10. Challenges In Endodontics

Question 1

What are endo-periodontal lesions and how do they form?

Answer 1

Endo-perio lesions (EPL) refer to conditions associated with the microbial contamination of both the pulpal and periodontal tissues. This can be due to endodontic and/or periodontal infections, trauma or iatrogenic factors.

Question 2

Describe the features and differential diagnosis of: Primary endodontic disease

Answer 2

• Necrotic pulp
• Presence of a pseudopocket which is a sinus tract of pulpal origin for drainage
• A deep solitary pocket in the absence of perio disease, described as a “broad based pocket” or “narrow pocket that lacks width”

Differential diagnosis: Cracked tooth, Vertical Root Fracture

Question 3

Describe the features and differential diagnosis of: Primary periodontal disease

Answer 3

• Periodontitis progresses apically with the presence of plaque and calculus
• Presents as “narrow-based pockets” or wider pockets
• Has radiographic angular bone loss
• Lesion often involves adjacent teeth
• Normal pulpal responses to tests

Differential diagnosis: Developmental anomalies

Question 4

Describe the features and differential diagnosis of: Primary endodontic disease with periodontal involvement.

Answer 4

• Untreated suppurating endo disease for prolonged period
• Plaque at sinus tract leads to marginal breakdown
• Adjacent teeth may not be involved
• Negative pulp tests

Differential diagnosis: Root fracture, root perforation

Question 5

Describe the features and differential diagnosis of: Primary periodontal disease with endodontic involvement.

Answer 5

• Progression of perio pocket until apical foramen is involved
• Necrosis occurs if neurovascular supply of pulp succumbs to perio disease
• Generalized periodontitis with angular bone loss
• Complaints of pulpal pain seen in early pulpal involvement

Question 6

Describe the features and differential diagnosis of: Combined endo-perio lesion

Answer 6

• Endo lesion progressing coronally joins with perio lesion progressing apically
• Attachment loss is severe
• Presence of necrotic pulp
• Pocket has the characteristics of a perio pocket (wide and narrow-based)

Differential diagnosis: Vertical root fracture

Question 7

How does the prognosis differ for different perio-endo involved teeth?

Answer 7

• Prognosis better with primary endo lesions
• Prognosis better for multi-rooted teeth
• For multi-rooted teeth, root resection is a consideration

Question 8

What are the signs and symptoms of cracked teeth?

Answer 8

• Acute pain on mastication (during or upon release of bite)
• Sensitive to thermal changes
• Symptoms can range from slight to vere severe spontaneous pain, depending on the extent of the fracture to the pulp
• Pain can be referred

Question 9

What are the tests we can use diagnose cracked teeth?

Answer 9

• Transillumination
• Staining
• Narrow periodontal probing depths
• Bite tests with wooden wedges
• Magnification

Note 1: Cracks usually not visible radiographically… Only hinted at by surrounding radiographic bone loss

Note 2: Cracks are considered findings, not diagnosis! Pulpal and periapical diagnosis have to be established