Diagnosis of Perforation

Diagnosis is based in clinical and radiological assessments. Symptoms tend to be acute, with periodontal abscess formation associated with pain, swelling, pus exudate, pocket formation due to gingival epithelium down-growth to the perforation site, and tooth mobility. However, a more chronic response may sometimes occur without pain, involving the sudden appearance of a pocket with bleeding on probing or shy pus exudation.

Accurate detection and location of the root perforation are crucial for the treatment. Blood at the tip of a paper point may be, apart from the presence of a lateral canal, indicative of root perforation. A gutta-percha cone can follow a sinus track up to a perforation site, but it should be used in addition to a radiograph.

The information provided by a radiograph is helpful when the defect is located either on the mesial or the distal side. Defects on buccal or lingual/palatal sides cannot be observed. However, newer technologies like CBCT can help the surgeon to accurately localize the root side and the extension of the lesion where the perforation is, and therefore choose the right access, technique, material, and appointment length.

Electronic apex locators (EALs) can accurately determine the location of root perforations, more reliably than radiographs14. Significantly shorter readings, after root instrumentation, than the original length can be an indication of root perforation.

A microscope, with coaxial illumination and high magnification, allows precise detection and easy treatment of perforations along straight, accessible, non-curved root canals.

A "tunnel" periodontal probing defect is a possible sign of root perforation, and differential diagnosis from a lateroradicular lesion and VRF should be made with explorative surgery.