Endodontic Periodontic Considerations

presented by: Mashael Foudah

Endodontic Periodontic Considerations

presented by: Mashael Foudah

Relationship between endodontics & periodontics

Effect of endodontics on periodontics

Effect of periodontics on endodntics

Classification of endo-perio lesions

Diagnosis

Treatment & prognosis

Endodonticperiodontal lesions present challenges to the clinician as far as diagnosis, prognosis and treatment.

The dental pulp and periodontal tissues are closely related. three main avenues for exchange of infectious elements between the two compartments are created by :

(1) (2) (3)

dentinal tubules lateral and accessory canals the apical foramina

Non-physiologic Pathways

Vertucci 2005

De Deus 1975

Endodontic disease and the periodontium

Contributing factors to endodontic lesions in the periodontium

Developmental

Trauma

Iatrogenic

Contributing factors to endodontic lesions in the periodontium

Developmental

Iatrogenic

Trauma

Contributing factors to endodontic lesions in the periodontium

- 1Developmental malformations

- 2- 4- 3-

Trauma

Coronal leakage Perforations Resorptions infective

Inadequate endodontic treatment

- 5Non-infective

- 6-

- 1- 2- 5Trauma

Developmental malformations

- 3- 4-

Coronal leakage

Perforations

Inadequate endodontic treatment

Non-infective

- 6-

Resorptions

infective

Transient Pressure-induced Chemical-induced Replacement Extracanal invasive External Internal

Andreasen (1981) classification: * Surface resorption * Replacement resorption * Inflammatory resorption

PIRR

EIRR

* Surface resorption = Transient PIRR = Extracanal invasive EIRR = External

PGG -1Provide a nidus for accumulation of bacterial biofilm and an avenue for the progression of periodontal disease that may also affect the pulp.

Trauma -2

concussion Subluxtion luxation Avulsion Intrusion

Vertical root fracture

1. loss of tooth structure and loss of fracture resistance after overzealous root canal preparation and subsequent restorative procedures leaving thin dentin walls.

2. Notches, ledges, and cracks induced by root canal preparation, root canal filling procedures, and seating of threaded pins and posts.

3. teeth serving as terminal abutments in cantilever bridges

Molars and premolars appear more often affected than incisors and canines

Clinical signs and symptoms associated with vertical root fractures vary hugely

pronounced pain and abscess formation or tenderness on mastication with mild dull pain and discomfort

Sinus tracts may emerge narrow, local deep periodontal pocket

Radiographic signs:

- Widening of the PDL - Lateral radiolucency along one or both of the lateral root surfaces

- Thin halo-like apical radiolucency

Often the diagnosis of a vertical root fracture has to be confirmed by surgical exposure

Treatment:

- There are reports of successful management of fractured teeth by re-attaching the fragments after extraction followed by re-implantation. - Fractured teeth are normally candidates for extraction.

- In multi-rooted teeth a treatment alternative is hemisection.

Leakage -3Root canals may become recontaminated by microorganisms due to delay in placement of a coronal restoration and fracture of the coronal restoration and/or the tooth

Poor RCT -4Poor endodontic treatment allows canal re-infection and treatment failure. Endodontic failures can be treated either by orthograde or retrograde retreatment techniques.

Perforations

-5Root perforations may result from:

extensive carious lesions resorption during RCT or post preparation

prognosis of root perforations depends on:

*size *location *time of diagnosis and treatment *degree of periodontal damage *sealing ability and biocompatibility of the repair material

MTA, Super EBA, Cavit , IRM, glass ionomer cements, composites, and amalgam

*controlled root extrusion*

Resorptions -6Transient (Remodeling) root resorption:

is a reparative process that occurs in response to minor trauma to the normal functioning teeth.

Pressure-induced

. Succedaneous teeth . Impacted teeth . Expanding lesions . Iatrogenic pressure, such as excessive orthodontic movements

Chmeical-induced:

intracoronal bleaching with highly concentrated oxiding agents.

Replacement root resorption:

occurs following extensive necrosis of the periodontal ligament with formation of bone onto a denuded area of the root surface.

This condition is most often seen as a complication of luxation and avulsion injuries.

Extracanal invasive:

uncommon form of root resorption.characterized by its cervical location, and invasive nature. There may be no signs or symptoms unless the resorption is associated with pulpal or periodontal infection.

Heithersay GS. 1999

The etiology of invasive cervical resorption is not fully understood. but, predisposing factors like traumatic injuries, orthodontic treatment, and intracoronal bleaching may be associated.

- Surgical exposure and removal of the granulation tissue, filling the defect followed by re-suturing the flap. "apically"

- Orthodontic extrusion of the tooth.

- GTR has also been advocated

External Resorption
caused by stimuli such as: pulpal and/or sulcular infection

traumatic displacement injuries

tumors

cysts certain systemic diseases

It can usually be stopped by focusing the treatment on the endodontic infection

Internal Resorption The etiology of this type of root resorption is usually trauma. Extreme heat was suggested as a possible cause.

Removal of the inflammed pulpal tissue and obturation of the root canal system is the treatment of choice

Periodontal disease and the pulp

The effect of periodontal inflammation on the pulp is controversial. It has been suggested that periodontal disease has no effect on the pulp before it involves the apex. On the other hand, several studies suggested that the effect of periodontal disease on the pulp is degenerative.

