The treatment of periapical periodontitis is a difficult and responsible task. The different types of the disease (acute, chronic, and exacerbated), the individual characteristics of the root canal of the teeth (curvy, narrow, and impassable) and the body’s defenses determine the outcome of treatment. In many cases, the general wellbeing of the patient is affected, which requires treatment to begin without delay. Treatment starts with an X-ray picture and a clinical examination to determine the type of periapical periodontitis. The treatment of periapical periodontitis aims to eliminate the infection in the root canals and the infection in the area around the root apex (top), whether it is acute or chronic (granuloma). The infection in the root canal system is eliminated through the standard endodontic treatment used for pulpitis. The main difference is that the infection around the root apex (acute periapical periodontitis) or in granuloma (chronic periapical periodontitis) requires to be treated.

Severe pain is characteristic of acute periapical periodontitis. It is due to the increase of the tissue pressure as a result of collection of pus or serous fluid, which have resulted from the inflammatory process. To relieve the pain and commence the healing process, the assembled pus or serous fluid around the tooth root must be removed. This is done through the root canals, which are cleaned and expanded using special endodontic files to be able to drain the collection of fluids.
The patient experiences rapid relief, but this does not mean that he/she is cured. The walls of the root canal and the area of the bone around the root apex are highly populated with the bacteria which has caused the periapical periodontitis. If the root canals are hermetically filled at this point, the bacteria will grow again and the disease will exacerbate in the same way. Here comes the main difference in the endodontic treatment of pulpitis and periapical periodontitis. In periapical periodontitis all bacteria should be eliminated in the root canals and periodontium. This is done by mechanical and drug treatment of the root canals and multiple rinsing with antiseptic and antibiotic solutions, and in severe cases prescribing of an oral antibiotic is necessary.

The mechanical treatment of the root canals consists of scraping of the walls of the root canals, thus removing bacteria attached to them. This is done by special endodontic files, which must reach the end of the root, otherwise the treatment is not safe enough. In many curvy, narrow or impassable root canals, there is no way to conduct the endodontic treatment and reach the infection around the root apex, and in this cases apical osteotomy is required or even removal of the tooth.


Besides mechanical treatment, drug treatment can be used. In the acute stages of the periapical periodontitis, rinsing with antiseptics and antibiotics of the root canal is performed in order to eliminate the virulent bacteria and to influence the inflammation in the root apex. The lavages are done every day and they may be continued for several weeks if there is persistent inflammation. After the acute process subsides and pain is completely relieved, it is checked if the tooth can be hermetically sealed. This is done by placing a temporary filling and the lavages are replaced by insertion of specific medicaments (drugs) in the root canals, which remain there for several days. If there are no problems – no pain or discomfort in the tooth – the dentist proceeds towards root canal obturation and completion of treatment.

In chronic periapical periodontitis (granuloma), the body’s immune system is strong enough not to allow the bacteria to cause acute inflammation, but it cannot battle the infection alone due to the continuous introduction of new bacteria in the open or incorrectly filled root canal. Chronic periapical periodontitis occur with minimal or no symptoms (mild pain or discomfort in the tooth when chewing). The conventional root canal treatment is the treatment of choice in this case as well. After completion of the treatment of the periapical periodontitis, an X-ray picture is done that shows whether the end of the root canal is filled correctly. In chronic periapical periodontitis (granuloma) after the root canal is filled, the healing process is followed every 6 months through X-ray pictures, where special attention is paid to check if there is reduction of the size of the granuloma or the cyst. In some cases, the bacteria are highly aggressive and resistant so the endodontic treatment is not sufficient and a surgical removal of the granuloma is required by apical osteotomy or hemisection.

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