The endodontic periodontic lesion: a diagnostic dilemma Flashcards
Infection from PDL to pulp
Pathogenic bacteria and inflammatory products of perio –> accessory canal/ lateral canals/ apical foramen –> pulpal infection/ necrosis (retrograde pulpitis)
Infection from pulp to PDL
Pulpal disease Procedural errors in RCT Perforations Vertical root fractures -----> Dentinal tubules Peri-radicular inflammation --------> Bone loss + CAL +/- Pus discharge (retrograde periodontitis)
Simplified classification of endo-perio lesions (look at diagram)
Primary endo lesion + secondary perio lesion or Primary perio + secondary endo lesion or 'True' combined perio-endo lesion
Primary endo secondary perio lesion
Originally an endo lesion, the infection spreads from the apex and along the root to the gingiva Pulpal infection can also spread from accessory canals to the gingiva or furcation
Primary perio secondary endo lesion
A periodontal pocket can deepen to
apex & secondarily involve the pulp
Alternatively a perio pocket can infect pulp through lateral
canal
‘True’ combined lesion
Two independent lesions (periapical and perio) can coexist and eventually
fuse with each other
Abott and Castro Salgado 2009 classification
Concurrent endodontic and periodontal disease without communication Concurrent endodontic and periodontal disease with communication
Communication
Knowing if the lesions are communicating can be useful Non-communicating lesions suggest a ‘true’ combined lesion with independent aetiologies However, communicating lesions may be ‘true’ combined lesions which have merged, or lesions which have started primarily as perio or endo and then spread to the other Knowing original source of infection can have an implication for management and prognosis of case
Diagnosis
History Examination -endo -perio Special tests -sensibility testing -radiographs -other tests?
History - clinical symptoms
May be no symptoms Swelling of gingiva Pus discharge Fistula tract TTP Mobility Sign: pocket formation
Examination
Endodontic Restorative status TTP Tenderness in sulcus Swelling/ sinus Periodontal Probing around tooth (all the way around the tooth - pocket can be very narrow) Pus discharge from pocket Mobility
Special testing
Sensibility testing
-cold testing (ethyl chloride)
-EPT
-tooth should be -ve to both tests to confirm non-vital status
Radiographs
Consider tooth sleuth
and transillumination to rule out root fracture if this is a possibility
Radiographs
PA radiographs are most appropriate modality to assess perio endo lesions Vertical perio defect often present Radiolucency around apex will be present ‘J-shaped lesion’ may be present OPT can be used, but this would only be indicated if multiple sites needed to be radiographed, likely for perio assessment -further IO radiographs would likely be needed in addition CBCT scan only indicated when conventional radiography does not provide sufficient detail -examples might include complex 3-D anatomy or suspicion of other causes such as resorption or perforation
Management of perio endo lesion
Treatment depends upon initial diagnosis
- primary endo secondary perio lesion –> RCT only
- primary perio secondary endo –> RCT and perio therapy
- ‘true’ combined lesions –> RCT and perio therapy
Rationale for management: Primary endo secondary perio lesions
Endo
aetiology
Endo infection just happens to be draining via PDL
Periodontal lesion usually presents as narrow defect
Endo treatment will usually resolve the issue as it will eradicate source of infection
Perio defect is often very narrow and not really conducive to
instrumentation
Review after 3 months and instigate
non-surgical periodontal therapy if the
pocketing is still present
Review after another three months – if
still no resolution consider other
options such as surgical intervention
Rationale for management - primary perio secondary endo lesion
Primary perio secondary endo lesions have a periodontal aetiology, but the tooth has become non-vital so also requires RCT This means endodontic therapy and periodontal therapy are both required and it is best to undertake these simultaneously Review after 3 months and instigate further non-surgical periodontal therapy if the pocketing is still present Review after another 3 months – if still no resolution consider other options such as surgical intervention
Rationale for management - ‘true’ combined lesions
‘True’ combined lesions have an endodontic and perio aetiology They may or may not communicate Either way, endodontic and periodontal therapy is indicated Again, it is best to undertake these simultaneously Review after 3 months and instigate further non-surgical periodontal therapy if the pocketing is still present Review after another three months – if still no resolution consider other options such as surgical intervention
Alternative management options
Some people advocate placing
CaOH inside
prepared canal rather than
obturating whilst assessing response to perio therapy
-obturation only undertaken once response to perio therapy seen
-no evidence to
suggest this is more preferable treatment regimen
Surgical intervention may be
indicated earlier with for example very deep pockets, not conducive to non-surgical perio therapy
In molars, if one
root considerably more affected than another root, consideration
should be given to
undertaking root
resection or hemisection
-often, root resection is
undertaken on the mesio-buccal
or disto buccal roots of upper
molar teeth and hemisection is
undertaken on lower molars
Prognosis
Primary endo secondary perio: generally good
Primary perio secondary endo / ‘true’ combined lesions: prognosis depends on extent of perio bone loss
Lesions masquerading as perio-endo lesions
Developmental grooves
Perforations
Root fracture
Resorption
Developmental grooves
Developmental grooves can predispose to formation of
deep perio pocket, which if untreated can result in pulp death (primary perio secondary endo
lesion)
Management involves endo treatment and
perio therapy, but surgery may be required due
to groove
Perforations
Perforations can occur during
endodontic treatment or
during placement of endo post or dentine pin
Clinically perforation may present as deep pocket
leading to site of
perforation
Perforations - radiographically
Radiographically,
perforation will often lead to bone loss around site of perforation
Perforation may or
may not be
radiographically obvious as radiograph is a 2D
view of 3D object
Management of perforations
Requires assessment of restorability of tooth If unrestorable, the tooth will require extraction If restorable the tooth will require repair of the perforation, either internally or externally using a biocompatible material such as MTA or Biodentine This management is probably best undertaken by an endodontist
