Journal of Dental Pathology and Medicine
Open Access

Endodontic pathology; Dental pulp disease; Periapical lesions; Root canal treatment; Pulpal necrosis; CBCT; Regenerative endodontics; Endodontic microbiology; Pulpitis; Apical periodontitis

Introduction

Endodontic pathology encompasses diseases affecting the dental pulp and periapical tissues. These conditions often arise due to microbial invasion, trauma, or iatrogenic factors [1]. The progression of endodontic disease involves complex inflammatory and immunological responses, which, if left untreated, may lead to pulp necrosis and periapical pathology [2]. This review provides an in-depth exploration of the etiology, pathogenesis, clinical presentation, diagnostic methods, and contemporary treatment modalities for endodontic diseases [3]. Endodontic pathology is a significant area of concern in dentistry, as it deals with the diagnosis and treatment of diseases involving the dental pulp and periapical tissues [4]. The primary objective of endodontic therapy is to prevent or eliminate microbial infection within the root canal system, thereby promoting healing and preserving the tooth.

Endodontic diseases are typically classified into pulpal and periapical diseases. Pulpal diseases range from reversible pulpitis to irreversible pulpitis and pulp necrosis, while periapical diseases include apical periodontitis, periapical abscess, and radicular cysts [6]. Endodontic pathology refers to a spectrum of disorders primarily affecting the dental pulp and surrounding periapical tissues. These conditions are among the most common reasons for dental pain and intervention, with significant implications for oral and systemic health. The dental pulp, a richly vascularized and innervated connective tissue, is highly susceptible to insults such as bacterial invasion, trauma, and restorative procedures. Once compromised, the pulp may undergo inflammation (pulpitis), necrosis, and ultimately lead to periapical pathology, including apical periodontitis, granulomas, and cyst formation [7]. The etiological factors driving endodontic disease are multifactorial and complex, often involving microbial infection as the principal cause, but also influenced by host immune response, anatomical variations, and external factors. As such, a nuanced understanding of these factors is essential for accurate diagnosis and effective treatment planning.

With the evolution of dental imaging and diagnostic tools, clinicians are now better equipped to detect and evaluate pulpal and periapical conditions. Technological innovations, such as CBCT and advanced pulp testing, have significantly improved diagnostic accuracy and treatment outcomes [8]. Simultaneously, advances in biomaterials and treatment modalities including regenerative endodontics and microsurgical techniques are redefining the boundaries of therapeutic possibilities.

This review aims to provide a comprehensive overview of endodontic pathology by synthesizing the latest insights into its etiology, diagnostic methodologies, and treatment strategies. Through this exploration, dental professionals can enhance their diagnostic acumen, refine their treatment approaches, and contribute to the preservation of natural dentition and the overall well-being of patients.

Etiology of endodontic pathology

Bacterial invasion, the most common cause of endodontic disease is microbial infection, predominantly by Porphyromonas endodontalis, Fusobacterium nucleatum, and Prevotella intermedia. These bacteria enter the pulp through carious lesions, cracks, or periodontal pathways.

Fungal and viral infection, Candida albicans and herpes viruses have also been implicated in chronic endodontic infections.

Physical trauma, Dental injuries, such as fractures or luxation, can lead to pulp necrosis due to disrupted blood supply.

Chemical or thermal trauma, Excessive use of dental materials or heat during restorative procedures can irritate the pulp, causing inflammation.

• Over-instrumentation during root canal therapy
• Inadequate irrigation or improper sealing
• Procedural errors, such as perforation or ledge formation

Pathophysiology of endodontic diseases

Reversible pulpitis, Characterized by transient inflammation, mild discomfort, and sensitivity to thermal stimuli.

Irreversible pulpitis, Inflammation progresses, leading to spontaneous pain and hypersensitivity. Histologically, the pulp displays hyperemia, edema, and necrosis of the odontoblast layer.

Pulp necrosis, complete loss of vitality, with no response to thermal or electric pulp testing. Necrotic tissue promotes bacterial growth and endotoxin release.

Acute apical periodontitis, Inflammation at the root apex due to microbial toxins, resulting in tenderness to percussion and mild radiographic changes.

Chronic apical periodontitis, Persistent infection causes periapical granuloma formation. Radiographs reveal periapical radiolucency.

Periapical abscess, acute infection with purulent exudate accumulation, leading to swelling, pain, and potential systemic involvement.

Radicular cyst, a true cyst formed by the proliferation of epithelial rests of Malassez in response to chronic inflammation.

Pulpitis, Sharp pain, sensitivity to temperature changes, and discomfort during mastication.

Periapical involvement, Dull, throbbing pain, tenderness on percussion, swelling, and occasional sinus tract formation.

Pulp testing, Thermal and electric pulp testing to assess pulp vitality.

Radiographic examination, Periapical radiographs and cone-beam computed tomography (CBCT) for detecting periapical lesions.

Vitality testing, Laser Doppler flowmetry and pulse oximetry for assessing blood flow in the pulp.

Treatment modalities

Pulp capping, Direct or indirect pulp capping using calcium hydroxide or mineral trioxide aggregate (MTA) for reversible pulpitis.

Pulpotomy, Partial removal of infected pulp tissue, commonly performed in pediatric patients.

Cleaning and shaping, Mechanical debridement of the root canal system using rotary or hand files.

Irrigation protocols, Use of sodium hypochlorite, EDTA, and chlorhexidine for microbial control.

Obturation, Sealing of the canal space with gutta-percha and biocompatible sealers.

• Indicated in cases of persistent or recurrent infection after initial RCT.
• Techniques include canal disinfection, removal of old obturation material, and re-obturation.

Apicoectomy, Surgical removal of the root apex and infected periapical tissue.

Root-end FILLING, Placement of MTA or bioceramic materials to seal the root apex.

Advances in endodontic pathology management

• Use of stem cells, platelet-rich plasma (PRP), and scaffolds to regenerate pulpal tissues.
• Promising results in revascularization of immature necrotic teeth.
• Bioceramics have superior biocompatibility, sealing ability, and antibacterial properties.
• Increased popularity in root canal obturation.
• Use of erbium and diode lasers for effective disinfection and enhanced tissue healing.

Conclusion

Endodontic pathology involves complex inflammatory and immunological responses to microbial, traumatic, or iatrogenic insults. Timely and accurate diagnosis, combined with effective therapeutic interventions, is essential to prevent further complications. Advancements in regenerative endodontics and laser-assisted techniques offer promising outcomes for managing challenging cases. Ongoing research and technological innovations continue to refine the field of endodontics, enhancing patient care and treatment success rates.