Perio-Endo and Periodontal Abscess

Question 1

what are the types of odontogenic or dental abscesses

Answer 1

• pericoronitis
• pulp necrosis
• endo-perio lesion
• periodontal infections

Question 2

what are periodontal infections split into

Answer 2

• gingival abscess

- periodontal abscess

Question 3

what are gingival abscesses

Answer 3

○ Localised to gingival margin

○ Most commonly as a result of trauma, maybe a result of food impaction
○ Or also potentially if the patient has had recent surgery it could be in the form of a stitch abscess

○ Localised infection within the gingiva but not associated with periodontal disease

Question 4

what are periodontal abscess

Answer 4

○ usually related to preexisting deep pocket
§ Ie patient already had pre/co-existing periodontal disease

○ also associated with food packing and tightening of gingival margin post HPT
§ Food can pack into the deep pockets present in the disease

Question 5

why can periodontal abscess occur after hygiene phase therapy

Answer 5

Sometimes after initial hygiene phase therapy you can get a tightening of the gingiva cuff coronally and there will be less of a flow of plaque and bacteria and their toxins and neutrophils out of the gingival crevice

Ie the material gets trapped in the depths of the pockets rather than being able to flow out of the inflamed pocket

Causes a change in the environment of that deep pocket and this can become an acute infection

Question 6

what is a pericoronal abscess

Answer 6

associated with partially erupted tooth most commonly 8s

More dealt with by oral surgery

Question 7

what is an Endodontic-periodontal lesion

Answer 7

tooth is suffering from varying degrees of endodontic and periodontal disease
These diseases are co-existing

Question 8

define periodontal abscess

Answer 8

Infection in a periodontal pocket which can be acute or chronic and asymptomatic if freely draining

If the pus is oozing out and it has somewhere to go then there is no pressure build up therefore patients are often unaware of the infection

Question 9

what is the 3rd most prevalent infection

Answer 9

Periodontal Abscess represents approximately 7.7–14.0% of all dental emergencies
Periodontal Abscess is ranked the third most prevalent infection demanding emergency treatment, after dentoalveolar abscesses and pericoronitis

Question 10

what happens if the patient has a periodontal abscess

Answer 10

Rapid destruction of periodontal tissues, with a negative effect on the prognosis of the affected tooth

○ This production of neutrophils as an acute infection causes rapid destruction of the periodontal tissues
○ Ordinarily, the chronic inflammatory process of periodontal disease / periodontitis is something which occurs over months / years / even decades
○ But with an acute infection with suppuration there is a greatly increased destruction of the periodontal tissues
○ This can have a very negative effect of the prognosis of the affected tooth

Question 11

what teeth are most likely to be extracted during periodontal maintenance

Answer 11

Teeth with a periodontal abscess

During periodontal maintenance these are the teeth that are most likely to be extracted because of recurrent periodontal abscesses

Question 12

what are the signs and symptoms of periodontal abscesses

Answer 12

• Swelling of the gingival margin

• Pain
[this is variable, It is usually less sore than a periapical abscess]

• Tooth may be TTP in lateral direction
• Deep periodontal pocket
• Bleeding
• Suppuration
• Enlarged regional lymph nodes

• Fever
[in severe or spreading cases]

• Tooth usually vital
[the problem lies within the periodontium rather than in the pulp]

• Commonly pre-existing periodontal disease
○ Usually always has to be a reason for a periodontal abscess occurring and this is usually it

Question 13

why might there be enlarged regional lymph nodes in patients with periodontal abscess

Answer 13

Sometime as result of a localised infection there can be response in the regional lymph nodes so there might be some regional lymphadenopathy

Question 14

how does a periodontal abscess present clinically

Answer 14

• Small,
• localised,
• fluctuant swelling,
• deep pocket,
• BOP and
• suppuration when you probe the tooth

Question 15

what is the treatment of a periodontal abscess

Answer 15

• Carry out careful sub-gingival instrumentation short of the base of the periodontal pocket
[local anaesthesia may be required]

• If pus is present in a periodontal abscess, drain by incision or through the periodontal pocket.
• 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.
[Antiseptic mouthwash]

• Following acute management, review and carry out definitive periodontal instrumentation and arrange an appropriate recall interval.

