an 18-gauge needle attached to a 20 ml syringe is used to penetrate the buccal mucosa and aspirate the cystic fluid A second syringe filled with saline is then used to rinse the bony lesion The new needle is inserted through the buccal wound and passed out through the palatal tissue creating a pathway for the escape of the irrigant

Aspiration through the root canal technique

In this technique aspiration of the cystic fluid is done through the root canal by passing the aspirating needle through the apical foramen This technique eliminates the creation of buccal and palatal wounds as in the traditional aspirationndashirrigation technique This minimizes the discomfort that the patient may experience

However it is advisable not to use either aspirationndashirrigation or aspiration through the root canal techniques where adjacent tissue spaces or sinus cavities are involved when there is no fluid aspiration from the lesion or in infected periapicallesions

Method using calcium hydroxide

Calcium hydroxide is a widely used material in endodontic treatment because of its bactericidal effectsIt is thought to create favorable conditions for periapical repair and stimulate hard tissue formationSouza et al suggested that the action of calcium hydroxide beyond the apex may be four-fold (a) anti-inflammatory activity (b) neutralization of acid products (c) activation of the alkaline phosphatase and (d) antibacterial action

Lesion sterilization and repair therapy

lsquoLesion Sterilization and Tissue Repair (LSTR)rsquo therapy that uses a triple antibiotic paste of ciprofloxacin metronidazole and minocycline for disinfection of oral infectious lesions including dentinal pulpal and periradicular lesions Repair of damaged tissues can be expected if lesions are disinfectedMetronidazole is the first choice because it has a wide antibacterial spectrum against anaerobesHowever some bacteria are resistant to metronidazole and hence ciprofloxacin and minocycline are added to the mix

Apexum procedure

Surgical removal of the periapical chronically inflamed tissue allows a fresh blood clot to form thereby converting a chronic inflammatory lesion into a new granulation tissue where healing might proceed much fasterThe Apexumprocedure uses two sequential rotary devices the Apexum NiTi Ablator and Apexum PGA Ablator (Apexum Ltd Or Yehuda Israel) designed to extend beyond the apex and mince the periapical tissues on rotation in a low-speed handpiece followed by washing out the minced tissue

Surgical management of Apical lesions Apical lesions maybe managed surgically to reduce

healing and recovery time

Indicated for emergency cases

Incision and drainagewith antibiotic therapy of the lesionfollowed by RCT with apisectomy is the usual modality of surgical treatment of apical lesions

Medical Management of apical lesions Antibiotic therapy is used to treat minor apical

lesionsin order to relieve the symptomsThis enables easier surgical or non0surgical management of the lesionThus medical management of apical lesions is used in conjunction with Surgical or non surgical management of apical lesions

Cellulitis-Cefazolin 1g iv Q8H7-10 days or cloxacillin500-1000mg po Q6H7-10 days

Acute osteomyelitis-Cefazolin 2g iv Q8H

Ludwigs angina-Clindamycin 600mg iv Q8H2-3 weeks

References J Conserv Dent 2010 Oct-Dec 13(4) 240-

245doi 1041030972070773384PMCID PMC3010029Nonsurgical management of periapical lesions Marina Fernandes and Ida de Ataide

Manual in maxillofacial surgery for senior house officers-Dental 2cmcvellore

Proliferative Periostitis Form of chronic osteomyelitis with proliferative

periostitis

Periosteal reaction in which layers of reactive vital bone are formedproducing cortical expansion(onion skinning) The periosteum is not destroyedbut lifted upwhen bone is formed beneath its layers

Chronic focal sclerosingosteomyelitis AKA Condensing osteitis Localised area of bone sclerosis associated with apices

of non-vital teeth

Most frequent in children and young adults involving mandibular molarspremolars

No cortical expansion

Differential diagnosisOsseous Dysplasia and idiopathic osseosclerosis

Osteomyelitis Bacterial infection of bone secondary to

A)Odontogenic infection

B)Traumatic injury

C)Necrotising Ulcerative GingivitisNoma or cancrumoris

Predisposition to decreased vascularity of bone-PagetrsquosOsteopetrosisflorid cemento-osseous dysplasia

Chronic PathwayPeriapical granuloma

It is a misnomerit is not a granulomatous reaction

Mass of chronically inflamed granulation tissue at apex of non-vital teethdesigned to wall off bacterial invasion at apex

Associated with chronic apical periodontitis

Periapical cyst AKA apical periodontal cystradicular cyst

Inflammatory odontogenic cystinduced by cell rests of malassez(Hertwigs Epithelial Root Sheath remnants) proliferation

Radiolucency at periapex of non-vital teeth

To differentiate from a granulomait must be tested histologically

Management of apical lesions Non-surgical management Periapical lesions develop as

sequelae to pulp disease They often occur without any episode of acute pain and are discovered on routine radiographic examination It is accepted that all inflammatory periapicallesions should be initially treated with conservative nonsurgical procedures

Methods1The conservative root canal treatment

2decompression technique3active nonsurgical decompression technique4aspiration-irrigation technique

5 method using calcium hydroxide6 Lesion Sterilization and Repair Therapy and7the Apexum procedure

Case selectionThe current philosophy in the management of periapical lesions includes the initial use of nonsurgical methods When this treatment approach is not successful a surgical approach may be adoptedThe following factors must be considered while deciding on the management approach

Diagnosis of the lesionMany bone destroying lesions closely resemble endodontically related periapicallesions on radiographs Some of these nonendodontic lesions include ameloblastoma central fibroma giant cell lesions fibrous dysplasia central hemangioma primary malignancies metastatic neoplasms and inflammatory bone diseases

Proximity of the periapical lesion to adjacent vital teethWhen in proximity to a vital toothadopting a surgical approach may result in injury to the blood vessels and nerves of the adjacent teeth thereby compromising their vitality

Encroachment on anatomical structuresSurgery increases the risk of damage to the anatomic structures such as mental foramen inferior alveolar nerve Also the aspirationndashirrigation technique a nonsurgical method is not recommended where adjacent tissue spaces or sinus cavities are involved

Patient cooperation

Considerable pain or discomfort can be experienced by the patient during or after a surgical procedure A nonsurgical approach would be recommended for apprehensive and uncooperative patients

Obstructions in the root canal system

Ledges calcified canals separated instruments may prevent access to the apical foramen and may warrant a surgical approach in managing periapical lesions related to such teeth

Time involved for treatment

Enhanced healing kinetics are observed after performing apical surgery in teeth with periapical lesions

Cases refractory to nonsurgical management methods

Inflammatory apical true cysts and the presence of cholesterol crystals have been suggested as possible causes that prevent healing of periapical lesionsSurgery is recommended for such cases

METHODS FOR NONSURGICAL MANAGMENT OF PERIAPICAL LESIONS Conservative root canal treatment without adjunctive therapy

Instrumentation should be carried 1 mm beyond the apical foramen when a periapical lesion is evident on a radiograph This may cause transitory inflammation and ulceration of the epithelial lining resulting in resolution of the cyst

Decompression technique

The decompression technique involves placement of a drain into the lesion regular irrigation periodic length adjustment and maintenance of the drain for various periods of time

Active nonsurgical decompression technique

This technique uses the Endo-eze vacuum system to create a negative pressure which results in the decompression of large periapical lesions The high-volume suction aspirator is connected to a micro 22-gauge needle which is inserted in the root canal and activated for 20 minutes creating a negative pressure which results in aspiration of the exudate When the drainage partially stops the access cavity is closed with temporary cement which helps in maintaining bacterial control

Aspiration and irrigation technique

Hoen et al suggested aspiration of the cystic fluid from the periapcial lesion using a buccal palatal approach In this technique an 18-gauge needle attached to a 20 ml syringe is used to penetrate the buccal mucosa and aspirate the cystic fluid A second syringe filled with saline is then used to rinse the bony lesion The new needle is inserted through the buccal wound and passed out through the palatal tissue creating a pathway for the escape of the irrigant

Aspiration through the root canal technique

In this technique aspiration of the cystic fluid is done through the root canal by passing the aspirating needle through the apical foramen This technique eliminates the creation of buccal and palatal wounds as in the traditional aspirationndashirrigation technique This minimizes the discomfort that the patient may experience

However it is advisable not to use either aspirationndashirrigation or aspiration through the root canal techniques where adjacent tissue spaces or sinus cavities are involved when there is no fluid aspiration from the lesion or in infected periapicallesions

