perio-endo and periodontal abscess Flashcards
3 most common reasons for people to attend dentist
- Periapical
- Pericoronal
- Periodontal
gingival abscess
no attachment loss
periodontal abscess
associated with periodontal bone loss
2 periodontal infection classifications in acute periodontal conditions
- gingival abscess
- periodontal abscess
4 types of abscesses of periodontium
gingival abscess
periodontal abscess
pericoronal abscess
endodontic-periodontal lesion
gingival abscess
- Localised to gingival margin
- Cause trauma, food impaction, stitch abscess if surgery recent
- Localised to gingival not associated with gingivitis
periodontal abscess
usually related to preexisting deep pocket also associated with food packing and tightening of gingival margin post HPT
- coronal tighten
- less flow of plaque and bacteria/toxins/neutrophil out of gingival crevice
- gets trapped in depth of pocket causes change in environment in depth of pocket = acute infection
pericoronal abscess
- associated with partially erupted tooth most commonly 8s (oral surgery)
endodontic-periodontal lesion
- tooth is suffering from varying degrees of endodontic and periodontal disease co-existing
SDCEP definition of periodontal abscess
Infection in a periodontal pocket which can be acute or chronic and asymptomatic if freely draining (SDCEP)
- Pus is oozing out – somewhere to go = no pressure building up
periodontal abscess effect
Rapid destruction of periodontal tissues, with a negative effect on the prognosis of the affected tooth
- Chronic inflammatory process of periodontitis – many years*
- Acute infection with suppuration – increased rate*
do periodontal abscessed teeth get extracted
yes
45% of teeth with periodontal abscess found during periodontal maintenance were extracted (main reason)
-
Suppurating, causing issues = extract
- Benefit to extract the tooth outweighs trying to treat the recurrent abscesses
10 signs and symptoms of periodontal abscess
- Swelling
- Pain usually less than periapical
- Tooth may be TTP in lateral direction rather than tapping on the top
- Deep periodontal pocket
- Bleeding
- Suppuration as it is an abscess
- Enlarged regional lymph nodes regional lymphadenopathy
- Fever
- Tooth usually vital problem lies in periodontium rather than pulpal space
- Commonly pre-existing periodontal disease most common reason
where is the pathology here
- Lower right 3*
- Between 3 and 2 localised small swelling*
- Not far down enough to be related to apex – periodontium*
- Check clinical probing depth, sensibility, radiograph*
- White lump between centrals – healed sinus, bony defect*
why do yuo want to carry out careful sub-gingival instrumentation short of the base of the pocket
to avoid iatrogenic damage
don’t want to be too aggressive
- may remove progenitor cells
- Down to bone – recession rather than healing (avoid going done to base of pocket)
SDCEP local measures of peirodontal abscess management
- Carry out careful sub-gingival instrumentation short of the base of the periodontal pocket to avoid iatrogenic damage; local anaesthesia may be required.
- If pus is present in a periodontal abscess, drain by incision or through the periodontal pocket.
- Probe in to try and let it drain
- Recommend optimal analgesia.
- Do not prescribe antibiotics unless there are signs of spreading infection or systemic involvement.
- Recommend the use of 0.2% chlorhexidine mouthwash until the acute symptoms subside.
Following acute management, review and carry out definitive periodontal instrumentation and arrange an appropriate recall interval.
signs of spreading infection or systemic involvement
require AB
Fever, lymphadenopathy, extra oral swelling – rare in periodontal abscess
when can systemic antibiotics be given as tx for periodontal abscess
Only if signs of spread and systemic effects or if symptoms do not resolve with local measures
- Careful RSD
- Penicillin V 250mg(preferred) or Amoxicillin 500mg 5 days
- Narrower spectrum antibiotic – cause less resistance
Or (if allergic to penicillin)
- Metronidazole 400mg 5 days
MUST only be used in conjunction with mechanical therapy in order to reduce the bacterial load and disrupt the biofilm
perio endo lesion aetiology
more complex
involve both pulpal tissues and periodontal tissues
Teeth often have more than one thing going on
- Deep restorations with endodontic pins
- Chronic periodontitis
endo-periosteal lesions
pathological communication between the endodontic and periodontal tissues of a given tooth
what happends to periodontium in perio-endo lesion
Normally periodontium is intact – cuff around the tooth
- Coalescesd together = problem
Initial presentation – not much different – pain, swelling, suppuration, BOP
Can see access cavity through the gold onlay
Localised gingival swelling
Examine entire tooth and cause of it
dentine connection
not solid
porous substance, dentinal tubules – bacteria can go through
communication between periodontal and periapical tissues can be
microscopic or macroscopic
- dentine
- lateral and/or apical canals
- caries/trauma breach pulpal space leach to PDL
- infection via PDL breach pulpal space
- fractures
- iatrogenic damage
*
