Clinical Manifestations
Clinical Manifestations
Chronic apical periodontitis is primarily a radiographic diagnosis. The vast majority of patients are completely asymptomatic — no pain, no swelling, no sensitivity to biting. The lesion is discovered incidentally during routine dental radiographs or investigation of adjacent teeth.
Occasionally patients report vague discomfort, awareness of the tooth, or mild aching — especially in larger lesions expanding against cortical bone. A sinus tract (fistula) may develop, presenting as a small intermittent swelling or 'pimple' on the gum with a sinus opening that intermittently drains pus, relieving pressure and maintaining the chronic, asymptomatic state.
Large cysts may cause buccal or palatal cortical expansion — a firm, egg-shaped, non-tender swelling. In extreme cases, cortical perforation produces a fluctuant cystic mass. Pressure on adjacent roots may cause resorption.
Vitality testing: the tooth does not respond to cold or EPT (non-vital) in the vast majority of cases, as the pulp is necrotic. Rarely, a posterior tooth with 4 canals may have necrotic canals producing the apical lesion while one canal remains vital — producing a paradoxical positive vitality response.