CLINICAL IMPLICATIONS OF ENDOPERIO LESIONS.pptx

The actual relationship between periodontal and pulpal disease was first described by Simring and Goldberg in 1964. Since then, the term “perio-endo” lesion has been used to describe lesions due to inflammatory products found in varying degrees in both the periodontium and the pulpal tissues. The pulp and periodontium have embryonic, anatomic and functional inter-relationships. The simultaneous existence of pulpal problems and inflammatory periodontal disease can complicate diagnosis and treatment planning. A perio-endo lesion can have a varied pathogenesis which ranges from quite simple to relatively complex one. Knowledge of these disease processes is essential in coming to the correct diagnosis. This is achievable by careful history taking, examination and the use of special tests. The prognosis and treatment of each endodontic-periodontal disease type varies. Primary periodontal disease with secondary endodontic involvement and true combined endodontic-periodontal diseases require both endodontic and periodontal therapies. The prognosis of these cases depends on the severity of periodontal disease and the response to periodontal treatment. This enables the operator to construct a suitable treatment plan where unnecessary, prolonged or even detrimental treatment is avoided.

Go to:
Introduction
The endodontium and periodontium are closely related and diseases of one tissue may lead to the involvement of the other. The differential diagnosis of endodontic and periodontal diseases can sometimes be difficult but it is of vital importance to make a correct diagnosis so that the appropriate treatment can be provided. Endodontic-periodontal lesions present challenges to the clinician as far as diagnosis and prognosis of the involved teeth are concerned. Etiologic factors such as bacteria, fungi, and viruses as well as various contributing factors such as trauma, root resorptions, perforations, and dental malformations play an important role in the development and progression of such lesions. The endo-perio lesion is a condition characterized by the association of periodontal and pulpal disease in the same dental element. The relationship between periodontal and pulpal disease was first described by Simring and Goldberg in 1964.1 Since then, the term ‘perio-endo lesion’ has been used to describe lesions due to inflammatory products found in varying degrees in both periodontium and pulpal tissues.

Inter Relationship between pulpal & periodontal tissues
The effect of periodontal inflammation on dental pulp is controversial and conflicting studies abound.2–10 It has been suggested that periodontal disease has no effect on the pulp before it involves the apex.5 On the other hand, several studies suggested that the effect of periodontal disease on the pulp is degenerative in nature including an increase in calcifications, fibrosis, and collagen resorption, in addition to the direct inflammatory sequelae.11,12 Dental pulp and periodontium have embryonic..

1. CLINICAL IMPLICATIONS OF ENDOPERIO LESIONS

2. About 50% of tooth loss is caused by either endodontic infection, periodontal disease or the combination of the two in the form of endo- perio lesions (EPL). Combined EPL develop due to the intimate anatomic and functional relation between endodontic and periodontal tissues. INTRODUCTION Both endodontic and periodontal lesions are polymicrobial anaerobic infections. Teeth with endo- perio lesions have a worse prognosis than isolated endodontic or periodontal lesions.

3. PATHWAYS

4. As far as the functional relation of the two systems is concerned, an endodontic infection can discharge through the periodontal ligament and worsen the periodontal disease by raising the pocket’s depth. An endodontic infection can also cause periodontal tissue destruction in the apical region which can likely migrate upwards reaching the gingival margin This lesion was termed as a retrograde periodontitis which is different from marginal periodontitis Reversely, microorganisms and other toxic irritants can enter the endodontic system through dentinal tubules after the gradual loss of the periodontal attachment.

5. Iatrogenic pathways which can cause combined EPL include : Accidental perforations of the root during endodontic treatment Root cracks as a result of extreme forces applied when cleaning and shaping the root canals Carious lesions affecting the external root surface below the cementoenamel junction Incorrectly adapted coronal restorations

6. CLASSIFICATION Simon et al

7. DIAGNOSTIC EXAMINATIONS

8. PRIMARY ENDODONTIC LESIONS

9. PRIMARY ENDODONTIC LESIONS Visual Presence of decay/ incorrect restorations/ erosion/abrasion Pain Sharp Percussion Normally tender Mobility Present only in fractured or Traumatized teeth Pulp vitality Lingering or noresponse Pocket Solitary narrow probing pocket Sinus tracing Radiograph with gutta-percha points to apex or furcation X-rays Periapical radiolucency Cracked tooth testing Painful when chewing

10. PRIMARY PERIODONTAL LESIONS

11. PRIMARY PERIODONTAL LESIONS Visual Inflammation/ recession of gingiva Presence of plaque/calculus Intact teeth Pain Usually dull ache Percussion Tender on percussion Mobility Localized/ generalized mobility Pulp vitality Positive Pocket probing Multiple wide and deep pockets Sinus tracing At lateral aspect of the root X-rays Vertical bone loss Wider bone loss coronally Cracked tooth testing No symptoms Palpation Pain on palpation