acute perio-endo infection causes (2)
- Trauma
- Dentoalveolar – significant amount causes perio-endo communication
- Root fractures
- Resorption in longer term
- Dentoalveolar – significant amount causes perio-endo communication
- Perforation
- One cone in canal, other out of canal in mesial aspect and into periodontal tissue (iatrogenic damage)
chronic perio-endo lesion cause
pre-existing periodontitis
- slow and chronic progression without evident symptoms
9 signs of perio-endo lesions
- deep periodontal pockets reaching or close to the apex
- negative or altered response to pulp vitality tests
- bone resorption in the apical or furcation region
- horizontal, apical, furcation
- spontaneous pain
- Pain on palpation and percussion
- Purulent exudate
- tooth mobility
- reduced periodontal support
- sinus tract
- draining buccal or palatal to the tooth
- crown, and gingival colour alterations
- dark, red, brown, blue possible
different ways of PDL-pulpal communication
lateral canals
furcal canal
apical foramen
perio develops to perio endo
describe a
necrotic pulp has bacteria, pus, infection
rather than discharging buccally (more common) it is discharging up through PDL (left) and on the right a cervical lateral canal – discharge into PDL – pocketing
- necrotic tooth can exude bacteria into PDL and cause inflammatory response causing increase in clinical probing depth
periodontal tx
describe B
microscopic level between floor of and furcation (furcal canal) – furcation disease – see furcal pathology rather than periapical on radiograph
Periodontal tx
descrive C
necrotic pulp pus oozing up through ligament – not root canal treated,
plaque mineralises becomes calculus – contaminated root surface
- (from top down – plaque in mouth; and bottom up – apex)
impact of good root canal treatment = will not get complete bony healing because there is still plaque covering root surface
- need endodontic treatment and subsequent periodontal treatment
describe D
periodontitis is very severe – tooth unrestored, pulp vital,
perio-endo lesion because as periodontal pocket developed to the apex – pulp get infected with bacteria from pocket = detrimental impact.
Start with perio and end with perio-endo lesion
exposed dentinal tubules
- application of soluble material from bacterial plaque to exposed dentin can cause pulpal inflammation
- normally covered over with cementum in health
- Exposure of dentin at the cemento– enamel junction occurs in about 18% of teeth in general and in 25% of anterior teeth in particular
- potential for ingress of bacteria and their products
lateral and accessory canals occurance
30–40% of all teeth have lateral and accessory canals,
- 17% of teeth presented multiple canal systems in the apical third of the root, about 9% in the middle third and fewer than 2% in the coronal third
- Apical third – not normally affect by mild-moderate periodontitis
- Contaminated with periodontal bacteria = infect pulp
study
- Only 2% of lateral and accessory canals were associated with the involved periodontal pocket
- Doesn’t happen often – body protection
- Not normally result in periodontal pocket
furcal canals occurance
furcation of molars may also be a direct pathway of communication between the pulp and the periodontium
- The incidence of furcal canals may vary from 23% to 76%.
- Not all of these canals extend the full length from the pulp chamber to the floor of the furcation
furcal/lateral communication
Pulp space with cleft through the tooth – communication
- Pulpal inflammation may cause an inflammatory reaction in the interradicular periodontal tissues.
patent small portals of exit are a potential pathway for:
- microorganisms
- toxic by-products
Pulp to the periodontal ligament and vice versa (non-vital or inflamed)
apical foramen communcation
Main route of communication between the pulp and the periodontium
- Non-vital tooth with necrotic contents to inflame PDL
- Microbial and inflammatory by-products
- Or PDL to progress to apex and bacteria to ingress cause pathology
- portal of entry for inflammatory by-products
perforation effect
- communication between the root-canal system and either peri-radicular tissues, periodontal ligament or the oral cavity.
possible causes of perforation (3)
-
extensive dental caries
- tooth unrestorable – need ex
- Dress the tooth – inform pt and make arrangement for extract
- tooth unrestorable – need ex
-
resorption
- tooth eaten away out in our in out due to communication - not see until investigate
-
operator error
- e.g. root-canal instrumentation or post preparation
- Iatrogenic
- Off course of canal
developmental groove
what and where
- invagination
- vertical developmental radicular groove
- Especially upper incisors
developmental groove effect on PDL
If epithelial attachment remains intact, the periodontium remains healthy but if attachment is breached the groove becomes contaminated, a self-sustaining infrabony pocket can form along its entire length
- Rapid severe localised attachment loss down length of groove
- provides a place for accumulation of bacterial biofilm and a route for the progression of periodontitis that may also affect the pulp if it extends to the apex.
