Perio-Endo? Get Some GP in it!

The second most common reason for extraction of root filled teeth is periodontal disease. So it’s important we identify periodontal disease when deciding if we should treat a tooth. Periodontal pockets around teeth can generally be due to three things:

1. Periodontal disease;

2. Vertical root fracture;

3. A sinus tract draining through the PDL.

Usually, a true periodontal pocket will be broad, whereas a pocket due to a root fracture or a draining sinus will be very narrow. We are more likely to find a true periodontal pocket in a patient who suffers periodontal disease in other teeth besides the one we are looking at.

When we do identify a periodontal pocket in a tooth that also has apical periodontitis, we want to know if the periodontal disease is separate to the apical disease. When these two are combined in a perio/endo lesion, the success rate in treating the teeth is lower than when we have separate perio and endo disease. If the pocket is narrow, then it’s important to differentiate between the draining sinus (which may be easy to treat) and the root fracture, which cannot be treated. I usually do this by raising a flap and inspecting the root with the microscope after staining with methylene blue.

Endo Perio lesion

GP placed into a sinus tract helps determine the true depth of the sinus tract.

In cases where I find a very deep, broad periodontal pocket which I think may be to the apex of the tooth, I place a GP point in the pocket to full length and take a radiograph. If the GP extends to the apex, then I know we have a fight on our hands to save the tooth.

The Endospot

A true perio/endo lesion makes this tooth a difficult prospect for successful treatment.

In the comments section, please leave your tips on identifying perio/endo lesions.

One Response to “Perio-Endo? Get Some GP in it!”

  1. Dylbert February 2, 2014 at 7:27 pm #

    Pulp sensibility tests are invaluable starting point. +ve result = perio, -ve result = endo. Potentially confusing in multi-rooted teeth though. Important to treat the endo first if there’s a possibility that pocket is of endodontic origin ie. draining sinus tract presenting as narrow deep pocket. Diving in with scalers can damage cementum and hinder/prevent healing of the pocket once you do finally get around to doing the endo. Personally, if root fracture has definitely been ruled out and a true combined lesion ruled in, I would instrument and dress the tooth with CaOH2 for one week. Following completion of the RCT I would then review in 6/52 to check for signs of marginal periodontal healing. If there is none, it’s a trip to the hygienist for a bit of gum gardening. Diagnosis can be an ongoing process, which I warn the patient about prior to treatment.
    Personal experience has taught me that prognosis is usually pretty bleak if it turns out to be a true combined lesion, though thankfully these appear to be rare compared to other causes of periodontal pocketing. I do have patients that manage to live with a degree of pocketing following treatment which doesn’t sit well with me, but I suppose it’s ultimately down to the success/survival fence and which side of it you sit on. The case upstairs looks daunting with the addition of a retreatment. Sorry for the long winded post, I’ve just had a vase of coffee.

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