Question 16

why should we carry out sub-gingival instrumentation short of the base of the periodontal pocket

Answer 16

to avoid iatrogenic damage;

Stop short of the periodontal pocket because the attachment is going to be very friable and easily damaged because of the inflammation and infection

So if we aggressively curette down to bone then the chances are we are going to get a lot more recession rather than healing in that area

Question 17

how can you sometimes easily drain the pus from the periodontal abscess

Answer 17

Quite often dilating the pocket with a probe and giving it a little press will cause the pus to just ooze up out of the pocket so you are able to drain it entirely that way

Question 18

what are symptoms of systemic involvement or spreading infection

Answer 18

Systemic involvement such as fever, lymphadenopathy or extra-oral swelling which is actually pretty rare in purely periodontal abscesses

Question 19

what should be reviewed and decided at recall appointments

Answer 19

○ Review the patient’s situation when they are not in pain and some healing has taken place

○ At this point carry out some more definitive periodontal instrumentation

○ Then decide on where you go with future maintenance and recall

Question 20

what sort of instrumentation do we not want in treatment of a periodontal abscesses

Answer 20

○ Don’t want aggressive instrumentation

○ But we do need some careful subgingival instrumentation

Question 21

when should antibiotics be prescribed

Answer 21

Only if signs of spread and systemic effects or if symptoms do not resolve with local measures

Question 22

what treatment must be carried out alongside prescribing antibiotics

Answer 22

Careful RSD

antibiotics MUST only be used in conjunction with mechanical therapy in order to reduce the bacterial load and disrupt the biofilm

Question 23

what antibiotics can be prescribed for the treatment of periodontal abscess

Answer 23

○ Penicillin V 250mg(preferred) or Amoxicillin 500mg 5 days
§ First line = penicillin V
§ Then amoxicillin is an acceptable alternative

Or

○ Metronidazole 400mg 5 days
§ Used if the patient is allergic to penicillin

Question 24

why is the use of penicillin V encouraged

Answer 24

§ Trying to encourage the use of penicillin V because it is a more narrow spectrum antibiotic so we would expect it to cause less resistance
§ It is an effective antibiotic and preferred over broad spectrum antibiotics

Question 25

if the patient is not ill, what is the routine treatment of periodontal abscesses

Answer 25

So in the absence of an ill patient with a spreading facial swelling then you are almost always carrying out local debridement plus / minus incision and drainage, with antiseptic mouthwash and analgesia then review

Question 26

what is an endo-periodontal lesion (EPL)

Answer 26

EPL is a pathological communication between the endodontic and periodontal tissues of a given tooth

Question 27

What is the normal relationship between the pulp and periodontal tissues

Answer 27

○ Periodontium is intact
○ There is a cuff around the neck of the tooth
○ Periapical tissues are 10-20mm away
○ The 2 tissues are completely separate

Question 28

what does the initial presentation of an EPL look like

Answer 28

○ Pain 
○ Swelling 
○ Pocketing 
○ Suppuration
○ BOP
○ Localised gingival swelling

Question 29

are periodontal disease and Endodontics disease linked

Answer 29

• There are both microscopic and macroscopic communications between the periodontal and periapical and pulpal tissues
• Dentinal tubules:
  ○ Dentine is not solid and is a porous substance
  ○ The pores / dentine tubules are large enough for bacteria and their products to go through
• There are lateral and apical canals
• There can be fractures
• Possible iatrogenic damage and perforation

There are potential routes of communication that would link periodontal disease and endodontic disease

• Can have caries / trauma which in some way breaches the pulpal space
  ○ May be a hairline crack
  ○ Or a significant carious lesion
• Can also get infection through the PDL
  ○ Periodontal disease works its way down the inside of the PDL
  ○ And as a result of that it will either communicate with lateral canals or if it gets severe enough it will work it’s way to the apex to then have an adverse effect on the pulp within

Question 30

what are the 4 components of the periodontium

Answer 30

• gum or gingiva
  > pink, visible cover
• PDL
  > attachment fibres fastening tooth to the bone
• cementum
  > covering and holding the root
• alveolar bone
  > where the root is anchored

Question 31

what are the possible routes leading to periapical infection

Answer 31

• infection via carious cavity or traumatised crown
• infection via PDL
• infected or necrotic pulp

Question 32

what are the acute causes of perio-endo lesions

Answer 32

○ Trauma
§ Significant amount of dento-alveolar trauma results in perio-end communication
§ Vertical and horizontal root fractures
§ Even in the longer term where there could be resorption which subsequently leads to a communication