Method using calcium hydroxide

Calcium hydroxide is a widely used material in endodontic treatment because of its bactericidal effectsIt is thought to create favorable conditions for periapical repair and stimulate hard tissue formationSouza et al suggested that the action of calcium hydroxide beyond the apex may be four-fold (a) anti-inflammatory activity (b) neutralization of acid products (c) activation of the alkaline phosphatase and (d) antibacterial action

Lesion sterilization and repair therapy

lsquoLesion Sterilization and Tissue Repair (LSTR)rsquo therapy that uses a triple antibiotic paste of ciprofloxacin metronidazole and minocycline for disinfection of oral infectious lesions including dentinal pulpal and periradicular lesions Repair of damaged tissues can be expected if lesions are disinfectedMetronidazole is the first choice because it has a wide antibacterial spectrum against anaerobesHowever some bacteria are resistant to metronidazole and hence ciprofloxacin and minocycline are added to the mix

Apexum procedure

Surgical removal of the periapical chronically inflamed tissue allows a fresh blood clot to form thereby converting a chronic inflammatory lesion into a new granulation tissue where healing might proceed much fasterThe Apexumprocedure uses two sequential rotary devices the Apexum NiTi Ablator and Apexum PGA Ablator (Apexum Ltd Or Yehuda Israel) designed to extend beyond the apex and mince the periapical tissues on rotation in a low-speed handpiece followed by washing out the minced tissue

Surgical management of Apical lesions Apical lesions maybe managed surgically to reduce

healing and recovery time

Indicated for emergency cases

Incision and drainagewith antibiotic therapy of the lesionfollowed by RCT with apisectomy is the usual modality of surgical treatment of apical lesions

Medical Management of apical lesions Antibiotic therapy is used to treat minor apical

lesionsin order to relieve the symptomsThis enables easier surgical or non0surgical management of the lesionThus medical management of apical lesions is used in conjunction with Surgical or non surgical management of apical lesions

Cellulitis-Cefazolin 1g iv Q8H7-10 days or cloxacillin500-1000mg po Q6H7-10 days

Acute osteomyelitis-Cefazolin 2g iv Q8H

Ludwigs angina-Clindamycin 600mg iv Q8H2-3 weeks

References J Conserv Dent 2010 Oct-Dec 13(4) 240-

245doi 1041030972070773384PMCID PMC3010029Nonsurgical management of periapical lesions Marina Fernandes and Ida de Ataide

Manual in maxillofacial surgery for senior house officers-Dental 2cmcvellore

Chronic focal sclerosingosteomyelitis AKA Condensing osteitis Localised area of bone sclerosis associated with apices

of non-vital teeth

Most frequent in children and young adults involving mandibular molarspremolars

No cortical expansion

Differential diagnosisOsseous Dysplasia and idiopathic osseosclerosis

Osteomyelitis Bacterial infection of bone secondary to

A)Odontogenic infection

B)Traumatic injury

C)Necrotising Ulcerative GingivitisNoma or cancrumoris

Predisposition to decreased vascularity of bone-PagetrsquosOsteopetrosisflorid cemento-osseous dysplasia

Chronic PathwayPeriapical granuloma

It is a misnomerit is not a granulomatous reaction

Mass of chronically inflamed granulation tissue at apex of non-vital teethdesigned to wall off bacterial invasion at apex

Associated with chronic apical periodontitis

Periapical cyst AKA apical periodontal cystradicular cyst

Inflammatory odontogenic cystinduced by cell rests of malassez(Hertwigs Epithelial Root Sheath remnants) proliferation

Radiolucency at periapex of non-vital teeth

To differentiate from a granulomait must be tested histologically

Management of apical lesions Non-surgical management Periapical lesions develop as

sequelae to pulp disease They often occur without any episode of acute pain and are discovered on routine radiographic examination It is accepted that all inflammatory periapicallesions should be initially treated with conservative nonsurgical procedures

Methods1The conservative root canal treatment

2decompression technique3active nonsurgical decompression technique4aspiration-irrigation technique

5 method using calcium hydroxide6 Lesion Sterilization and Repair Therapy and7the Apexum procedure

Case selectionThe current philosophy in the management of periapical lesions includes the initial use of nonsurgical methods When this treatment approach is not successful a surgical approach may be adoptedThe following factors must be considered while deciding on the management approach

Diagnosis of the lesionMany bone destroying lesions closely resemble endodontically related periapicallesions on radiographs Some of these nonendodontic lesions include ameloblastoma central fibroma giant cell lesions fibrous dysplasia central hemangioma primary malignancies metastatic neoplasms and inflammatory bone diseases

Proximity of the periapical lesion to adjacent vital teethWhen in proximity to a vital toothadopting a surgical approach may result in injury to the blood vessels and nerves of the adjacent teeth thereby compromising their vitality

Encroachment on anatomical structuresSurgery increases the risk of damage to the anatomic structures such as mental foramen inferior alveolar nerve Also the aspirationndashirrigation technique a nonsurgical method is not recommended where adjacent tissue spaces or sinus cavities are involved

Patient cooperation

Considerable pain or discomfort can be experienced by the patient during or after a surgical procedure A nonsurgical approach would be recommended for apprehensive and uncooperative patients

Obstructions in the root canal system

Ledges calcified canals separated instruments may prevent access to the apical foramen and may warrant a surgical approach in managing periapical lesions related to such teeth

Time involved for treatment

Enhanced healing kinetics are observed after performing apical surgery in teeth with periapical lesions

Cases refractory to nonsurgical management methods

Inflammatory apical true cysts and the presence of cholesterol crystals have been suggested as possible causes that prevent healing of periapical lesionsSurgery is recommended for such cases

METHODS FOR NONSURGICAL MANAGMENT OF PERIAPICAL LESIONS Conservative root canal treatment without adjunctive therapy

Instrumentation should be carried 1 mm beyond the apical foramen when a periapical lesion is evident on a radiograph This may cause transitory inflammation and ulceration of the epithelial lining resulting in resolution of the cyst

Decompression technique

The decompression technique involves placement of a drain into the lesion regular irrigation periodic length adjustment and maintenance of the drain for various periods of time

Active nonsurgical decompression technique

This technique uses the Endo-eze vacuum system to create a negative pressure which results in the decompression of large periapical lesions The high-volume suction aspirator is connected to a micro 22-gauge needle which is inserted in the root canal and activated for 20 minutes creating a negative pressure which results in aspiration of the exudate When the drainage partially stops the access cavity is closed with temporary cement which helps in maintaining bacterial control

Aspiration and irrigation technique

Hoen et al suggested aspiration of the cystic fluid from the periapcial lesion using a buccal palatal approach In this technique an 18-gauge needle attached to a 20 ml syringe is used to penetrate the buccal mucosa and aspirate the cystic fluid A second syringe filled with saline is then used to rinse the bony lesion The new needle is inserted through the buccal wound and passed out through the palatal tissue creating a pathway for the escape of the irrigant

Aspiration through the root canal technique

In this technique aspiration of the cystic fluid is done through the root canal by passing the aspirating needle through the apical foramen This technique eliminates the creation of buccal and palatal wounds as in the traditional aspirationndashirrigation technique This minimizes the discomfort that the patient may experience

However it is advisable not to use either aspirationndashirrigation or aspiration through the root canal techniques where adjacent tissue spaces or sinus cavities are involved when there is no fluid aspiration from the lesion or in infected periapicallesions

Method using calcium hydroxide

Calcium hydroxide is a widely used material in endodontic treatment because of its bactericidal effectsIt is thought to create favorable conditions for periapical repair and stimulate hard tissue formationSouza et al suggested that the action of calcium hydroxide beyond the apex may be four-fold (a) anti-inflammatory activity (b) neutralization of acid products (c) activation of the alkaline phosphatase and (d) antibacterial action

Lesion sterilization and repair therapy

lsquoLesion Sterilization and Tissue Repair (LSTR)rsquo therapy that uses a triple antibiotic paste of ciprofloxacin metronidazole and minocycline for disinfection of oral infectious lesions including dentinal pulpal and periradicular lesions Repair of damaged tissues can be expected if lesions are disinfectedMetronidazole is the first choice because it has a wide antibacterial spectrum against anaerobesHowever some bacteria are resistant to metronidazole and hence ciprofloxacin and minocycline are added to the mix

Apexum procedure

Surgical removal of the periapical chronically inflamed tissue allows a fresh blood clot to form thereby converting a chronic inflammatory lesion into a new granulation tissue where healing might proceed much fasterThe Apexumprocedure uses two sequential rotary devices the Apexum NiTi Ablator and Apexum PGA Ablator (Apexum Ltd Or Yehuda Israel) designed to extend beyond the apex and mince the periapical tissues on rotation in a low-speed handpiece followed by washing out the minced tissue

