Endo- periodontal lesions and periodontal abscess

Gingival abscess

Localised to gingival margin (no depth, no loss of attachment)

Periodontal abscess - definition

Usually related to pre-existing deep pocket - patient probably has localised/generalised periodontitis - can be associated with a change in the patient's immune system and also associated with food packing after tightening of gingival margin post HPT

Pericoronal abscess

Associated with partially erupted 8s

Endodontic - periodontal lesions

tooth is suffering from varying degrees of endodontic and periodontal disease

Periodontal abscess - why in diabetic patients

can be seen in patients with poorly controlled diabetes because they cannot induce an effective inflammatory/immune response

periodontal abscess - when is there pain

Pain is associated if the pus is trapped and pressure develops

asymptomatic if it is freely draining

Prognosis of periodontal abscess tooth

characterised by rapid destruction of periodontal tissues, with a negative effect on the prognosis of the affected tooth

A tooth that has a PA has a very poor prognosis → 45% of teeth with a periodontal abscess found during PeM were extracted

Signs and symptoms of periodontal Abscess

Swelling

Pain

Tooth may be TTP when the tooth is tapped in a lateral direction

Deep periodontal pocket

Bleeding

Suppuration (Pus)

Enlarged regional lymphnodes

Fever (rare)

Tooth is usually vital

Commonly associated in pre-existing periodontal disease

occasionally it can happen because of food trapping and/or trauma → things getting stuck in the gingival margin can induce a PA

Management of a periodontal abscess - SDCEP

1- subgingival instrumentation short of the base of pocket to avoid damage (can cause significant recession and LOA if you carry on instrumentation down in depth of pocket)

2 - Drain any pus

3 - NO Rx but recommend analgesia

4- ABX only if signs of spreading infection or systemic involvement

5 - CHX mouthwash until acute symptoms settle

6 - review and carry out definative perio instrumentation

Abx - periodontal abscess

Only if signs of spread and systemic effects or if symptoms do not resolve after local measures (detailed above) implemented

Careful RSD → Penicillin V 250mg(preferred) or Amoxicillin 500mg 5 days OR Metronidazole 400mg 5 days

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

Distinction of EPL and PAs

Vitality testing

TTP or Mobility will not distinguish between them

PA - Vital, EPL - Non-Vital (typically but not always)

What is an EPL

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

Are periodontal disease and endodontic disease linked

Yes due to microcopic communications

Acute EPL

Trauma (root fractures, crown-root fractures)

Perforations out the side of the tooth during an rct

Chronic EPL

Slow and chronic progression without evident symptoms

associated with Pre-existing periodontitis

Signs and symptoms of EPL

very deep periodontal pockets reaching close to the apex

negative or altered response to pulp vitality tests (altered response → this means the response could be delayed)

Radiographically there may be bone resorption in the apical or furcation region

spontaneous pain

Pain on palpation and percussion

Purulent exudate (pus)

tooth mobility (due to the loss of bone)

sinus tract present

crown, and gingival colour alterations

What can cause necrotic pulp?

Caries or trauma

What are the potential exits for necrotic pulp contents?

Apical foramen or lateral canals

What can happen when necrotic pulp contents leech out through the furcal canal?

It can cause furcal pathology, which is destruction seen on a radiograph.

What usually happens to furcation disease after endodontic treatment if the periodontium is intact?

It usually heals up.

What complicates the healing of furcation disease?

The presence of both attachment loss and furcation involvement.

What is indicated by a deepening pocket with exposed dentine and a non-vital tooth?

The two conditions coalesce.

What can occur in a healthy vital tooth with periodontal disease?

Bone loss can reach the apex, allowing biofilm on the root surface to infect the pulp.

How can exposed dentinal tubules cause pulpal inflammation

Application of soluble material (bacterial toxins) from bacterial plaque to exposed dentin can cause pulpal inflammation

can also occur after periodontal therapy if the cementum is removed and dentine exposed underneath

How can lateral and accessory canals cause EPLs

1,000 human teeth with periodontal disease

Only 2% of lateral and accessory canals were associated with the involved periodontal pocket

This is uncommon because the lateral canals are so far down the root it takes a long time for any pocket to actually reach any lateral or accessory canal.

What is the communication pathway between the pulp and periodontium?

Furcations

How can furcal pathology be categorized?

Into two types: A) intact periodontium with furcal pathology B) reduced periodontium with furcal pathology.

What is the expected outcome of endodontic treatment in a tooth with intact periodontium and furcal pathology?

The furcal disease will heal up in the same way as periapical disease.

What is the effect of a combined lesion of periodontitis and a non-vital tooth on periodontal outcome?

It will have a detrimental effect on the periodontal outcome of that tooth.

What can pulpal inflammation cause in the interradicular periodontal tissues?

An inflammatory reaction.

What can pulpal infection or inflammation adversely affect?

The periodontal ligament (PDL).

What are potential pathways for microorganisms and toxic by-products from the pulp?

Patent small portals of exit to the periodontal ligament and vice versa.

Apical foramen - route of communication between pulp and peridontium

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

causes of perforations

extensive dental caries

resorption

operator error (iatrogenic damage) e.g. incorrect root-canal instrumentation or post preparation

classifications of EPLs

by a carious lesion that affects the pulp and, secondarily, affects the periodontium.

by periodontal destruction that secondarily affects the root canal

or by both events occurring at the same time.

Grade 1,2,3 for endo peridontal lesion in periodontitis patients

1 - Narrow deep peridontal pocket in 1 tooth surface

2 - Wide deep peridontal pocket in 1 tooth surface

3 - Deep peridontal pockets in more than 1 tooth surface

Endo-Periodontal Lesions 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)

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

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

Treatment of EPLs SDCEP

Non vital - endo treatment

no ABX unless sytemic infection

CHX mouthwash until accute symptoms subside

Management of lesion and review within 10 days with sub and supra gingival instrumentation if necessary

Additional treatment

Open flap debridement

Regenerative Flap Surgery:

Guided tissue regeneration (GTR) - involves bone graft and barrier membrane placement

Enamel Matrix Derivative (EMD - Emdogain)

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 (e.g. lateral/furcal canals)

Patients who were more susceptible to periodontitis and exhibited evidence of endodontic treatment failures showed an increase, of approximately threefold, in marginal bone loss compared with patients without endodontic infection.

Endodontic infection in mandibular molars was associated with more attachment loss in the furcal area.

Endodontic infection in molars associated with periodontal disease might enhance periodontitis progression by spreading pathogens through accessory canals and dentinal tubules. When the endodontic infection was treated successfully, the peridontal disease disappeared

Does periodontal disease affect the pulp in endodontics?

No effect on the pulp, at least until it involves a large accessory canal or if it gets down to the apex.

When does periodontal disease significantly affect the pulp?

When recession affects a lateral or accessory canal to the mouth.

What can happen if bacteria access the pulp through lateral or accessory canals?

It can cause chronic inflammation and possibly pulp necrosis.

What protects lateral or accessory canals from necrosis in periodontal disease?

If they are protected by cementum.

What keeps the pulp vital despite periodontal disease?

If the blood supply from the apical foramen is still intact.

What can cause pathogenic invasion and pulp necrosis during periodontal procedures?

If accessory canals are severed and/or opened to the oral environment.