○ Perforation
§ Patient can be having routine endodontic treatment carried out and then something goes wrong
§ Caused be iatrogenic damage during endodontic treatment

Question 33

what are the chronic causes of perio-endo lesions

Answer 33

○ Pre-existing periodontitis

○ slow and chronic progression without evident symptoms

Question 34

what are the signs and symptoms in EPL

Answer 34

• deep periodontal pockets reaching or close to the apex
[Several mm, even all the way down to the apex]

• negative or altered response to pulp vitality tests

• bone resorption in the apical or furcation region
[In horizontal and alveolar bone]

• spontaneous pain
• Pain on palpation and percussion
• Purulent exudate

• tooth mobility
○ Because of the extent of the bone loss that these teeth have experienced, they often have a hugely reduced periodontium support which in turn leads to mobility

• sinus tract
○ Can be draining buccal or palatal / lingual to the tooth

• crown, and gingival colour alterations
Non-vital teeth may be dark / red / brown / black / blue
[often discolour]

Question 35

What happens when a necrotic pulp discharges through the PDL

Answer 35

○ bacteria, pus and infection which is coming out of the apex of the tooth and discharging up through the PDL

○ Coming out of the apex and oozing up through the PDL space

○ which is resulting in pocketing and bone loss

○A non-vital tooth can exudate bacteria, their products, and the inflammatory response (the pus exudate) exit out of the communications and causes increase in clinical probing depths

Question 36

what happens when a tooth has a necrotic pulp and a furcal canal

Answer 36

○ It is very common (at least on a microscopic level) to have a communication between the floor of the pulp chamber and the furcation

○ If you have a non-vital / necrotic tooth, then the bacteria and their products can make their way through the furcal canal and cause furcation disease

○ Can present on a radiograph as radiographic bone loss at the furcation rather than down at the apex

Question 37

how can you treat a necrotic pulp with either a furcal canal or when it discharges through the PDL

Answer 37

Because there is no contamination of the root surface they will both heal entirely with just endodontic treatment

Question 38

what happens if the pulp is necrotic but is not root canal treated and the plaque is subsequently allowed to mineralise on the root surface

Answer 38

there is a contaminated root surface which is now being contaminated from the top down (from the plaque in the mouth) as well as from the bottom up

This is going to have an impact on the treatment that is going to be required
□ Would not get complete bony healing and pocket closure by just root canal treating this tooth because there is still another source of infection

Root surface is covered in plaque so even if you address the apical problem, you are not going to get reapposition of the periodontal ligament back onto the contaminated space of the root

Need to carry out root canal treatment and subgingival instrumentation (periodontal treatment) in order to get periodontal healing

Question 39

what happens when the tooth is vital but the periodontitis is really severe

Answer 39

○ The tooth is presumably unrestored and hasn’t been traumatised and there are no dental caries

○ There is a perio-endo lesion because the periodontitis and the pocket has developed down the tooth until such times that it involves the apex

○ Then when the pulp gets infected by the bacteria now present at the apex, it will potentially have a detrimental impact on the pulp

○ Start off with perio and finish with perio accompanied by a potential endo problem

Question 40

what is important to remember about dentinal tubules

Answer 40

dentine tubules are open and patent and are a potential place of ingress for bacteria

Question 41

how common are lateral / accessory canals

Answer 41

30–40% of all teeth have lateral and accessory canals, majority are found in the apical third of the root

○ But there are lateral canals that can occur throughout the whole length of the root of the tooth
○ 10% of teeth will have a lateral canal in the middle or coronal third of the tooth
So if these lateral canals get contaminated with periodontal bacteria they can then infect the pulp

Question 42

what are furcal canals

Answer 42

The furcation of molars may also be a direct pathway of communication between the pulp and the periodontium

Communications between the furcation (floor of the pulp) into the inter-radicular bone

Question 43

what are the problems with furcal / lateral communication with periodontal tissues

Answer 43

• 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

Question 44

what is the main route (and largest) of communication between the pulp and the periodontium

Answer 44

apical foramen

Question 45

what can exit the apical foramen

Answer 45

Microbial and inflammatory by-products may exit the apical foramen causing periradicular pathoses

It is possible for the non-vital tooth with necrotic material within it to inflame and infect the periodontal tissues

Question 46

what can enter the apical foramen

Answer 46

The apex is a portal of entry for inflammatory by-products from deep periodontal pockets to affect the pulp

when the periodontitis is really severe and works all the way down to the apex of the tooth, once it reaches the apical foramen there is the potential for loss of vitality of the tooth due to microbial colonisation of the apical vasculature

