The endodontic-periodontic lesion Flashcards
How do you get a perio-endo infection?
Get infection from the PDL going into the pulp - the pocket can extend to the apex of the tooth or via a lateral canal bacteria gains access to the pulp
Then get pulpitis -> periapical pathology
What is the steps to getting pulpal infection/necrosis from perio disease?
Pathogenic bacteria and inflammatory products of perio disease -> accessory canals/apical foramen -> pulpal infection/necrosis
What are the steps for getting infection from the pulp to the PDL?
Pulpal disease/procedural errors in RCT/ Perforations/ vertical root fractures -> Dentinal tubules/peri-radicular inflammation -> bone loss +/ CAL + / pus discharge
Rather than draining into a sinus, it drains through the PDL - get periodontitis
What is a primary endo, secondary perio lesion?
Originally an endo lesion, the infection spreads from the apex along the root to the gingiva
Pulpal infection can also spread from accessory canals along the gingiva or furcation
What is a primary perio, secondary endo lesion?
A periodontal pocket can deepen to the apex and secondarily involve the pulp
Alternatively, a perio pocket can infect the pulp through a lateral canal
What is a true combined lesion?
2 independent lesions (periapical and periodontal) can coexist and eventually fuse with each other - the 2 may or may not combine
What other classification of a true combined lesion allows you to decide where the original source of the infection is from
Whether on a radiograph the endodontic and periodontal lesions have communication or not
How does knowing whether the lesions are communicating suggest?
Non-communicating suggests the true combined lesion has independent aetiologies
What are the possible options for how a combined lesion started?
May be true combined which have merged or lesions that started as perio or endo and then spread to the other
What does knowing the original source of the infection allow?
Can have an implication for the management and prognosis of the case
How do you get to a diagnosis?
History
Examination
Special tests
Other tests
What is involved in an endodontic examination?
Restorative status - whether restorable
TTP
Tenderness in sulcus
Swelling/sinus
What is involved in a periodontal examination?
Probing around the tooth - easy to miss
Pus discharge from the pocket
Mobility
What are the 2 sensibility tests?
Cold testing
EPT
Need to be negative to both to confirm it is non-vital
What is the most appropriate radiograph to take?
Periapical
What is seen on the radiogrpah?
A vertical periodontal defect often present
A radiolucency around the apex
A J-shaped lesion may be present - bone loss that extends down the root and around the apex, but only on one side
When would an OPT be used?
if multiple sites needed to be radiographed - for periodontal assessment
When would a CBCT scan be indicated?
When conventional radiography does not provide sufficient detail
e.g. complex 3D anatomy or suspicion of other causes; resorption or perforation
What other tests can be done?
Consider tooth sleuth and transillumination to rule out root fracture
Teeth with fractures and cracks are present with J shaped lesions and non-vital pulp
What symptoms may you associate with a perio-endo lesion
Swelling of the gingiva Pus discharge Pocket formation Fistula tract (sinus) TTP Mobility
What is the treatment for primary endo, secondary perio lesion?
RCT only
What is the treatment for primary perio secondary endo lesion?
RCT and periodontal therapy
What is the treatment for true combined leisons?
RCT and periodontal therapy
What is the rationale for primary endo, secondary perio lesions
They have an endodontic aetiology: dead pulp and periapical infection draining down the PDL - if do RCT the sinus will heal up, then get reattchment of the PDL
What is the appearance of the perio lesion due to primary endo infection?
Usually presents as a narrow defect - narrow, not conductive to instrumentation
When do you review the perio lesion?
After 3 months, instigate non-surgical periodontal therapy if the pocketing is still present
If after another 3 months, no resolution, then consider surgical intervention, may need to lift flap
What is the rationale for primary perio, secondary endo lesions
Has a periodontal aetiology but tooth has become non-vital so requires RCT
Have a deep perio pocket established perio disease caused an endo infection
Both therapies are required - best to undertake these simultaneously - to eradicate as much bacteria in one go as possible
When do you review the primary perio, secondary endo lesions?
3 months and instigate further non-surgical periodontal therapy if the pocketing is still present
Review after another 3 months, if still no resolution, then consider surgical intervention or reconsider diagnosis
What is the rationale for the treatment of a true combined lesion?
