Perio Endo Lesions

• Perio Endo Lesion Definition?

  The combined periodontic – endodontic lesion is a lesion where there is any coalescence of periodontic or endodontic lesions, irrespective of the primary origin of the lesion
• Perio tissue communicate with the pulp by?

  • The apical foramen
  • Dentinal tubules
  • Lateral root canals
  • Furcation root canals
  • Cracks and fracture lines
  • Perforation by dental instruments during RCT
• Perio disease with secondary endo involvement?

  A periodontal pocket extends to involve the apex or lateral canal causing loss of pulp vitality

  • little evidence to suggest happens on a significant scale
  • most likely only when perio disease involves the apex of the root and apical vessels traversing through apical foramen
• Primary endo with secondary perio involvement ?

  A non-vital pulp causes an acute abscess which drains via the periodontal ligament forming a “pseudopocket” which may be relatively narrow
• inflammation in pulp system can be reduced by:

  • Restorative procedures e.g. exposure, thermal damage or chemical damage
  • Caries
  • Trauma
  • Dentine exposureThis can lead to pulp necrosis and subsequent infection leading to a non-vital pulp
• Combined perio endo lesion ?

  Both  a periodontal pocket and endodontic lesion co-exist and progress to communicate with each other
• Diagnosis?

  • history of onset and dev of signs and symptoms
  • Clinical examination
  • special tests - rads and vitality
• History?

  • not easy to obtain a clear hisotry for chronic symptomless and periodontal pulpal lesions
  • Dx easier during acute episode
  • history of severe bouts of pain, awake at night, violent stimulation by hot cold sweet = irrev pulpitis
  • alludes to non vital tooth
• Primary endo lesions typically present when...

  • tooth heavily restored
  • marked surface loss w attrition, erosion and abrasion (combined or in isolation)
  • Tooth discoloured (esp. anteriorly = trauma)
  • Isolated deep pocket , probe disappears in a narrow, deep defect and is atypical of the general level of periodontal destruction.
  • Pocket often, but not always, on the buccal / palatal surface - not interdentally as in established Chronic Periodontitis.
  • root surface relatively free of sub-gingival deposits unless the lesion is long-standing and no other periodontally involved teeth in the mouth.
• Chronic periodontitis ?

  • pockets usually possess wide orifice at GM
  • calc deposits are present
  • Pockets deepest ID
  • teeth rarely affected in isolation
• Vitality testing ?

  • thermal, electric and tactile stimulus
  • non vital tooth with endodontic component responsed negatively
  • be aware of false positives and negatives
• A perio lesion will repond in which way to cold and electric pulp testing

  normal
• Radiographic exam:

  look for signs of endo origin:

  • Loss of lamina dura or widening of the periodontal membrane space.
  • Apical or lateral areas of rarefaction i.e. “apical areas.”
  • Furcation radiolucencies may be endodontic in origin.
  • Deep fillings ,deep caries, pulp caps
• Perio signs on a radiograph:

  bone loss and calculus deposits
• Tx for perio disease with secondary endo involvement

  if pocket reached apex the disease is advanced and tooth untreatable, XLA best option
• Tx for primary endo with secondary perio involement?

  • diag early = RCT
  • little chance of secondary plaque accumulation of the “pseudopocket”.
  • Conversely a longstanding lesion will develop the features of Chronic Periodontitis and success will depend upon successful RCT and RSD
• Perio component of TX for primary endo lesion w secondary perio involement?

  • Periodontal treatment may not be required if the duration of communication is short.
  • Regeneration can be expected if plaque contamination of the root surface has not occurred
• Tx of combined lesion?

  • Much more difficult to treat and diagnose
  • Not possible to determine to what extent each of the combined aetiologies has contributed to the lesion.
  • RCT should always be carried out first followed by periodontal treatment to cope with the residual pocket
  • Difficult to manage
  • Treatment success unpredictable
• Combined lesion Tx sequence?

  1. RCT
  2. Rv at 2-3 months
  3. if lesion shows no signs of resolving perform perio therapy
  4. rv after 2-3 months and re eval radiographically
• Abscess?

  a collection of pus within a pyogenic membrane
• Gingival abscess?

  • Previously healthy site and caused by foreign body impaction
• Peri coronal?


  associated with an incompletely erupted tooth
• perio abscess can occur by...

  extensive of infection from a perio pocket

  may follow physical damage to perio tissues ie. a foreign body
• Where and when do they typically occur ?

  • In relation to pockets of bi/trifurcation of molars. These are deep and narrow and easily blocked
  • Incomplete removal of calculus and tissue debris from a periodontal pocket results in healing over incompletely removed pocket contents impeding drainage
• Initial abscess signs/symptoms ?

  • deep throbbing pain
  • tooth slightly mobile and sensitive to touch
  • overlying gingivae = red, swollen tender
  • no fluctuation/ discharge of pus
• abscess sings and symptoms EO?

  • Infection may spread into the surrounding tissues and a cellulitis may occur.
  • Swelling of the face, lip, lower eyelid depending on the site of the abscess
  • Lower tooth infection may in addition be associated with trismus and difficulty in swallowing
  • Associated lymphadenopathy
  • Malaise and increased temperature
• Developing signs and symptoms of an abscess ?

  • pus can discharge into pocket and drain through it
  • pus may track through alveolar bone and form an abscess under mucoperiosteum
  • in this case abscess is red, shiny, fluctuant and sensitive
• Intra oral signs of abscess ?

  • Deep pocket
  • Pus discharge through pocket
  • Gingival swelling
  • Mobile tooth
  • Sinus if the abscess is an acute episode of an existing chronic abscess
  • Tooth tender to bite on
• Radiographic appearance of an abscess ?

  • Evidence of crestal bone loss and periodontal disease
  • Late radiographic evidence may include bone loss at the side of the tooth especially in long standing abscesses
• Will a abscessed tooth respond positively or negatively to a vitality test

  positively
• Treatment in the acute phase ?

  • PR
  • drainage
  • control of infection spread
• Drainage of the abscess?

  • via the open pocket
  • incision of fluctuant swelling by the dentist
  • HSWMW (1/2 TB salt to glass of hot water every 2 hours)
• Controlling the spread of infection

  ABx given in cases of systemic upset, this is shown by: temperature rise, malaise, medically compromised

  Amoxicillin 500 tds 5/7

  metronidazole 400mg tds 5/7
• Chronic phase Tx of abscess?

  • RSD
  • XLA
  • surgery
• Apical abscess ?

  • more severe pain
  • discharge over apex but can be at gm
  • swelling +tenderness over apex
  • pain before swelling
  • TTP
  • not always a pocket formation but can be
  • usually previous trauma, restoration, freq pulpitis
  • tooth non vital
  • apical rarefaction