Surgical management of Apical lesions Apical lesions maybe managed surgically to reduce

healing and recovery time

Indicated for emergency cases

Incision and drainagewith antibiotic therapy of the lesionfollowed by RCT with apisectomy is the usual modality of surgical treatment of apical lesions

Medical Management of apical lesions Antibiotic therapy is used to treat minor apical

lesionsin order to relieve the symptomsThis enables easier surgical or non0surgical management of the lesionThus medical management of apical lesions is used in conjunction with Surgical or non surgical management of apical lesions

Cellulitis-Cefazolin 1g iv Q8H7-10 days or cloxacillin500-1000mg po Q6H7-10 days

Acute osteomyelitis-Cefazolin 2g iv Q8H

Ludwigs angina-Clindamycin 600mg iv Q8H2-3 weeks

References J Conserv Dent 2010 Oct-Dec 13(4) 240-

245doi 1041030972070773384PMCID PMC3010029Nonsurgical management of periapical lesions Marina Fernandes and Ida de Ataide

Manual in maxillofacial surgery for senior house officers-Dental 2cmcvellore

Osteomyelitis Bacterial infection of bone secondary to

A)Odontogenic infection

B)Traumatic injury

C)Necrotising Ulcerative GingivitisNoma or cancrumoris

Predisposition to decreased vascularity of bone-PagetrsquosOsteopetrosisflorid cemento-osseous dysplasia

Chronic PathwayPeriapical granuloma

It is a misnomerit is not a granulomatous reaction

Mass of chronically inflamed granulation tissue at apex of non-vital teethdesigned to wall off bacterial invasion at apex

Associated with chronic apical periodontitis

Periapical cyst AKA apical periodontal cystradicular cyst

Inflammatory odontogenic cystinduced by cell rests of malassez(Hertwigs Epithelial Root Sheath remnants) proliferation

Radiolucency at periapex of non-vital teeth

To differentiate from a granulomait must be tested histologically

Management of apical lesions Non-surgical management Periapical lesions develop as

sequelae to pulp disease They often occur without any episode of acute pain and are discovered on routine radiographic examination It is accepted that all inflammatory periapicallesions should be initially treated with conservative nonsurgical procedures

Methods1The conservative root canal treatment

2decompression technique3active nonsurgical decompression technique4aspiration-irrigation technique

5 method using calcium hydroxide6 Lesion Sterilization and Repair Therapy and7the Apexum procedure

Case selectionThe current philosophy in the management of periapical lesions includes the initial use of nonsurgical methods When this treatment approach is not successful a surgical approach may be adoptedThe following factors must be considered while deciding on the management approach

Diagnosis of the lesionMany bone destroying lesions closely resemble endodontically related periapicallesions on radiographs Some of these nonendodontic lesions include ameloblastoma central fibroma giant cell lesions fibrous dysplasia central hemangioma primary malignancies metastatic neoplasms and inflammatory bone diseases

Proximity of the periapical lesion to adjacent vital teethWhen in proximity to a vital toothadopting a surgical approach may result in injury to the blood vessels and nerves of the adjacent teeth thereby compromising their vitality

Encroachment on anatomical structuresSurgery increases the risk of damage to the anatomic structures such as mental foramen inferior alveolar nerve Also the aspirationndashirrigation technique a nonsurgical method is not recommended where adjacent tissue spaces or sinus cavities are involved

Patient cooperation

Considerable pain or discomfort can be experienced by the patient during or after a surgical procedure A nonsurgical approach would be recommended for apprehensive and uncooperative patients

Obstructions in the root canal system

Ledges calcified canals separated instruments may prevent access to the apical foramen and may warrant a surgical approach in managing periapical lesions related to such teeth

Time involved for treatment

Enhanced healing kinetics are observed after performing apical surgery in teeth with periapical lesions

Cases refractory to nonsurgical management methods

Inflammatory apical true cysts and the presence of cholesterol crystals have been suggested as possible causes that prevent healing of periapical lesionsSurgery is recommended for such cases

METHODS FOR NONSURGICAL MANAGMENT OF PERIAPICAL LESIONS Conservative root canal treatment without adjunctive therapy

Instrumentation should be carried 1 mm beyond the apical foramen when a periapical lesion is evident on a radiograph This may cause transitory inflammation and ulceration of the epithelial lining resulting in resolution of the cyst

Decompression technique

The decompression technique involves placement of a drain into the lesion regular irrigation periodic length adjustment and maintenance of the drain for various periods of time

Active nonsurgical decompression technique

This technique uses the Endo-eze vacuum system to create a negative pressure which results in the decompression of large periapical lesions The high-volume suction aspirator is connected to a micro 22-gauge needle which is inserted in the root canal and activated for 20 minutes creating a negative pressure which results in aspiration of the exudate When the drainage partially stops the access cavity is closed with temporary cement which helps in maintaining bacterial control

Aspiration and irrigation technique

Hoen et al suggested aspiration of the cystic fluid from the periapcial lesion using a buccal palatal approach In this technique an 18-gauge needle attached to a 20 ml syringe is used to penetrate the buccal mucosa and aspirate the cystic fluid A second syringe filled with saline is then used to rinse the bony lesion The new needle is inserted through the buccal wound and passed out through the palatal tissue creating a pathway for the escape of the irrigant

Aspiration through the root canal technique

In this technique aspiration of the cystic fluid is done through the root canal by passing the aspirating needle through the apical foramen This technique eliminates the creation of buccal and palatal wounds as in the traditional aspirationndashirrigation technique This minimizes the discomfort that the patient may experience

However it is advisable not to use either aspirationndashirrigation or aspiration through the root canal techniques where adjacent tissue spaces or sinus cavities are involved when there is no fluid aspiration from the lesion or in infected periapicallesions

Method using calcium hydroxide

Calcium hydroxide is a widely used material in endodontic treatment because of its bactericidal effectsIt is thought to create favorable conditions for periapical repair and stimulate hard tissue formationSouza et al suggested that the action of calcium hydroxide beyond the apex may be four-fold (a) anti-inflammatory activity (b) neutralization of acid products (c) activation of the alkaline phosphatase and (d) antibacterial action

Lesion sterilization and repair therapy

lsquoLesion Sterilization and Tissue Repair (LSTR)rsquo therapy that uses a triple antibiotic paste of ciprofloxacin metronidazole and minocycline for disinfection of oral infectious lesions including dentinal pulpal and periradicular lesions Repair of damaged tissues can be expected if lesions are disinfectedMetronidazole is the first choice because it has a wide antibacterial spectrum against anaerobesHowever some bacteria are resistant to metronidazole and hence ciprofloxacin and minocycline are added to the mix

Apexum procedure

Surgical removal of the periapical chronically inflamed tissue allows a fresh blood clot to form thereby converting a chronic inflammatory lesion into a new granulation tissue where healing might proceed much fasterThe Apexumprocedure uses two sequential rotary devices the Apexum NiTi Ablator and Apexum PGA Ablator (Apexum Ltd Or Yehuda Israel) designed to extend beyond the apex and mince the periapical tissues on rotation in a low-speed handpiece followed by washing out the minced tissue

Surgical management of Apical lesions Apical lesions maybe managed surgically to reduce

healing and recovery time

Indicated for emergency cases

Incision and drainagewith antibiotic therapy of the lesionfollowed by RCT with apisectomy is the usual modality of surgical treatment of apical lesions

Medical Management of apical lesions Antibiotic therapy is used to treat minor apical

lesionsin order to relieve the symptomsThis enables easier surgical or non0surgical management of the lesionThus medical management of apical lesions is used in conjunction with Surgical or non surgical management of apical lesions

Cellulitis-Cefazolin 1g iv Q8H7-10 days or cloxacillin500-1000mg po Q6H7-10 days

Acute osteomyelitis-Cefazolin 2g iv Q8H

Ludwigs angina-Clindamycin 600mg iv Q8H2-3 weeks

References J Conserv Dent 2010 Oct-Dec 13(4) 240-

245doi 1041030972070773384PMCID PMC3010029Nonsurgical management of periapical lesions Marina Fernandes and Ida de Ataide

Manual in maxillofacial surgery for senior house officers-Dental 2cmcvellore

Chronic PathwayPeriapical granuloma

It is a misnomerit is not a granulomatous reaction

Mass of chronically inflamed granulation tissue at apex of non-vital teethdesigned to wall off bacterial invasion at apex

