Endo - Perio lesions

endo perio lesions

1. PERI O DON T IUM PULP

2. CONTENTS INTRODUCTION PATHWAYS OF COMMUNICATION OF PULP AND PERIODONTIUM CONTRIBUTING AND ETIOLOGICAL FACTORS INFLUENCE OF PULPAL DISEASE ON PERIODONTIUM INFLUENCE OF PERIODONTAL DISEASE ON PULP CLASSIFICATIONS OF ENDO PERIO LESIONS CLINICAL SIGNS DIAGNOSIS MANAGEMENT OF ENDO PERIO LESIONS(PROGNOSIS AND TREATMENT) CONCLUSION REFERENCES

3. The tooth , pulp tissue within it and its supporting structures should be viewed as one biological unit Pulp and the periodontium have embryonic, functional and anatomical relationship. Embryonic- both develops from ectomesenchyme Functional - common blood supply Anatomic - patent pathways - apical foramen, lateral canals INTRODUCTION

4. These inter-relationship of these structures influences each other during heath function and disease process. 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 pulp The relationship between the periodontium and pulp was first discovered by SIMRING and GOLDBERG in 1964 The term pulpodontic periodontal syndrome was first described by BENDER AND SELTZER in 1972

5. Rubach and Mitchell suggested that the periodontal disease may affect the pulp heath when the accessory canal exposure occurs Lindhe also reported that bacterial infiltrates of the inflammatory process may reach the pulp when there is accessory canal exposure ,through apical foramens and canals in furcation areas Adrians et al demonstrated that bacteria coming from the periodontal pockets have the capacity of reaching the root canals ,suggesting that the dentinal tubules may serve as the reservior for these microorganisms

6. PATHWAYS OF COMMUNICATIONS BETWEEN PULP AND PERIODONTIUM

7. PATHWAYS OF DEVELOPMENTAL ORIGIN (ANATOMIC PATHWAYS)

8. EMPTY SPACES ON ROOT CREATED BY SHARPEY’S FIBERS ROOT FRACTURE FOLLOWING TRAUMA IDIOPATHIC INTERNAL AND EXTERNAL ROOT RESORPTION LOSS OF CEMENTUM DUE TO EXTERNAL IRRITANTS PATHWAYS OF PATHOLOGICAL ORIGIN

9. PATHWAYS OF IATROGENIC ORIGIN

10. CONTRIBUTING FACTORS

11. ETIOLOGICAL FACTORS

12. INFLUENCE OF PULPAL DISEASE ON PERIODONTIUM Pulpal disease Procedural errors in RCT Perforations Vertical root fractures P e r i - ra d ic u l a r inflammation Bone loss + CAL +/- Pus discharge RETROGRADE PERIODONTITIS

13. INFLUENCE OF PERIODONTAL DISEASE ON PULP P a th o g e n i c Bacteria and i n flamm a tory products of periodontal disease Accessory canal / Lateral canals / apical foramen P u l p al infection/necrosis R E TROG R ADE PULPITIS

14. Severe breakdown of the pulp apparently does not occur until periodontitis has reached a terminal state- that is, when bacterial plaque has involved the main apical foramina. Effect depend on cemental and remaining dentin thickness The pulp has a good capacity for defense as long as the blood supply via the apical foramina is intact. Therefore retrograde pulpitis , if it occurs, is exceedingly rare.

15. CLASSIFICATION: Primary Endodontic Disease Primary Periodontal disease Combined Disease Primary Periodontal Secondary Endodontic Primary Endodontic Secondary Periodontal True Combined Lesion Simon, Glick and Frank in 1972

16. Class I : Tooth in which symptoms clinically and radiographically simulate periodontal disease but are infact due to pulpal inflammation and/or necrosis. Class II : Tooth that has both pulpal or periapical disease and periodontal disease concomitantly. Class III : Tooth that has no pulpal problem but requires endodontic therapy plus root amputation to gain periodontal healing. Class IV : Tooth that clinically and radiographically simulates pulpal or periapical disease but infact has periodontal disease. According to Weine

17. TORABINEJAD AND TROPE CLASSIFICATION -1996 1.ENDODONTIC ORIGIN 2.PERIODONTAL ORIGIN 3.COMBINED ENDO-PERIO LESION 4.SEPARATE ENDODONTIC PERIODONTAL LESION 5.LESION WITH COMMUNICATION 6. LESION WITHOUT COMMUNICATION International journal of dentistry volume 2014

18. ENDODONTIC PERIODONTAL LESION PERIODONTIC ENDODONTIC LESION COMBINED LESION WORKSHOP FOR CLASSIFICATION OF PERIODONTAL DISEASE -1999 International journal of dentistry volume 2014

19. Lesions that require endodontic treatment procedures only. Lesions that require periodontal treatment procedures only. Lesions that require combined endodontic – periodontic treatment procedures. According to Oliet and Pallock – Based on treatment procedures :

20. Lesions that require endodontic procedures only necrotic pulp and apical granulomatous tissue replacing periodontium with or without sinus tract Chronic periapical abscess with sinus tract Longitudinal and horizontal root fractures Pathologic and iatrogenic root perforations Teeth with incomplete apical root development Teeth that require hemisection or radisectomy

21. Lesions that require periodontal procedures only Occlusal trauma causing reversible pulpitis Occlusal trauma plus gingival inflammation resulting in pocket formation Suprabony or infrabony pocket formation treated with overzealous root planning and curettage leading to pulpal sensitivity Extensive infrabony pocket formation extending beyond the root apex and sometimes coupled with lateral or apical resorption yet with pulp that responds with in normal limits to clinical testing