Question 47

what does perforation result in

Answer 47

Results in communication between the root-canal system and either peri-radicular tissues, periodontal ligament or the oral cavity

Question 48

what causes perforation

Answer 48

○ extensive dental caries
§ After removing all the dental caries you might find that it is perforating into the PDL ~ tooth unrestorable so it is likely just have to extract this tooth now

○ resorption
§ Tooth has kind of been eaten away from the outside in (not the inside out) and when this is addressed a communication is discovered

○ operator error  
e.g. root-canal instrumentation or post preparation
Eg an inappropriately sized post
eg tooth at a fun angle 
eg sclerosed canal

Question 49

What would you do mid-treatment if you realised the tooth was unrestorable?

Answer 49

□ Either extract it at the time
□ Or (maybe more likely) dress the tooth and inform the patient before then making arrangements for an extraction and subsequent prosthetic replacement if appropriate

Question 50

what is a developmental groove

Answer 50

• invagination

* vertical developmental radicular groove especially upper incisors

Question 51

what happens if the epithelial attachment of the periodontal is breached what can happen to the developmental groove

Answer 51

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

In perfect health you can probe these invaginations and they don’t go anywhere as they are healthy and intact

But if the patient develops periodontitis and the epithelial attachment is breached then you can get very rapid and severe and localised attachment loss all the way down the length of that groove

This can then be really challenging to address because there is a groove on the root surface so would then find this root surface very hard to hea

Question 52

what does the developmental groove provide

Answer 52

The channel 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

Question 53

what is the 1972 classification of perio

Answer 53

• primary endodontic lesions
• primary periodontal lesions
• primary endodontic lesions with secondary periodontal involvement
  
  • primary periodontal lesions with secondary endodontic involvement
• “true” combined lesions.

Question 54

according to the old classification, what are primary Endodontic lesions

Answer 54

○ Single non vital tooth, likely restored, localised deep pocket
○ The tooth has died and as a result of that it has drained through the pocket and caused a deep pocket
§ So the tooth has died first and then it has infected the PDL

Question 55

according to the old classification, what are primary periodontal lesions

Answer 55

○ Generalised periodontitis, severe localised or generalised bone loss, pulp vital at this stage

○ Tooth was fine (vital and unrestored and no reason to assume it was dead), but the periodontitis extended to the severity that is affected the single deep pockets affecting the periapical tissue

Question 56

according to the old classification what are primary Endodontics lesions with secondary periodontal involvement

Answer 56

○ Sinus tract draining through the pocket becomes colonised with dental plaque biofilm, tooth likely restored and non vital

○ Started off as a dead tooth then it developed into periodontal involvement
§ Dead tooth which has been draining
§ It has been left ie there has been no treatment
§ Plaque and calculus have accumulated on the root
§ Then there is now subsequent / secondary periodontal involvement

○ Started as only a periapical problem but then because it got colonised by bacteria it then became a periodontal problem

Question 57

according to the old classification, what are primary periodontal lesions with secondary Endodontics involvement

Answer 57

○ Microbial colonisation of root surface, lateral canals and apical foramin leads to loss of pulpal vitality

○ Severe periodontitis then colonises the root surface and then gets in either through a lateral canal or it is all the way down at the apical foramen and secondarily causes a loss of pulpal vitality

○ The tooth loses vitality because of the severity of the periodontal disease

Question 58

according to the old classification, what are true combined lesions

Answer 58

○ endodontic disease progressing coronally joins with an infected periodontal pocket progressing apically

Question 59

how does the new classification classify EPL

Answer 59

An endo-perio lesion with root damage

An endo-perio lesion without root damage

Question 60

what are the grades used in the new classification

Answer 60

grade 1: narrow deep periodontal pocket 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

Question 61

if the patient has an EPL without root damage what do you then need to consider about the patient

Answer 61

Then you want to consider whether the patient had pre-existing periodontitis or whether these lesions have occurred in a patient who did not have periodontitis prior to this event
Ie looking at with or without periodontitis

Question 62

how can EPL be associated with trauma and iatrogenic factors

Answer 62

• root/pulp chamberfurcation 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)

• external root resorption
○ (e.g., because of trauma)