Associated with chronic apical periodontitis

Periapical cyst AKA apical periodontal cystradicular cyst

Inflammatory odontogenic cystinduced by cell rests of malassez(Hertwigs Epithelial Root Sheath remnants) proliferation

Radiolucency at periapex of non-vital teeth

To differentiate from a granulomait must be tested histologically

Management of apical lesions Non-surgical management Periapical lesions develop as

sequelae to pulp disease They often occur without any episode of acute pain and are discovered on routine radiographic examination It is accepted that all inflammatory periapicallesions should be initially treated with conservative nonsurgical procedures

Methods1The conservative root canal treatment

2decompression technique3active nonsurgical decompression technique4aspiration-irrigation technique

5 method using calcium hydroxide6 Lesion Sterilization and Repair Therapy and7the Apexum procedure

Case selectionThe current philosophy in the management of periapical lesions includes the initial use of nonsurgical methods When this treatment approach is not successful a surgical approach may be adoptedThe following factors must be considered while deciding on the management approach

Diagnosis of the lesionMany bone destroying lesions closely resemble endodontically related periapicallesions on radiographs Some of these nonendodontic lesions include ameloblastoma central fibroma giant cell lesions fibrous dysplasia central hemangioma primary malignancies metastatic neoplasms and inflammatory bone diseases

Proximity of the periapical lesion to adjacent vital teethWhen in proximity to a vital toothadopting a surgical approach may result in injury to the blood vessels and nerves of the adjacent teeth thereby compromising their vitality

Encroachment on anatomical structuresSurgery increases the risk of damage to the anatomic structures such as mental foramen inferior alveolar nerve Also the aspirationndashirrigation technique a nonsurgical method is not recommended where adjacent tissue spaces or sinus cavities are involved

Patient cooperation

Considerable pain or discomfort can be experienced by the patient during or after a surgical procedure A nonsurgical approach would be recommended for apprehensive and uncooperative patients

Obstructions in the root canal system

Ledges calcified canals separated instruments may prevent access to the apical foramen and may warrant a surgical approach in managing periapical lesions related to such teeth

Time involved for treatment

Enhanced healing kinetics are observed after performing apical surgery in teeth with periapical lesions

Cases refractory to nonsurgical management methods

Inflammatory apical true cysts and the presence of cholesterol crystals have been suggested as possible causes that prevent healing of periapical lesionsSurgery is recommended for such cases

METHODS FOR NONSURGICAL MANAGMENT OF PERIAPICAL LESIONS Conservative root canal treatment without adjunctive therapy

Instrumentation should be carried 1 mm beyond the apical foramen when a periapical lesion is evident on a radiograph This may cause transitory inflammation and ulceration of the epithelial lining resulting in resolution of the cyst

Decompression technique

The decompression technique involves placement of a drain into the lesion regular irrigation periodic length adjustment and maintenance of the drain for various periods of time

Active nonsurgical decompression technique

This technique uses the Endo-eze vacuum system to create a negative pressure which results in the decompression of large periapical lesions The high-volume suction aspirator is connected to a micro 22-gauge needle which is inserted in the root canal and activated for 20 minutes creating a negative pressure which results in aspiration of the exudate When the drainage partially stops the access cavity is closed with temporary cement which helps in maintaining bacterial control

Aspiration and irrigation technique

Hoen et al suggested aspiration of the cystic fluid from the periapcial lesion using a buccal palatal approach In this technique an 18-gauge needle attached to a 20 ml syringe is used to penetrate the buccal mucosa and aspirate the cystic fluid A second syringe filled with saline is then used to rinse the bony lesion The new needle is inserted through the buccal wound and passed out through the palatal tissue creating a pathway for the escape of the irrigant

Aspiration through the root canal technique

In this technique aspiration of the cystic fluid is done through the root canal by passing the aspirating needle through the apical foramen This technique eliminates the creation of buccal and palatal wounds as in the traditional aspirationndashirrigation technique This minimizes the discomfort that the patient may experience

However it is advisable not to use either aspirationndashirrigation or aspiration through the root canal techniques where adjacent tissue spaces or sinus cavities are involved when there is no fluid aspiration from the lesion or in infected periapicallesions

Method using calcium hydroxide

Calcium hydroxide is a widely used material in endodontic treatment because of its bactericidal effectsIt is thought to create favorable conditions for periapical repair and stimulate hard tissue formationSouza et al suggested that the action of calcium hydroxide beyond the apex may be four-fold (a) anti-inflammatory activity (b) neutralization of acid products (c) activation of the alkaline phosphatase and (d) antibacterial action

Lesion sterilization and repair therapy

lsquoLesion Sterilization and Tissue Repair (LSTR)rsquo therapy that uses a triple antibiotic paste of ciprofloxacin metronidazole and minocycline for disinfection of oral infectious lesions including dentinal pulpal and periradicular lesions Repair of damaged tissues can be expected if lesions are disinfectedMetronidazole is the first choice because it has a wide antibacterial spectrum against anaerobesHowever some bacteria are resistant to metronidazole and hence ciprofloxacin and minocycline are added to the mix

Apexum procedure

Surgical removal of the periapical chronically inflamed tissue allows a fresh blood clot to form thereby converting a chronic inflammatory lesion into a new granulation tissue where healing might proceed much fasterThe Apexumprocedure uses two sequential rotary devices the Apexum NiTi Ablator and Apexum PGA Ablator (Apexum Ltd Or Yehuda Israel) designed to extend beyond the apex and mince the periapical tissues on rotation in a low-speed handpiece followed by washing out the minced tissue

Surgical management of Apical lesions Apical lesions maybe managed surgically to reduce

healing and recovery time

Indicated for emergency cases

Incision and drainagewith antibiotic therapy of the lesionfollowed by RCT with apisectomy is the usual modality of surgical treatment of apical lesions

Medical Management of apical lesions Antibiotic therapy is used to treat minor apical

lesionsin order to relieve the symptomsThis enables easier surgical or non0surgical management of the lesionThus medical management of apical lesions is used in conjunction with Surgical or non surgical management of apical lesions

Cellulitis-Cefazolin 1g iv Q8H7-10 days or cloxacillin500-1000mg po Q6H7-10 days

Acute osteomyelitis-Cefazolin 2g iv Q8H

Ludwigs angina-Clindamycin 600mg iv Q8H2-3 weeks

References J Conserv Dent 2010 Oct-Dec 13(4) 240-

245doi 1041030972070773384PMCID PMC3010029Nonsurgical management of periapical lesions Marina Fernandes and Ida de Ataide

Manual in maxillofacial surgery for senior house officers-Dental 2cmcvellore

Periapical cyst AKA apical periodontal cystradicular cyst

Inflammatory odontogenic cystinduced by cell rests of malassez(Hertwigs Epithelial Root Sheath remnants) proliferation

Radiolucency at periapex of non-vital teeth

To differentiate from a granulomait must be tested histologically

Management of apical lesions Non-surgical management Periapical lesions develop as

sequelae to pulp disease They often occur without any episode of acute pain and are discovered on routine radiographic examination It is accepted that all inflammatory periapicallesions should be initially treated with conservative nonsurgical procedures

Methods1The conservative root canal treatment

2decompression technique3active nonsurgical decompression technique4aspiration-irrigation technique

5 method using calcium hydroxide6 Lesion Sterilization and Repair Therapy and7the Apexum procedure

Case selectionThe current philosophy in the management of periapical lesions includes the initial use of nonsurgical methods When this treatment approach is not successful a surgical approach may be adoptedThe following factors must be considered while deciding on the management approach

Diagnosis of the lesionMany bone destroying lesions closely resemble endodontically related periapicallesions on radiographs Some of these nonendodontic lesions include ameloblastoma central fibroma giant cell lesions fibrous dysplasia central hemangioma primary malignancies metastatic neoplasms and inflammatory bone diseases

Proximity of the periapical lesion to adjacent vital teethWhen in proximity to a vital toothadopting a surgical approach may result in injury to the blood vessels and nerves of the adjacent teeth thereby compromising their vitality

Encroachment on anatomical structuresSurgery increases the risk of damage to the anatomic structures such as mental foramen inferior alveolar nerve Also the aspirationndashirrigation technique a nonsurgical method is not recommended where adjacent tissue spaces or sinus cavities are involved

Patient cooperation

Considerable pain or discomfort can be experienced by the patient during or after a surgical procedure A nonsurgical approach would be recommended for apprehensive and uncooperative patients