Have both a perio and an endo aetiology
Need to treat the perio and endo - best to do this simultaneously
Review after 3 months
What is an alternative management option for perio-endo lesion involving calcium hydroxide?
Place calcium hydroxide inside the prepared canal rather than obturating whilst assessing the response to periodontal therapy
do the periodontal therapy, if this has worked, can then obturate after
Is this method better?
No evidence to suggest this is more effective
What other alternative to management of perio-endo lesion?
Surgical intervention may be indicated earlier if have very deep pockets not conductive to non-surgical periodontal therapy
what is an involvement for management if the tooth is a molar?
If one root is more affected than the other can do root-resction or hesmisection on that root and do RCT on the root youre keeping.
The root will support the tooth if there is enough bone around it
What is a root resection
just the root is removed
Is taken on the mesio-buccla or disto-buccal roots of the molar
What is a hemisection?
Section of the tooth is removed as well as as the root
Undertaken on lower molars
What are the prognosis’ of each one?
Primary endo = good
Primary perio and true combined = prognosis depends on extend of periodontal bone loss
What can developmental grooves lead to?
Can predispose to formation of a deep periodontal pocket which can extend to the apex, if untreated cab result in pulp death
How do you manage a periodontal pocket developed from a developmental groove?
Endodontic treatment
and periodontal therapy, surgery may be required due to the groove - surgical bone removal to expose the defect, repair it, add biogide
What is biogide?
Synthetic bone and collagen to repair the bone in the area
When can perforations occur?
During endodontic treatment, placement of an endodontic post or dentine pin
What can perforations give the appearance of?
Perio-endo lesion as infection will develop around the perforation site and may drain through the pocket that forms via the PDL
How can the perforation appear clinically?
Deep pocket leading to the site of perforation
How does the perforation appear radiograpically?
Leads to bone loss, may be radiographically visible
What is the management of a perforation
Assess the restorability of the tooth
if restorable, the tooth will require repair of perforation internally or externally using a biocompatible material: MTA or biodentine
Undertaken by an endodontist
How may a fracture present?
And radiographically
Similar to perio-endo lesion: narrow, deep, isolated periodontal pocket
A J shaped lesion radiographically
What is the management of a fracture?
Need to assess the extent of the facture
Vertical fracture that extends on to the root face will require extraction
If only extends to the ACJ - then still restorable
What are the different root resorption?
External: cervical resorption, replacement resorption
Or internal
What is the aetiology of external cervical root resorption?
unknown
Orthodontics/internal bleaching/trauma
Dentinoclasts form on the outside of the tooth if have lost some cementum
Where does external cervical root resorption start?
Subgingivally in the cervical region
How does external cervical root resorption present clinically?
Pulp is vital
Asymptomatic
pocketing may be present around the tooth - not deep because fills with gingival tissue
How does external cervical root resorption present radiographically?
Mottled appearance just below bone level
What is the treatment of external cervical root resorption?
Surgical exploration followed by repair
May or may not need endo treatment
What is the surgical treatment of external cervical root resorption?
if extends into the pulp,
need to keep the canal patent by putting in a GP, then put restoration, go back and do the RCT
Or can repair internally first with some MTA, do the RCT then do the restoration
How would an internal lesion appear radiographically?
The root canal will balloon out and lose the line of the root canal
What is external replacement resorption?
Root surface is gradually replaces with bone = ankylosis
Can be self-limiting and transient but will progress until complete root replacement occurs
How does external replacement resorption present clinically?
A catch present at the gingival margin - mimic perio-endo
mottled appearance on the whole root surface
High pitched, metallic sound on percussion
What is internal root resorption?
Occurs within the canal system, results in ovoid expansion of the root canal
The outline of canal is lost around area of resorption
How does internal root resorption appear clinically?
Pulp will be chronically inflamed,
A pink spot lesion will appear through the enamel
In internal root resorption the tooth is partially vital what symptoms does the patient feel and why?
Symptoms of pulpitis
Vital tissue needed to form the dentinoclasts to eat away
Nectrotic pulp acts as a source of irritant - then the whole pulp dies
It can stop before it penetrates
What can happen if the internal root resorption continues to expand and perforates the root?
a periodontal lesion may form
What obturation technique is used to fill the root canal that has been resorbed internally?
Thermal obturation - backfill with molten GP
If expanded to extent that has perforated the side of tooth, has poor prognosis