Radiographically, the area of bone destruction follows the course of the groove
developmental groove leading to perio endo lesion
if attachment is breached the groove becomes contaminated, a self-sustaining infrabony pocket can form along its entire length
- Rapid severe localised attachment loss down length of groove
- provides a place for accumulation of bacterial biofilm and a route for the progression of periodontitis that may also affect the pulp if it extends to the apex.
Radiographically, the area of bone destruction follows the course of the groove
2018 classification first assesses
endo-periosteal lesion with or without root damage
possible diagnoses for endo-periostal lesion with root damage (3)
root fracture or cracking (vertical)
root canal or pulp chamber perforation
external root resorption
prognosis of perio endo due to root damage
poor
endo-perio lesions with no root damage then looks at
if pt a periodontitis pt
3 grades for endo-perio lesions with no root damage and pt is/isn’t periodontitis pt
grade 1 - narrow deep periodontal pcoket in 1 tooth surface
grade 2 - wide deep periodontal pocket in 1 tooth surface
grade 3 - deep periodontal pockets in more than 1 tooth surface
4 possible endo-perio lesion associated with trauma and iatrogenic factors
- root/pulp chamber furcation perforation
- e.g. because of root canal instrumentation or to tooth preparation for post‐retained restorations
- root fracture or cracking
- e.g., because of trauma or tooth preparation for post‐retained restorations - failed
- external root resorption
- e.g., because of trauma, idiopathic cervical root resorption
- pulp necrosis
- e.g. because of trauma
- draining through periodontium
SDCEP tx for perio endo lesions
Carry out endodontic treatment of the affected tooth (non-vital)
- Recommend optimal analgesia.
- Do not prescribe antibiotics unless there are signs of spreading infection or systemic involvement.
- Recommend the use of 0.2% chlorhexidine mouthwash until the acute symptoms subside.
Following acute management of the lesion, review within ten days and then carry out supra- and sub-gingival instrumentation if necessary and arrange an appropriate recall interval
tx sequence for perio-endo lesions
endo tx precedes periodontal tx
- allow tissues to heal a bit before RSD – hopefully allow some long junctional epithelium attachment
- but root still colonised by plaque so needs RSD
then may be necessary for
- Surgical investigation and treatment
- cracked, perforations, enamel pearns, invaginations etc
- lift flap to carry out more advanced tx
tx sequence for endodontic lesion
endo tx only will be sufficient to allow healing (root not colonised yet by plaque)
possible addtional treatment for EPL
more abnormal extraradicular - enamel pearls, invaginations etc
- Non surgical scaling unlikely to be successful
- Surgical instrumentation and mechanical removal needed
- Sometimes more advanced techniques – need special training
- Guided tissue regeneration
- Emdogain
issue here
Tooth prev RCT
Large furcation involvement – need re RCT treated
Primarily endo lesion – redo and wait for healing to reassess
Multiple lateral canals
New RCT has lead to furcal healing
issue here and how was it addressed
Moderate to severe cervical bone loss
- Endo tx improvement in intraradicualr area – healing taken place
- Combined lesion
Bone loss as a result of apical destruction – heal through good RCT
BUT
- 6 months post op
- Still deep pocketing – GP point
- Still got ongoing suppuration to do with distal root – think of more complex interventions
technique here
Open flap debridement
Bone loss limited around distal aspect
Peroration through buccal
Crater/gutter around distal root
- remove granulation tissue and perio tx (endo done already)
what tx here
localised severe walled defect
not responded to initial Endo tx alone
- flap raised
- granuloma removed
- bone substitute placed to fill in gap
- guided tissue regeneration – filler scaffold for bony healing
= reduction in clinical probing depth
tx here
- Significant distal bone loss*
- Membrane used for guided tissue regeneration*
- Need specialist level of skill*
does endodontic disease affect periodontal health
- When the pulp becomes infected, it elicits an inflammatory response in the periodontal ligament at the apical foramen and/or adjacent to openings of the small portals of exit
- Non-vital tooth – detriment to perio? Yes*
study
- endo infection in mandibular molars was associated with more attachment loss in the furcal area.
- endo infection in molars associated with periodontal disease might enhance periodontitis progression by spreading pathogens through accessory canals and dentinal tubules.
- endo tx successfully, the perio disease disappeared.
does periodontal disease affect endodontics
Controversial, Many conflicting studies
- no effect on the pulp, at least until it involves the apex
- or lateral/accessory canal
- Bacteria access through the lateral or accessory canal into the pulp causing chronic inflammation and possibly pulp necrosis.
- If protected by cementum, necrosis usually does not occur.
- If the blood supply from the apical foramen is still intact, the pulp will remain vital
- if during scaling, curettage or periodontal surgery accessory canals are severed and/ or opened to the oral environment then invasion can occur
Periodontal disease on the pulp is degenerative and causes calcification, fibrosis and collagen resorption, as well as a direct inflammatory affect