Obstructions in the root canal system

Ledges calcified canals separated instruments may prevent access to the apical foramen and may warrant a surgical approach in managing periapical lesions related to such teeth

Time involved for treatment

Enhanced healing kinetics are observed after performing apical surgery in teeth with periapical lesions

Cases refractory to nonsurgical management methods

Inflammatory apical true cysts and the presence of cholesterol crystals have been suggested as possible causes that prevent healing of periapical lesionsSurgery is recommended for such cases

METHODS FOR NONSURGICAL MANAGMENT OF PERIAPICAL LESIONS Conservative root canal treatment without adjunctive therapy

Instrumentation should be carried 1 mm beyond the apical foramen when a periapical lesion is evident on a radiograph This may cause transitory inflammation and ulceration of the epithelial lining resulting in resolution of the cyst

Decompression technique

The decompression technique involves placement of a drain into the lesion regular irrigation periodic length adjustment and maintenance of the drain for various periods of time

Active nonsurgical decompression technique

This technique uses the Endo-eze vacuum system to create a negative pressure which results in the decompression of large periapical lesions The high-volume suction aspirator is connected to a micro 22-gauge needle which is inserted in the root canal and activated for 20 minutes creating a negative pressure which results in aspiration of the exudate When the drainage partially stops the access cavity is closed with temporary cement which helps in maintaining bacterial control

Aspiration and irrigation technique

Hoen et al suggested aspiration of the cystic fluid from the periapcial lesion using a buccal palatal approach In this technique an 18-gauge needle attached to a 20 ml syringe is used to penetrate the buccal mucosa and aspirate the cystic fluid A second syringe filled with saline is then used to rinse the bony lesion The new needle is inserted through the buccal wound and passed out through the palatal tissue creating a pathway for the escape of the irrigant

Aspiration through the root canal technique

In this technique aspiration of the cystic fluid is done through the root canal by passing the aspirating needle through the apical foramen This technique eliminates the creation of buccal and palatal wounds as in the traditional aspirationndashirrigation technique This minimizes the discomfort that the patient may experience

However it is advisable not to use either aspirationndashirrigation or aspiration through the root canal techniques where adjacent tissue spaces or sinus cavities are involved when there is no fluid aspiration from the lesion or in infected periapicallesions

Method using calcium hydroxide

Calcium hydroxide is a widely used material in endodontic treatment because of its bactericidal effectsIt is thought to create favorable conditions for periapical repair and stimulate hard tissue formationSouza et al suggested that the action of calcium hydroxide beyond the apex may be four-fold (a) anti-inflammatory activity (b) neutralization of acid products (c) activation of the alkaline phosphatase and (d) antibacterial action

Lesion sterilization and repair therapy

lsquoLesion Sterilization and Tissue Repair (LSTR)rsquo therapy that uses a triple antibiotic paste of ciprofloxacin metronidazole and minocycline for disinfection of oral infectious lesions including dentinal pulpal and periradicular lesions Repair of damaged tissues can be expected if lesions are disinfectedMetronidazole is the first choice because it has a wide antibacterial spectrum against anaerobesHowever some bacteria are resistant to metronidazole and hence ciprofloxacin and minocycline are added to the mix

Apexum procedure

Surgical removal of the periapical chronically inflamed tissue allows a fresh blood clot to form thereby converting a chronic inflammatory lesion into a new granulation tissue where healing might proceed much fasterThe Apexumprocedure uses two sequential rotary devices the Apexum NiTi Ablator and Apexum PGA Ablator (Apexum Ltd Or Yehuda Israel) designed to extend beyond the apex and mince the periapical tissues on rotation in a low-speed handpiece followed by washing out the minced tissue

Surgical management of Apical lesions Apical lesions maybe managed surgically to reduce

healing and recovery time

Indicated for emergency cases

Incision and drainagewith antibiotic therapy of the lesionfollowed by RCT with apisectomy is the usual modality of surgical treatment of apical lesions

Medical Management of apical lesions Antibiotic therapy is used to treat minor apical

lesionsin order to relieve the symptomsThis enables easier surgical or non0surgical management of the lesionThus medical management of apical lesions is used in conjunction with Surgical or non surgical management of apical lesions

Cellulitis-Cefazolin 1g iv Q8H7-10 days or cloxacillin500-1000mg po Q6H7-10 days

Acute osteomyelitis-Cefazolin 2g iv Q8H

Ludwigs angina-Clindamycin 600mg iv Q8H2-3 weeks

References J Conserv Dent 2010 Oct-Dec 13(4) 240-

245doi 1041030972070773384PMCID PMC3010029Nonsurgical management of periapical lesions Marina Fernandes and Ida de Ataide

Manual in maxillofacial surgery for senior house officers-Dental 2cmcvellore

Management of apical lesions Non-surgical management Periapical lesions develop as

sequelae to pulp disease They often occur without any episode of acute pain and are discovered on routine radiographic examination It is accepted that all inflammatory periapicallesions should be initially treated with conservative nonsurgical procedures

Methods1The conservative root canal treatment

2decompression technique3active nonsurgical decompression technique4aspiration-irrigation technique

5 method using calcium hydroxide6 Lesion Sterilization and Repair Therapy and7the Apexum procedure

Case selectionThe current philosophy in the management of periapical lesions includes the initial use of nonsurgical methods When this treatment approach is not successful a surgical approach may be adoptedThe following factors must be considered while deciding on the management approach

Diagnosis of the lesionMany bone destroying lesions closely resemble endodontically related periapicallesions on radiographs Some of these nonendodontic lesions include ameloblastoma central fibroma giant cell lesions fibrous dysplasia central hemangioma primary malignancies metastatic neoplasms and inflammatory bone diseases

Proximity of the periapical lesion to adjacent vital teethWhen in proximity to a vital toothadopting a surgical approach may result in injury to the blood vessels and nerves of the adjacent teeth thereby compromising their vitality

Encroachment on anatomical structuresSurgery increases the risk of damage to the anatomic structures such as mental foramen inferior alveolar nerve Also the aspirationndashirrigation technique a nonsurgical method is not recommended where adjacent tissue spaces or sinus cavities are involved

Patient cooperation

Considerable pain or discomfort can be experienced by the patient during or after a surgical procedure A nonsurgical approach would be recommended for apprehensive and uncooperative patients

Obstructions in the root canal system

Ledges calcified canals separated instruments may prevent access to the apical foramen and may warrant a surgical approach in managing periapical lesions related to such teeth

Time involved for treatment

Enhanced healing kinetics are observed after performing apical surgery in teeth with periapical lesions

Cases refractory to nonsurgical management methods

Inflammatory apical true cysts and the presence of cholesterol crystals have been suggested as possible causes that prevent healing of periapical lesionsSurgery is recommended for such cases

METHODS FOR NONSURGICAL MANAGMENT OF PERIAPICAL LESIONS Conservative root canal treatment without adjunctive therapy

Instrumentation should be carried 1 mm beyond the apical foramen when a periapical lesion is evident on a radiograph This may cause transitory inflammation and ulceration of the epithelial lining resulting in resolution of the cyst

Decompression technique

The decompression technique involves placement of a drain into the lesion regular irrigation periodic length adjustment and maintenance of the drain for various periods of time

Active nonsurgical decompression technique

This technique uses the Endo-eze vacuum system to create a negative pressure which results in the decompression of large periapical lesions The high-volume suction aspirator is connected to a micro 22-gauge needle which is inserted in the root canal and activated for 20 minutes creating a negative pressure which results in aspiration of the exudate When the drainage partially stops the access cavity is closed with temporary cement which helps in maintaining bacterial control

Aspiration and irrigation technique

Hoen et al suggested aspiration of the cystic fluid from the periapcial lesion using a buccal palatal approach In this technique an 18-gauge needle attached to a 20 ml syringe is used to penetrate the buccal mucosa and aspirate the cystic fluid A second syringe filled with saline is then used to rinse the bony lesion The new needle is inserted through the buccal wound and passed out through the palatal tissue creating a pathway for the escape of the irrigant

Aspiration through the root canal technique

In this technique aspiration of the cystic fluid is done through the root canal by passing the aspirating needle through the apical foramen This technique eliminates the creation of buccal and palatal wounds as in the traditional aspirationndashirrigation technique This minimizes the discomfort that the patient may experience

However it is advisable not to use either aspirationndashirrigation or aspiration through the root canal techniques where adjacent tissue spaces or sinus cavities are involved when there is no fluid aspiration from the lesion or in infected periapicallesions

