PERIODONTAL- ENDODONTIC LESIONS

OJUOLA G.TFATODU A.A

Outline Introduction. Pathways of communication. The dilemma. Classification. Diagnosis. Treatment. Conclusion. References.

Introduction The pulp and periodontium are interrelated in

several ways The relationship between the periodontium and

the pulp was first discovered by Simring and Goldberg in 1964

The periodontium and pulp have embryonic, anatomic and functional interrelationship.

Introduction Ectomesenchymal cells proliferate to form the

dental papilla and follicle, which are the precursors of the periodontium and the pulp respectively.

Pulpal and periodontal problems are responsible for more than 50% of tooth mortality.(Simring M, Goldberg M 1964)

Pathways of communication. Anatomical Non physiological pathways

Anatomical pathways Apical foramen:

The apical foramen is the principal and most direct route of communication between the periodontium and the pulp.

accessory canals multitude of branches connecting the main root

canal system with the periodontal ligament. The frequency of these canals on the root surface

are as follows: apical third 17%, coronal third 1.6% and body of the root 8.8% (DeDeus QD, J Endod. 1975)

Anatomical pathways Accessory canals cont’d

periodontal endodontic problems were much more frequent in the molars than in the anterior teeth because of the greater number of accessory canals present in the molars. (Bender et al)

Dentine tubules It contains the odontoblastic process that extends

from the odontoblast at the pulpal dentin border to the dentino-enamel junction or the cement-dentinal junction

Nonphysiological pathways Root perforations

During access cavity preparation using powered rotary instruments or preparation for post

Improper manipulation of endodontic instrument. Vertical root fracture Chemicals used in dentistry.

Agents, such as 30–35% hydrogen peroxide used in intracoronal bleaching can diffuse through dentine tubules to cause necrosis of the cementum, inflammation of the periodontal ligament, and subsequently root resorption (S. Madison and R. Walton, Journal of endodontics, 1990)

The Dilemma: the effect of periodontal lesions on pulp Periodontal disease or sequelae of periodontal

treatment does not affect the pulp(Jaoui L. et al 1995; Torabinejad M, Kiger RD 1985; Bergenholtz G, Nyman S. 1984).

The effect of periodontal disease on the pulp is atrophic and degenerative in nature (Petka K 2001, Langeland K. et al 1974, Mandi FA 1972).

The Dilemma: the effect of periodontal lesions on pulp Periodontal disease and periodontal treatments

should be regarded as potential causes of pulpitis and pulpal necrosis (Wang HL, Glickman GN 2002)

The Dilemma: the effect of periodontal lesions on pulp It has been advocated that periodontal disease

has no effect on the pulp, unless it extends all the way to the tooth apex, the dental pulp is capable of surviving significant insults and that the effect of periodontal disease as well as periodontal treatment on the dental pulp is negligible. (Czarnecki RT, Schilder H, 1979, Zender et al 2002)

Classification By Simon et al 1972

primary endodontic lesions, primary endodontic lesions with secondary

periodontal involvement, primary periodontal lesions, primary periodontal lesions with secondary

endodontic involvement, true combined lesions.

Classification By Torabinejad and Trope in 1996, based on the

origin of the periodontal pocket: endodontic origin, periodontal origin, combined endo-perio lesion, separate endodontic and periodontal lesions, lesions with communication, lesions with no communication.

Classification world workshop for classification of periodontal

diseases (1999) Periodontitis Associated with Endodontic Disease endodontic-periodontal lesion, periodontal-endodontic lesion, combined lesion.

Classification A new endodontic-periodontal interrelationship

classification, based on the primary disease with its secondary effect, was suggested by Khalid S. Al-Fouzan in International Journal of DentistryVolume 2014 (2014)

He classified it into:

Classification retrograde periodontal disease:

primary endodontic lesion with drainage through the periodontal ligament,

primary endodontic lesion with secondary periodontal involvement;

primary periodontal lesion; primary periodontal lesion with secondary endodontic

involvement; combined endodontic-periodontal lesion; iatrogenic periodontal lesions.