Teeth with caries or restorations that also have periodontal disease have more atrophic pulps than teeth with caries or restorations but no periodontal disease.

The effect of periodontal treatment on the pulp

scaling, curettage as well as periodontal surgery may not induce severe inflammatory changes of the pulp

Bergenholtz G and Lindhe J. 1978

Pathogenesis

Living pathogens

Pathogenesis

Living pathogens Non- living pathogenes

Bacteria Fungi Viruses

Biofilm

A.a

T.f E.corrodens

C. albicans

~ HSV ~ CMV ~ EBV

Foreign bodies (food,calculus, resto.)

Classification

Primary Endo Acute exacerbation of a chronic AP on a tooth with a necrotic pulp to drain through the PDL into sulcus mimicking a periodontal abscess, a deep periodontal pocket or a Grade III furcation in multirooted teeth

Primary Perio

It is the result of progression of chronic periodontitis apically along the root surface with wide generalized pockets.

Primary Endo with secondary Perio When primary endodontic disease remains untreated.

Plaque forms at the gingival margin of the sinus tract and leads to plaque-induced periodontitis in the area

Primary Perio with secondary Endo

Apical progression of a periodontal pocket continues until the apical tissues are involved via the apical foramen

Concomitant Lesion Concomitant endo-perio lesion is an additional classification that has been proposed to describe the presence of endo and perio disease as two separate and distinct entities

True Combined Lesion

True combined endo/perio disease occurs less frequently than other endo/perio problems

Diagnosis

Inspection

"Swelling, erythema, sinus/fistula, fracture & any etiologic or contributing factors"

Swelling caused by endodontic infections often occurs in the mucobuccal fold or spreads to the fascial planes.

Swelling associated with periodontal problems is found in the KAG and rarely spreads beyond the mucogingival line.

Palpation

Percussion

When a periodontal abscess is present, these clinical entities may be positive.

A tooth with an endodontic problem usually produces tenderness and pain on percussion and palpation.

Mobility

In the acute stage of an endodontic infection,mobility involves a single tooth.

Generalized mobility suggests periodontal or occlusal origin.

Ice test

Heat test

Hot gutta-percha applied to the tooth coated with petroleum jelly to prevent sticking to the tooth surface.

If a crown is present, a rotating rubber prophylaxis cup can be run on a dried tooth to create heat.

EPT

Blood flow test e.g: Laser Doppler Flowmetry

Cavity test
Preparation of a test cavity should be done without anesthesia.

A small access preparation is made through a crown or through the enamel to determine whether vitality is present in the pulp.

Probing

Sinus tracing

Dx: Endodontic lesion Periodontitis Vertical root fracture Perforation

Craks & fractures

Aided inspection

Transillumination

dyes

Bite test

Radiographs

Periodontal and endodontic problems can radiographically mimic each other;therefore pulp testing and periodontal probing must be used along with the radiograph.

Treatment & Prognosis

1ry endo

1ry perio

sequelae

-Necrotic pulp with a chronic AP -Draining sinus tract -Swelling in the mucobuccal fold is pathognomonic.

-Chronic in nature and often observed on other teeth -Minimal or no pain

Dx

-Negative pulp vitality tests -Periodontal probing is within normal limits -sinus tracing

-Probing -Plaque & calculus -Vital pulp

Tx

NSRCT

Peiodontal Tx

Px

Excellent

Dependent on the CAL

1ry endo\2ry perio

1ry perio\2ry endo

sequelae

plaque and calculus often form in the draining sinus tract

-Retro infection of the pulp tissue may occur - severe pain

Dx

-Probing "generalized -Pulp vitality tests are negative periodontitis' -plaque and calculus in the -Pulp vitality test results can be pocket mixed -NSRCT -Perio.Tx

Tx

Perio. Tx + RCT

Px

Excellent for endo. case dependent for perio.

Depends on the periodontal condition & Tx

True combined

Concomitant

sequelea

-Pulpal and periodontal pathoses develop independently and unite -Significant periodontalinvolvement

Pulpal lesion separate from the periodontal lesion BUT occurring at the same time

Dx

-Different Diagnostic methods for pulp & periodontium D.D: vertical root fracture perforations resorption -Good conservative NSRCT. - Periodontal therapy can be performed before, during, or immediately after the endodontic treatment. -Hemisection or root resection. -SRCT

Thorough clinical and radiographic examination

Tx

-Good conservative NSRCT. - Periodontal therapy can be performed before, during, or immediately after the endodontic treatment. -Hemisection or root resection. -SRCT

Px

Dependent on the periodontal condition.

Dependent on the periodontal condition.

References
- Periodontics: Medicine, Surgery and Implants, 1e Louis F. Rose , Brian Mealey , Robert Genco

Clinical Periodontology and Implant Dentistry, 5e Jan Lindhe, Niklaus P. Lang, Thorkild Karring

Diagnosis, prognosis and decision-making in the treatmentof combined periodontal-endodontic lesions by Ilan Rotstein & James H. S. Simon "2000"

The endo-perio lesion: a criticalappraisal of the disease condition by ILAN ROTSTEIN & JAMES H. SIMON "2006"

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