Method using calcium hydroxide

Calcium hydroxide is a widely used material in endodontic treatment because of its bactericidal effectsIt is thought to create favorable conditions for periapical repair and stimulate hard tissue formationSouza et al suggested that the action of calcium hydroxide beyond the apex may be four-fold (a) anti-inflammatory activity (b) neutralization of acid products (c) activation of the alkaline phosphatase and (d) antibacterial action

Lesion sterilization and repair therapy

lsquoLesion Sterilization and Tissue Repair (LSTR)rsquo therapy that uses a triple antibiotic paste of ciprofloxacin metronidazole and minocycline for disinfection of oral infectious lesions including dentinal pulpal and periradicular lesions Repair of damaged tissues can be expected if lesions are disinfectedMetronidazole is the first choice because it has a wide antibacterial spectrum against anaerobesHowever some bacteria are resistant to metronidazole and hence ciprofloxacin and minocycline are added to the mix

Apexum procedure

Surgical removal of the periapical chronically inflamed tissue allows a fresh blood clot to form thereby converting a chronic inflammatory lesion into a new granulation tissue where healing might proceed much fasterThe Apexumprocedure uses two sequential rotary devices the Apexum NiTi Ablator and Apexum PGA Ablator (Apexum Ltd Or Yehuda Israel) designed to extend beyond the apex and mince the periapical tissues on rotation in a low-speed handpiece followed by washing out the minced tissue

Surgical management of Apical lesions Apical lesions maybe managed surgically to reduce

healing and recovery time

Indicated for emergency cases

Incision and drainagewith antibiotic therapy of the lesionfollowed by RCT with apisectomy is the usual modality of surgical treatment of apical lesions

Medical Management of apical lesions Antibiotic therapy is used to treat minor apical

lesionsin order to relieve the symptomsThis enables easier surgical or non0surgical management of the lesionThus medical management of apical lesions is used in conjunction with Surgical or non surgical management of apical lesions

Cellulitis-Cefazolin 1g iv Q8H7-10 days or cloxacillin500-1000mg po Q6H7-10 days

Acute osteomyelitis-Cefazolin 2g iv Q8H

Ludwigs angina-Clindamycin 600mg iv Q8H2-3 weeks

References J Conserv Dent 2010 Oct-Dec 13(4) 240-

245doi 1041030972070773384PMCID PMC3010029Nonsurgical management of periapical lesions Marina Fernandes and Ida de Ataide

Manual in maxillofacial surgery for senior house officers-Dental 2cmcvellore

Case selectionThe current philosophy in the management of periapical lesions includes the initial use of nonsurgical methods When this treatment approach is not successful a surgical approach may be adoptedThe following factors must be considered while deciding on the management approach

Diagnosis of the lesionMany bone destroying lesions closely resemble endodontically related periapicallesions on radiographs Some of these nonendodontic lesions include ameloblastoma central fibroma giant cell lesions fibrous dysplasia central hemangioma primary malignancies metastatic neoplasms and inflammatory bone diseases

Proximity of the periapical lesion to adjacent vital teethWhen in proximity to a vital toothadopting a surgical approach may result in injury to the blood vessels and nerves of the adjacent teeth thereby compromising their vitality

Encroachment on anatomical structuresSurgery increases the risk of damage to the anatomic structures such as mental foramen inferior alveolar nerve Also the aspirationndashirrigation technique a nonsurgical method is not recommended where adjacent tissue spaces or sinus cavities are involved

Patient cooperation

Considerable pain or discomfort can be experienced by the patient during or after a surgical procedure A nonsurgical approach would be recommended for apprehensive and uncooperative patients

Obstructions in the root canal system

Ledges calcified canals separated instruments may prevent access to the apical foramen and may warrant a surgical approach in managing periapical lesions related to such teeth

Time involved for treatment

Enhanced healing kinetics are observed after performing apical surgery in teeth with periapical lesions

Cases refractory to nonsurgical management methods

Inflammatory apical true cysts and the presence of cholesterol crystals have been suggested as possible causes that prevent healing of periapical lesionsSurgery is recommended for such cases

METHODS FOR NONSURGICAL MANAGMENT OF PERIAPICAL LESIONS Conservative root canal treatment without adjunctive therapy

Instrumentation should be carried 1 mm beyond the apical foramen when a periapical lesion is evident on a radiograph This may cause transitory inflammation and ulceration of the epithelial lining resulting in resolution of the cyst

Decompression technique

The decompression technique involves placement of a drain into the lesion regular irrigation periodic length adjustment and maintenance of the drain for various periods of time

Active nonsurgical decompression technique

This technique uses the Endo-eze vacuum system to create a negative pressure which results in the decompression of large periapical lesions The high-volume suction aspirator is connected to a micro 22-gauge needle which is inserted in the root canal and activated for 20 minutes creating a negative pressure which results in aspiration of the exudate When the drainage partially stops the access cavity is closed with temporary cement which helps in maintaining bacterial control

Aspiration and irrigation technique

Hoen et al suggested aspiration of the cystic fluid from the periapcial lesion using a buccal palatal approach In this technique an 18-gauge needle attached to a 20 ml syringe is used to penetrate the buccal mucosa and aspirate the cystic fluid A second syringe filled with saline is then used to rinse the bony lesion The new needle is inserted through the buccal wound and passed out through the palatal tissue creating a pathway for the escape of the irrigant

Aspiration through the root canal technique

In this technique aspiration of the cystic fluid is done through the root canal by passing the aspirating needle through the apical foramen This technique eliminates the creation of buccal and palatal wounds as in the traditional aspirationndashirrigation technique This minimizes the discomfort that the patient may experience

However it is advisable not to use either aspirationndashirrigation or aspiration through the root canal techniques where adjacent tissue spaces or sinus cavities are involved when there is no fluid aspiration from the lesion or in infected periapicallesions

Method using calcium hydroxide

Calcium hydroxide is a widely used material in endodontic treatment because of its bactericidal effectsIt is thought to create favorable conditions for periapical repair and stimulate hard tissue formationSouza et al suggested that the action of calcium hydroxide beyond the apex may be four-fold (a) anti-inflammatory activity (b) neutralization of acid products (c) activation of the alkaline phosphatase and (d) antibacterial action

Lesion sterilization and repair therapy

lsquoLesion Sterilization and Tissue Repair (LSTR)rsquo therapy that uses a triple antibiotic paste of ciprofloxacin metronidazole and minocycline for disinfection of oral infectious lesions including dentinal pulpal and periradicular lesions Repair of damaged tissues can be expected if lesions are disinfectedMetronidazole is the first choice because it has a wide antibacterial spectrum against anaerobesHowever some bacteria are resistant to metronidazole and hence ciprofloxacin and minocycline are added to the mix

Apexum procedure

Surgical removal of the periapical chronically inflamed tissue allows a fresh blood clot to form thereby converting a chronic inflammatory lesion into a new granulation tissue where healing might proceed much fasterThe Apexumprocedure uses two sequential rotary devices the Apexum NiTi Ablator and Apexum PGA Ablator (Apexum Ltd Or Yehuda Israel) designed to extend beyond the apex and mince the periapical tissues on rotation in a low-speed handpiece followed by washing out the minced tissue

Surgical management of Apical lesions Apical lesions maybe managed surgically to reduce

healing and recovery time

Indicated for emergency cases

Incision and drainagewith antibiotic therapy of the lesionfollowed by RCT with apisectomy is the usual modality of surgical treatment of apical lesions

Medical Management of apical lesions Antibiotic therapy is used to treat minor apical

lesionsin order to relieve the symptomsThis enables easier surgical or non0surgical management of the lesionThus medical management of apical lesions is used in conjunction with Surgical or non surgical management of apical lesions

Cellulitis-Cefazolin 1g iv Q8H7-10 days or cloxacillin500-1000mg po Q6H7-10 days

Acute osteomyelitis-Cefazolin 2g iv Q8H

Ludwigs angina-Clindamycin 600mg iv Q8H2-3 weeks

References J Conserv Dent 2010 Oct-Dec 13(4) 240-

245doi 1041030972070773384PMCID PMC3010029Nonsurgical management of periapical lesions Marina Fernandes and Ida de Ataide

Manual in maxillofacial surgery for senior house officers-Dental 2cmcvellore

Patient cooperation

Considerable pain or discomfort can be experienced by the patient during or after a surgical procedure A nonsurgical approach would be recommended for apprehensive and uncooperative patients