Primary endodontic lesion Acute exacerbation of a chronic apical lesion on

a tooth with a necrotic pulp may drain coronally through the periodontal ligament into the gingival sulcus.

This condition may mimic, clinically, the presence of a periodontal abscess.

When the pocket is probed, it is narrow and lacks width. Primary endodontic diseases usually heal following root canal treatment.

Primary endodontic lesions with secondary periodontal involvement. If a primary endodontic lesion remains

untreated, it may become secondarily involved with periodontal breakdown.

Plaque accumulation at the gingival margin of the sinus tract leads to plaque induced periodontitis in this area

It can also be as a result of non physiologic pathways of communication which can be associated with pain, swelling, pus or exudates, pocket formation and tooth mobility

Primary periodontal lesion The periodontal disease has gradually spread

along the root surface towards the apex. The pulp may remain vital but may show some

degenerative changes over time.

Primary periodontal lesion with secondary endodontic involvement Progression of the periodontal disease and the

pocket leads to pulpal involvement via either a lateral canal foramen or the main apical foramen

Unless periodontal disease has progressed to involve the tooth apex, the effect of periodontal disease on the pulp appears to be negligible. Zender et al 2002

Prognosis better in multi rooted tooth than single tooth. (principles and practice of endodontics,Richard Walton and Mahmoud Torabinejad)

True combined lesions These lesions occur when an endodontically

induced periapical lesion exists at a tooth that is also affected by marginal periodontitis

The tooth has a pulpless, infected root canal system and a coexisting periodontal defect.

It can be merged or exist seperately

DIAGNOSIS

Culled from: Endo-perio lesion: a dilemma from 19th until 21st century. (Parolia et al 2013

Treatment

Treatment of Periodontal-Endodontic Lesions Conventional endodontic therapy is indicated

when pulp is nonvital and infected. Surgical endodontic treatment is not necessary,

even in the presence of large periradicular radiolucencies and periodontal abscesses.

If primary endodontic lesions persist, despite endodontic treatment, the lesion may have secondary periodontal involvement or it may be a true combined lesion.

Treatment of Periodontal-Endodontic Lesions In Cases of primary endo with secondary perio,

start RCT and dress canal with CaOH before obturation

Review treatment in a few weeks If perio lesion is not resolve, do periodontal

treatment

Prognosis of primary endodontic disease with secondary periodontal involvement depends on periodontal treatment and patient response

Treatment of Periodontal-Endodontic Lesions In cases of primary perio with secondary endo

lesion: If sign of reversible pulpitis is present, periodontal

treatment only will resolve the condition If pulp is irreversible inflamed or nonvital, start with

RCT followed by appropriate periodontal treatment

Prognosis of periodontal lesions is poorer than endodontic lesions and is dependent on the apical extensions of the lesion

Treatment of Periodontal-Endodontic Lesions In cases of true combined lesions:

Treat initially as primary endo with secondary perio lesion

The prognosis is often poor or even hopeless, especially when periodontal lesions are chronic, with extensive loss of attachment.

Root amputation, hemisection or bicuspidization maybe done to save part of the tooth

Culled from: Endo-perio lesion: a dilemma from 19th until 21st century. (Parolia et al 2013

Conclusion Periodontitis Associated with Endodontic

Disease may be difficult to diagnose, but an understanding of the the lesions help in diagnosis, proper treatment and better prognosis.

Treatment is often multidisciplinary.

References Parolia A, Gait TC, Porto IC, Mala K. Endo-perio

lesion: A dilemma from 19th until 21st century. J Interdiscip Dentistry 2013;3:2-11

Raja Sunitha V et al. The periodontal – endodontic continuum: A review. J Conservatory Dent. 2008 Apr-Jun; 11(2): 54–62.

Khalid S. Al-Fouzan. A New Classification of Endodontic-Periodontal Lesions. International Journal of Dentistry Volume 2014 (2014)

References. Shenoy N, Shenoy A. Endo-perio lesions:

Diagnosis and clinical considerations. Indian J Dent Res 2010;21:579-85