12. PRIMARY ENDODONTIC SECONDARY PERIODONTAL LESIONS

13. PRIMARY ENDODONTIC SECONDARY PERIODONTAL LESIONS Visual Plaque/calculus at the gingival margin Root perforation/fracture Pain Usually sharp Percussion Tender on percussion Mobility Localized mobility Pulp vitality Negative Pocket probing Solitary wide pocket Sinus tracing Mainly at the apex/ furcation area X-rays Wide based apical radioluscency Cracked tooth testing Painful when chewing Palpation Pain on palpation

14. PRIMARY PERIODONTAL SECONDARY ENDODONTIC LESIONS Visual Plaque/ calculus And swelling around multiple teeth Puss + exudate Pain Usually dull ache Percussion Tender on percussion Mobility Generalized mobility Pulp vitality Positive Pocket probing Multiple wide and deep pockets Sinus tracing At lateral aspect of the root X-rays Angular bone loss in multiple teeth Cracked tooth testing No symptoms Palpation Pain on palpation

15. TRUE COMBINED LESIONS Visual Periodontitis around single or multiple teeth Puss + exudate Pain Usually dull ache, sharp only in acute condition Percussion Tender on percussion Mobility Generalized Higher grade mobility on involved tooth Pulp vitality Negative Pocket probing Typical conic periodontal type of probing Sinus tracing Difficult to trace X-rays Similar to vertically fractured tooth Cracked tooth testing Painful when chewing Palpation Pain on palpation

16. TREATMENT OPTIONS

17. PRIMARY ENDODONTIC LESION

18. PRIMARY PERIODONTAL LESIONS Primary periodontal lesions only require periodontal therapy. Treatment options include etiologic therapy by eliminating all factors which can promote epithelial downgrowth followed by surgical periodontics .

19. TRUE COMBINED LESION As a first step , true combined lesions should be addressed with an endodontic treatment. Before any periodontal surgical procedure, etiologic therapy should be initiated as the prognos is of these combined lesions is closely related to the efficiency of the periodontal management . However, apical resection, root amputation or even hemisection of the molar teeth may allow enough change in the configuration of the roots in order for part of the root structure to be saved.

20. Prognosis of an affected tooth can also be improved by increasing bone support around the denuded cement surface, achieved through bone grafting and Guided tissue regeneration(GTR) Bone grafting materials can be broadly classified into natural and synthetic types Natural bone grafts include autogenous bone, allograft, and xenograft, while the synthetic types are commonly known as alloplastic materials Hydroxyapaptite (HA) has been used as a bone replacement material for many years and that has been demonstrated that HA has excellent biocompatibility, high osteogenic potential and anti-infection capacity.

21. An accurate diagnosis is mandatory for the successfully treated endo- perio lesions. This diagnosis must cover both endodontic and periodontal component of the lesion. If the primary aspect cannot be evaluated, endodontic treatment should be given precedence,followed by a wait-and-see approach until a decision for any addi-tional endosurgical and/or periodontal procedure can be focussed .

22. EPL can be a challenge to clinicians as interdisciplinary collaboration is needed in order to obtain a favourable outcome. Due to the lack of current literature documenting these multi factorial illnesses, the first step of diagnosis can be challenging. CONCLUSION Only by careful diagnosis can the most effective therapy method be selected and the succes rate increased. The guidelines to a precise treatment method are straightforward once the lesion is cathegorized properly.

23. Clinically, periodontal regeneration may be achieved by application of barrier membranes, grafts, wound-healing modifiers, and their combinations. Currently, two preparations containing growth and/or differentiation factors are available for clinical application in periodontal regeneration procedures: enamel matrix derivative and platelet-derived growth factor mixed in a beta-tricalcium phosphate bone-replacement graft .  J. Modern clinical procedures in periodontal reconstructive treatment

24. Ozone therapy is beneficial for the successful treatment of endo- perio lesions with narrow periodontal pockets in patients with aggressive periodontitis and poor prognosis.

25. Medicina Clínica Práctica . 2020 June

26. References Nemcovsky CE, Nart J. Modern clinical procedures in periodontal reconstructive treatment. Endodontic-Periodontal Lesions: Evidence-Based Multidisciplinary Clinical Management. 2019:87-123. Oktawati S, Siswanto H, Mardiana A, Neormansyah I, Basir I. Endodontic–periodontic lesion management: A systematic review. Medicina Clínica Práctica . 2020 Jun 1;3:100098. Friedrich F, Scalabrin SA, Weissheimer T, Rösing CK, Só GB, da Rosa RA, Só MV. Influence of the timing of periodontal intervention on periapical/periodontal repair in endodontic-periodontal lesions: a systematic review. Clinical Oral Investigations. 2023 Mar;27(3):933-42. Dakó T, Lazăr AP, Bică CI, Lazăr L. Endo- perio lesions: Diagnosis and interdisciplinary treatment options. Acta Stomatologica Marisiensis Journal. 2020;3(1):257-61. Makeeva MK, Daurova FY, Byakova SF, Turkina AY. Treatment of an endo- perio lesion with ozone gas in a patient with aggressive periodontitis: A clinical case report and literature review. Clinical, cosmetic and investigational dentistry. 2020 Oct 28:447-64.

27. THANK YOU