Obstructions in the root canal system

Ledges calcified canals separated instruments may prevent access to the apical foramen and may warrant a surgical approach in managing periapical lesions related to such teeth

Time involved for treatment

Enhanced healing kinetics are observed after performing apical surgery in teeth with periapical lesions

Cases refractory to nonsurgical management methods

Inflammatory apical true cysts and the presence of cholesterol crystals have been suggested as possible causes that prevent healing of periapical lesionsSurgery is recommended for such cases

METHODS FOR NONSURGICAL MANAGMENT OF PERIAPICAL LESIONS Conservative root canal treatment without adjunctive therapy

Instrumentation should be carried 1 mm beyond the apical foramen when a periapical lesion is evident on a radiograph This may cause transitory inflammation and ulceration of the epithelial lining resulting in resolution of the cyst

Decompression technique

The decompression technique involves placement of a drain into the lesion regular irrigation periodic length adjustment and maintenance of the drain for various periods of time

Active nonsurgical decompression technique

This technique uses the Endo-eze vacuum system to create a negative pressure which results in the decompression of large periapical lesions The high-volume suction aspirator is connected to a micro 22-gauge needle which is inserted in the root canal and activated for 20 minutes creating a negative pressure which results in aspiration of the exudate When the drainage partially stops the access cavity is closed with temporary cement which helps in maintaining bacterial control

Aspiration and irrigation technique

Hoen et al suggested aspiration of the cystic fluid from the periapcial lesion using a buccal palatal approach In this technique an 18-gauge needle attached to a 20 ml syringe is used to penetrate the buccal mucosa and aspirate the cystic fluid A second syringe filled with saline is then used to rinse the bony lesion The new needle is inserted through the buccal wound and passed out through the palatal tissue creating a pathway for the escape of the irrigant

Aspiration through the root canal technique

In this technique aspiration of the cystic fluid is done through the root canal by passing the aspirating needle through the apical foramen This technique eliminates the creation of buccal and palatal wounds as in the traditional aspirationndashirrigation technique This minimizes the discomfort that the patient may experience

However it is advisable not to use either aspirationndashirrigation or aspiration through the root canal techniques where adjacent tissue spaces or sinus cavities are involved when there is no fluid aspiration from the lesion or in infected periapicallesions

Method using calcium hydroxide

Calcium hydroxide is a widely used material in endodontic treatment because of its bactericidal effectsIt is thought to create favorable conditions for periapical repair and stimulate hard tissue formationSouza et al suggested that the action of calcium hydroxide beyond the apex may be four-fold (a) anti-inflammatory activity (b) neutralization of acid products (c) activation of the alkaline phosphatase and (d) antibacterial action

Lesion sterilization and repair therapy

lsquoLesion Sterilization and Tissue Repair (LSTR)rsquo therapy that uses a triple antibiotic paste of ciprofloxacin metronidazole and minocycline for disinfection of oral infectious lesions including dentinal pulpal and periradicular lesions Repair of damaged tissues can be expected if lesions are disinfectedMetronidazole is the first choice because it has a wide antibacterial spectrum against anaerobesHowever some bacteria are resistant to metronidazole and hence ciprofloxacin and minocycline are added to the mix

Apexum procedure

Surgical removal of the periapical chronically inflamed tissue allows a fresh blood clot to form thereby converting a chronic inflammatory lesion into a new granulation tissue where healing might proceed much fasterThe Apexumprocedure uses two sequential rotary devices the Apexum NiTi Ablator and Apexum PGA Ablator (Apexum Ltd Or Yehuda Israel) designed to extend beyond the apex and mince the periapical tissues on rotation in a low-speed handpiece followed by washing out the minced tissue

Surgical management of Apical lesions Apical lesions maybe managed surgically to reduce

healing and recovery time

Indicated for emergency cases

Incision and drainagewith antibiotic therapy of the lesionfollowed by RCT with apisectomy is the usual modality of surgical treatment of apical lesions

Medical Management of apical lesions Antibiotic therapy is used to treat minor apical

lesionsin order to relieve the symptomsThis enables easier surgical or non0surgical management of the lesionThus medical management of apical lesions is used in conjunction with Surgical or non surgical management of apical lesions

Cellulitis-Cefazolin 1g iv Q8H7-10 days or cloxacillin500-1000mg po Q6H7-10 days

Acute osteomyelitis-Cefazolin 2g iv Q8H

Ludwigs angina-Clindamycin 600mg iv Q8H2-3 weeks

References J Conserv Dent 2010 Oct-Dec 13(4) 240-

245doi 1041030972070773384PMCID PMC3010029Nonsurgical management of periapical lesions Marina Fernandes and Ida de Ataide

Manual in maxillofacial surgery for senior house officers-Dental 2cmcvellore

METHODS FOR NONSURGICAL MANAGMENT OF PERIAPICAL LESIONS Conservative root canal treatment without adjunctive therapy

Instrumentation should be carried 1 mm beyond the apical foramen when a periapical lesion is evident on a radiograph This may cause transitory inflammation and ulceration of the epithelial lining resulting in resolution of the cyst

Decompression technique

The decompression technique involves placement of a drain into the lesion regular irrigation periodic length adjustment and maintenance of the drain for various periods of time

Active nonsurgical decompression technique

This technique uses the Endo-eze vacuum system to create a negative pressure which results in the decompression of large periapical lesions The high-volume suction aspirator is connected to a micro 22-gauge needle which is inserted in the root canal and activated for 20 minutes creating a negative pressure which results in aspiration of the exudate When the drainage partially stops the access cavity is closed with temporary cement which helps in maintaining bacterial control

Aspiration and irrigation technique

Hoen et al suggested aspiration of the cystic fluid from the periapcial lesion using a buccal palatal approach In this technique an 18-gauge needle attached to a 20 ml syringe is used to penetrate the buccal mucosa and aspirate the cystic fluid A second syringe filled with saline is then used to rinse the bony lesion The new needle is inserted through the buccal wound and passed out through the palatal tissue creating a pathway for the escape of the irrigant

Aspiration through the root canal technique

In this technique aspiration of the cystic fluid is done through the root canal by passing the aspirating needle through the apical foramen This technique eliminates the creation of buccal and palatal wounds as in the traditional aspirationndashirrigation technique This minimizes the discomfort that the patient may experience

However it is advisable not to use either aspirationndashirrigation or aspiration through the root canal techniques where adjacent tissue spaces or sinus cavities are involved when there is no fluid aspiration from the lesion or in infected periapicallesions

Method using calcium hydroxide

Calcium hydroxide is a widely used material in endodontic treatment because of its bactericidal effectsIt is thought to create favorable conditions for periapical repair and stimulate hard tissue formationSouza et al suggested that the action of calcium hydroxide beyond the apex may be four-fold (a) anti-inflammatory activity (b) neutralization of acid products (c) activation of the alkaline phosphatase and (d) antibacterial action

Lesion sterilization and repair therapy

lsquoLesion Sterilization and Tissue Repair (LSTR)rsquo therapy that uses a triple antibiotic paste of ciprofloxacin metronidazole and minocycline for disinfection of oral infectious lesions including dentinal pulpal and periradicular lesions Repair of damaged tissues can be expected if lesions are disinfectedMetronidazole is the first choice because it has a wide antibacterial spectrum against anaerobesHowever some bacteria are resistant to metronidazole and hence ciprofloxacin and minocycline are added to the mix

Apexum procedure

Surgical removal of the periapical chronically inflamed tissue allows a fresh blood clot to form thereby converting a chronic inflammatory lesion into a new granulation tissue where healing might proceed much fasterThe Apexumprocedure uses two sequential rotary devices the Apexum NiTi Ablator and Apexum PGA Ablator (Apexum Ltd Or Yehuda Israel) designed to extend beyond the apex and mince the periapical tissues on rotation in a low-speed handpiece followed by washing out the minced tissue

Surgical management of Apical lesions Apical lesions maybe managed surgically to reduce

healing and recovery time

Indicated for emergency cases

Incision and drainagewith antibiotic therapy of the lesionfollowed by RCT with apisectomy is the usual modality of surgical treatment of apical lesions

Medical Management of apical lesions Antibiotic therapy is used to treat minor apical

lesionsin order to relieve the symptomsThis enables easier surgical or non0surgical management of the lesionThus medical management of apical lesions is used in conjunction with Surgical or non surgical management of apical lesions