• pulp necrosis (e.g., because of trauma) draining through the periodontium

Question 63

how can root fracture or cracking occur

Answer 63

○ Might be due to acute trauma eg patient was in a fight or fell off their bike
○ Or can be more of a chronic issue where a tooth might have been restored with a post and that post has eventually failed resulting in longitudinal fracture of the tooth

Question 64

what can cause external root resorption

Answer 64

§ Most common reason is probably due to trauma

○ Can also be because of idiopathic root resorption or unknown causes

§ Sometimes due to orthodontics or bleaching

○ But usually cannot pin down why a patient has root resorption

Question 65

how do you treat EPL

Answer 65

• Carry out endodontic treatment of the affected tooth
○ The teeth which are 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 carry out supra- and sub-gingival instrumentation if necessary and arrange an appropriate recall interval

    ○ Endodontic treatment precedes the perio treatment   • Once things are a little bit better (ie the tissues have started to heal a little bit) then you can carry out your periodontal cleaning (supra and subgingival instrument) to then clean the root orifices to hopefully allow some long junctional epithelial reattachment

Question 66

when should the patient be reviewed

Answer 66

○ Once you have initiated endodontic treatment and prescribed antiseptic mouthwash with analgesia, review the patient

Question 67

what should be carried out at review appointments

Answer 67

○ And then at that stage carry out supra and sub gingival instrumentation

Question 68

what treatment is appropriate in cases where it has been primarily Endodontic and the root surfaces are not yet heavily colonised

Answer 68

In cases where it has been primarily endodontic and the root surfaces are not yet heaviliy colonised, endodontic treatment alone will be sufficient to cause the entire lesion to heal up because it is not a perio problem it is an endo problem

○ Even where it is an endo problem that has gotten secondarily infected, you will get healing apically by addressing the non-vital tooth

Once things are a little bit better (ie the tissues have started to heal a little bit) then you can carry out your periodontal cleaning (supra and subgingival instrument) to then clean the root orifices to hopefully allow some long junctional epithelial reattachment

Question 69

summarise treatment for EPL

Answer 69

• Primary endodontic therapy
• Periodontal therapy

• Surgical investigation and treatment
○ Sometimes this is required if there are cracks or perforations
○ With the more significantly damaged teeth we need to lift a flap to see what is going on in there before carrying out some more advanced treatment

Question 70

what addition treatment can be carried out for EPL

Answer 70

• Non surgical scaling unlikely to be successful
• Surgical instrumentation and mechanical removal
• Guided tissue regeneration
• Emdogain

Question 71

does Endodontic disease affect periodontal health

Answer 71

• 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

Question 72

If you have a non-vital tooth can it then make your perio worse?

Answer 72

When the pulp becomes infected it can elicit an inflammatory response in the PDL at the apical foramen or adjacent to any lateral canals
Therefore theoretically it is conceivable that endodontic disease (ie a non-vital tooth) might adversely affect the progression of periodontitis

Patients who are more susceptible to periodontitis and exhibited evidence of endodontic treatment failures showed an increase in marginal bone loss
○ So periodontal bone loss was increased in patients with endodontic infection

So even in the absence of acute perio-endo lesions, if a tooth is non-vital it is more likely to increase the rate of progression of periodontal disease

Endodontic disease does seem to have the potential to adversely affect periodontal health

Question 73

does periodontal disease affect endodontics

Answer 73

· Controversial

· Many conflicting studies

· no effect on the pulp, at least until it involves the apex
○ In terms of loss of vitality it probably doesn’t really happen until the apex is involved
○ So you have to have fairly severe periodontal disease that works its way all the way down to the apex before you have the loss of vitality

· Periodontal disease on the pulp is degenerative and causes calcification, fibrosis and collagen resorption, as well as a direct inflammatory affect
○ There are other effects shown that may be less severe and acute but may be more chronic
○ This calcification means that when the tooth does have an assault through caries or trauma that the pulp may be more likely to lose vitality rather than to maintain it’s vitality

· Pulp is usually not significantly affected by periodontal disease until recession affects a lateral or accessory canal to the mouth.

· Bacteria access through the lateral or accessory canal into the pulp causing chronic inflammation and possibly pulp necrosis.

· If the lateral or accessory canals are protected by cementum, necrosis usually does not occur. If the blood supply from the apical foramen is still intact, the pulp will remain vital

· Pathogenic invasion and secondary inflammation and necrosis of the pulp can occur if during scaling, curettage or periodontal surgery accessory canals are severed and/ or opened to the oral environment.