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Diagnosis and Management of Endodontic-Periodontic Lesions

Definition: Endodontic‐periodontal lesions, defined by a pathological communication between the pulpal and periodontal tissues at a given tooth, occur in either an acute or a chronic form, and are classified according to signs and symptoms that have direct impact on their prognosis and treatment.

Classification of endodontic-periodontic lesions.

  1. retrograde periodontal disease:
    1. primary endodontic lesion with drainage through the periodontal ligament,
    2. primary endodontic lesion with secondary periodontal involvement;
  2. primary periodontal lesion;
  3. primary periodontal lesion with secondary endodontic
  4. involvement;
  5. combined endodontic-periodontal lesion;
  6. iatrogenic periodontal lesions.

Classification of endo‐periodontal lesions 2018

Progression of the pulpal and periradicular pathosis. A, Normal tooth without any pulpal pathosis is richly vascularized and innervated. B, With microbial challenges, such as caries, local tissue inflammation can occur in the pulp adjacent to the site of carious lesions as well as in the apical regions (arrowheads)C, Pulpal inflammation can lead to reduction in pulpal blood flow (PBF) caused by an increase in intrapulpal pressure (IPP), causing pulpal necrosis (shown in gray). D, Pulpal necrosis, if left untreated, can lead to the chronic inflammation of periradicular tissues and abscess formation, leading to a draining sinus tract

Retrograde periodontitis. A, Large periapical lesion extending around the periapex of tooth 47. No visible fractures were detected on the mesial or distal marginal ridges. The tooth tested nonvital. A sinus tract was visible on the buccal gingiva. B, Endodontic therapy was completed in two visits, and the canals were obturated. C, Healing of the periradicular bone is evident at 6 months, and a crown providing complete coverage has been placed.

Lateral canal-led periodontal defect from a primary endodontic infection. A, Bone loss is present in the furcation with sinus tract present on the buccal mucosa. Tooth 46 tested nonvital. B, During condensation, a large amount of sealer was expressed through a large lateral canal in the distal root. C, Sealer was removed after obturation by curettage of the furcation and irrigation with anesthetic solution through the sinus tract. D, Healing at 12 months demonstrates complete repair of periradicular bone.

 Primary periodontal defects causing periradicular bony lesions and pulpal irritation. A, Primary periodontal lesion is evident on the distal of tooth 47. The defect was probed to a depth of 7 mm, and the tooth tested vital to both thermal and electrical pulp testing. The defect was most likely the result of the impacted third molar and formation of a chronic periodontal abscess. B, Primary periodontal lesions both probing 12 mm into the furcation. Teeth 26 and 27 tested vital to thermal and electrical testing. The patient's chief complaint was discomfort to cold, thus exemplifying pulpitis secondary to the primary periodontal infection.

 The distinction between pulpal or periodontal infection

 This requires collectively dissecting the multiple findings and synthesizing the most probable diagnosis based on  patients' symptoms which may  suggest an origin of  a pulpal or periodontal infection

  • coronal integrity: extensive failing restorations, recurring decay,  pulpal involvement.
  • shape and size of the radiographic lesions,
  • periodontal probing,
  • tooth vitality:tooth may test completely vital and lack any evidence of an irreversible pulpitis
  • Root integrity
  • Objective findings:  patients' responses to percussion, palpation, biting, periodontal probing, and vitality testing
  • Radiographic bone loss is significantly greater in teeth with periodontal or combined endodontic-periodontal lesions compared to teeth that are vertically fractured
  • CBCT will localise the type of destruction

Root Pathology : Root fracture

Horizontal root fracture. A, Radiograph of tooth 21, 4 weeks after instrumentation. The radiograph shows a midroot intraalveolar horizontal root fracture with separation of the coronal and apical segments. Resorptive defects are evident at the fracture site and slight periapical bone loss is present at the periapex and mesial root surfaces. The tooth displayed slight mobility with normal probing depths. B, The segments were stabilized using a size #140 Thermafil obturator with a metal carrier. The tooth was restored with an acid-etched composite restoration. C, 12-year recall radiograph shows excellent long-term treatment success and a normal periradicular appearance.

Vertical root fracture. A, Patient whose chief complaint is pain from bite pressure irritation, bleeding, and redness on the lingual marginal tissues. The radiograph reveals a slight loss of bone on the distal surface of tooth 25 and a short screw post. A lingual periodontal pocket probing 6 mm was present. A diagnosis of vertical root fracture was made. B, After extraction of the tooth, a vertical root fracture extending two-thirds of the root is evident.

Root Resorption

Root resorption. A, Radiograph of tooth 36 after obturation of the canals. The shortened distal root is the result of apical inflammatory root resorption. A large radiolucent lesion extending into the bifurcation is evident. B, A 1-year recall radiograph shows complete repair of periradicular bone and some additional resorption of extruded filling material at the root apex. C, An internal resorptive lesion of relatively large size. The expansion of the canal space is diagnostic of a resorptive defect inside the tooth. However, it is not possible to diagnose the possibility of a possible external perforation from a two-dimensional radiograph. D, The final obturation film seems to indicate that the lesion and filling material appears to be confined to the canal space.

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