Cellulitis-Cefazolin 1g iv Q8H7-10 days or cloxacillin500-1000mg po Q6H7-10 days

Acute osteomyelitis-Cefazolin 2g iv Q8H

Ludwigs angina-Clindamycin 600mg iv Q8H2-3 weeks

References J Conserv Dent 2010 Oct-Dec 13(4) 240-

245doi 1041030972070773384PMCID PMC3010029Nonsurgical management of periapical lesions Marina Fernandes and Ida de Ataide

Manual in maxillofacial surgery for senior house officers-Dental 2cmcvellore

Aspiration and irrigation technique

Hoen et al suggested aspiration of the cystic fluid from the periapcial lesion using a buccal palatal approach In this technique an 18-gauge needle attached to a 20 ml syringe is used to penetrate the buccal mucosa and aspirate the cystic fluid A second syringe filled with saline is then used to rinse the bony lesion The new needle is inserted through the buccal wound and passed out through the palatal tissue creating a pathway for the escape of the irrigant

Aspiration through the root canal technique

In this technique aspiration of the cystic fluid is done through the root canal by passing the aspirating needle through the apical foramen This technique eliminates the creation of buccal and palatal wounds as in the traditional aspirationndashirrigation technique This minimizes the discomfort that the patient may experience

However it is advisable not to use either aspirationndashirrigation or aspiration through the root canal techniques where adjacent tissue spaces or sinus cavities are involved when there is no fluid aspiration from the lesion or in infected periapicallesions

Method using calcium hydroxide

Calcium hydroxide is a widely used material in endodontic treatment because of its bactericidal effectsIt is thought to create favorable conditions for periapical repair and stimulate hard tissue formationSouza et al suggested that the action of calcium hydroxide beyond the apex may be four-fold (a) anti-inflammatory activity (b) neutralization of acid products (c) activation of the alkaline phosphatase and (d) antibacterial action

Lesion sterilization and repair therapy

lsquoLesion Sterilization and Tissue Repair (LSTR)rsquo therapy that uses a triple antibiotic paste of ciprofloxacin metronidazole and minocycline for disinfection of oral infectious lesions including dentinal pulpal and periradicular lesions Repair of damaged tissues can be expected if lesions are disinfectedMetronidazole is the first choice because it has a wide antibacterial spectrum against anaerobesHowever some bacteria are resistant to metronidazole and hence ciprofloxacin and minocycline are added to the mix

Apexum procedure

Surgical removal of the periapical chronically inflamed tissue allows a fresh blood clot to form thereby converting a chronic inflammatory lesion into a new granulation tissue where healing might proceed much fasterThe Apexumprocedure uses two sequential rotary devices the Apexum NiTi Ablator and Apexum PGA Ablator (Apexum Ltd Or Yehuda Israel) designed to extend beyond the apex and mince the periapical tissues on rotation in a low-speed handpiece followed by washing out the minced tissue

Surgical management of Apical lesions Apical lesions maybe managed surgically to reduce

healing and recovery time

Indicated for emergency cases

Incision and drainagewith antibiotic therapy of the lesionfollowed by RCT with apisectomy is the usual modality of surgical treatment of apical lesions

Medical Management of apical lesions Antibiotic therapy is used to treat minor apical

lesionsin order to relieve the symptomsThis enables easier surgical or non0surgical management of the lesionThus medical management of apical lesions is used in conjunction with Surgical or non surgical management of apical lesions

Cellulitis-Cefazolin 1g iv Q8H7-10 days or cloxacillin500-1000mg po Q6H7-10 days

Acute osteomyelitis-Cefazolin 2g iv Q8H

Ludwigs angina-Clindamycin 600mg iv Q8H2-3 weeks

References J Conserv Dent 2010 Oct-Dec 13(4) 240-

245doi 1041030972070773384PMCID PMC3010029Nonsurgical management of periapical lesions Marina Fernandes and Ida de Ataide

Manual in maxillofacial surgery for senior house officers-Dental 2cmcvellore

Method using calcium hydroxide

Calcium hydroxide is a widely used material in endodontic treatment because of its bactericidal effectsIt is thought to create favorable conditions for periapical repair and stimulate hard tissue formationSouza et al suggested that the action of calcium hydroxide beyond the apex may be four-fold (a) anti-inflammatory activity (b) neutralization of acid products (c) activation of the alkaline phosphatase and (d) antibacterial action

Lesion sterilization and repair therapy

lsquoLesion Sterilization and Tissue Repair (LSTR)rsquo therapy that uses a triple antibiotic paste of ciprofloxacin metronidazole and minocycline for disinfection of oral infectious lesions including dentinal pulpal and periradicular lesions Repair of damaged tissues can be expected if lesions are disinfectedMetronidazole is the first choice because it has a wide antibacterial spectrum against anaerobesHowever some bacteria are resistant to metronidazole and hence ciprofloxacin and minocycline are added to the mix

Apexum procedure

Surgical removal of the periapical chronically inflamed tissue allows a fresh blood clot to form thereby converting a chronic inflammatory lesion into a new granulation tissue where healing might proceed much fasterThe Apexumprocedure uses two sequential rotary devices the Apexum NiTi Ablator and Apexum PGA Ablator (Apexum Ltd Or Yehuda Israel) designed to extend beyond the apex and mince the periapical tissues on rotation in a low-speed handpiece followed by washing out the minced tissue

Surgical management of Apical lesions Apical lesions maybe managed surgically to reduce

healing and recovery time

Indicated for emergency cases

Incision and drainagewith antibiotic therapy of the lesionfollowed by RCT with apisectomy is the usual modality of surgical treatment of apical lesions

Medical Management of apical lesions Antibiotic therapy is used to treat minor apical

lesionsin order to relieve the symptomsThis enables easier surgical or non0surgical management of the lesionThus medical management of apical lesions is used in conjunction with Surgical or non surgical management of apical lesions

Cellulitis-Cefazolin 1g iv Q8H7-10 days or cloxacillin500-1000mg po Q6H7-10 days

Acute osteomyelitis-Cefazolin 2g iv Q8H

Ludwigs angina-Clindamycin 600mg iv Q8H2-3 weeks

References J Conserv Dent 2010 Oct-Dec 13(4) 240-

245doi 1041030972070773384PMCID PMC3010029Nonsurgical management of periapical lesions Marina Fernandes and Ida de Ataide

Manual in maxillofacial surgery for senior house officers-Dental 2cmcvellore

Surgical management of Apical lesions Apical lesions maybe managed surgically to reduce

healing and recovery time

Indicated for emergency cases

Incision and drainagewith antibiotic therapy of the lesionfollowed by RCT with apisectomy is the usual modality of surgical treatment of apical lesions

Medical Management of apical lesions Antibiotic therapy is used to treat minor apical

lesionsin order to relieve the symptomsThis enables easier surgical or non0surgical management of the lesionThus medical management of apical lesions is used in conjunction with Surgical or non surgical management of apical lesions

Cellulitis-Cefazolin 1g iv Q8H7-10 days or cloxacillin500-1000mg po Q6H7-10 days

Acute osteomyelitis-Cefazolin 2g iv Q8H

Ludwigs angina-Clindamycin 600mg iv Q8H2-3 weeks

References J Conserv Dent 2010 Oct-Dec 13(4) 240-

245doi 1041030972070773384PMCID PMC3010029Nonsurgical management of periapical lesions Marina Fernandes and Ida de Ataide

Manual in maxillofacial surgery for senior house officers-Dental 2cmcvellore

Medical Management of apical lesions Antibiotic therapy is used to treat minor apical

lesionsin order to relieve the symptomsThis enables easier surgical or non0surgical management of the lesionThus medical management of apical lesions is used in conjunction with Surgical or non surgical management of apical lesions

Cellulitis-Cefazolin 1g iv Q8H7-10 days or cloxacillin500-1000mg po Q6H7-10 days

Acute osteomyelitis-Cefazolin 2g iv Q8H

Ludwigs angina-Clindamycin 600mg iv Q8H2-3 weeks

References J Conserv Dent 2010 Oct-Dec 13(4) 240-

245doi 1041030972070773384PMCID PMC3010029Nonsurgical management of periapical lesions Marina Fernandes and Ida de Ataide

Manual in maxillofacial surgery for senior house officers-Dental 2cmcvellore

References J Conserv Dent 2010 Oct-Dec 13(4) 240-

245doi 1041030972070773384PMCID PMC3010029Nonsurgical management of periapical lesions Marina Fernandes and Ida de Ataide

Manual in maxillofacial surgery for senior house officers-Dental 2cmcvellore

DrVikram PerakathBDS