22. lesions that require combined endodontic and periodontic treatment Any lesion in Group I That results in irreversible reactions in the attachment apparatus and requires periodontal treatment Any lesion in Group II that results in irreversible reactions to the pulp tissue and also requires endodontic treatment

23. PRIMARY ENDODONTIC: Etiology Dental caries,restorative procedures, Chemical irritants, traumatic injuries Clinical features Pain ,tenderness to palpation and percussion Sinus opening Abnornal response to vitality test

24. Examination Primary endodontic lesion VISUAL Presence of caries,large restorations,fractured restorations or teeth attrition,abrasion,erosion,cracks , discoloration PAIN sharp PALPATION It does not indicate whether the Inflammation is pulpal or periodontal origin PERCUSSION Present MOBILITY Fractured roots ,recently traumatized teeth shows mobility PULP VITALITY Lingering response – irreversible pulpitis No response – non vital teeth POCKET PROBING Deep narrow solitary pockets SINUS TRACING Gp points to apex or furcation areas RADIOGRAPH Deep carious lesions,extensive restorations,periapical radiolucency , Poor rct , mishaps like root fractures, perforations, root resorptions CRACKED TEETH TESTING Painful response during chewing especially when releasing the biting pressure

25. PRIMARY PERIODONTAL: Etiology Plaque and calculus are the primary etiological factors Clinical features Pocket formation Attachment loss Bone loss

26. Examination Primary periodontal lesions VISUAL Presence of plaque and calculus , inflammed gingiva , gingival recession, presence of swelling and pus discharge through gingival crevice in case of periodontal abscess PAIN Usually dull ache PALPATION Presence of pain on palpation PERCUSSION present MOBILITY Localized to generalized mobility of teeth PULP VITALITY Pulp is vital and responsive to testing POCKET PROBING Multiple wide deep pockets SINUS TRACING Sinus tract mainly at lateral aspect of the root RADIOGRAPH Horizontal or vertical bone loss, bone loss wider coronally CRACKED TEETH TESTING No symptoms

27. PRIMARY ENDO SECONDARY PERIODONTAL: Etiology Progression of chronic primary endodontic lesion Plaque and calculus

28. Examination PRIMARY ENDO SECONDARY PERIO VISUAL Plaque formed at the gingival margin of the sinus tract PAIN Usually sharp shooting pain. dullache in chronic cases PALPATION Pain on palpation PERCUSSION Tenderness on percussion MOBILITY Localized mobility PULP VITALITY negative POCKET PROBING Localized solitary wide pocket. SINUS TRACING Sinus tract mainly at apex or furcation areas RADIOGRAPH Presence of deep carious lesions,extensive restorations,previous poor root canal treatment, root fractures, root resorptions CRACKED TEETH TESTING Painful response during chewing especially when releasing the biting pressure

29. PRIMARY PERIODONTAL SECONDARY ENDODONTIC: Etiology Progression of periodontal disease apically Clinical features Pocket formation ,bone loss,attachment loss Acute pulpal pain

30. Examination PRIMARY PERIO SECONDARY ENDO VISUAL Paque calculus,gingival swelling around the multiple teeth, g ingival recession,presence of pus exudate , PAIN Usually dull ache ,sharp pain in case of acute periodontal abscess PALPATION Pain on palpation PERCUSSION Tenderness on percussion MOBILITY Generalized mobility PULP VITALITY Positive in cases of multi rooted teeth POCKET PROBING Presence of multiple wide deep periodontal pockets SINUS TRACING Sinus tract mainly at the lateral surface of the root RADIOGRAPH Angular bone loss in multiple teeth wide base coronally and narrow at the apex of the root CRACKED TEETH TESTING No symptoms

31. TRUE COMBINED PERIODONTAL & ENDODONTIC: Distinct etiological factors which donot influence each other

32. Pus disch a r ge Pocket form a tion Sinus tract Tender to per c ussion Mobility CLINICAL SIGNS GINGIVAL SWELLING

33. FEATURES OF PULPAL AND PERIODONTAL LESIONS : Pulpal Periodontal Clinical Cause Pulp infection Periodontal infection Vitality Nonvital Vital Restorative Deep or extensive Not related Plaque / calculus Not related Primary cause Inflammation Acute Chronic Pockets Single, narrow Multiple,wide coronally pH value Often acid Usually alkaline

34. Radiographic Pattern Localized Generalized Bone loss Wider apically Wider coronally Periapical Radiolucent Not often related Vertical bone loss No Yes Histopathology Junctional epithelium No apical migration Apical migration Granulation tissues Apical (minimal) Coronal (Larger) Gingival Normal Some recession Therapy Treatment Root canal therapy Periodontal treatment Pulpal Periodontal

35. DIAGNOSIS : History taking Examination Pulp testing Periodontal evaluation Radiographic evaluation Fistula tracking

36. Visual Examination Soft Tissue Inflammation Ulceration Sinus tracts Teeth Caries Defective restorations Cracks Fractures Discolorations Palpation - Peri-radicular abnormality Percussion – Peri-radicular inflammation

37. o Pulp Testing (EPT + Cold test): LESION RESPONSE Primary Periodontal + Primary Periodontal Secondary Endodontic +/- Primary Endodontic +/- Primary Endodontic Secondary Periodontal - Combined pulpal - False Positive response may be interpreted in combined lesion in multi rooted teeth as either intact vital pulp or partially necrotic pulp.

38. o Mobility Loss of periodontal support Peri-radicular abscess Fractured roots Probing Deep solitary pocket – Endo cause Broad and deep pockets - Perio Fistula Tracking #25 GP/Probe - radiopaque Until Resistance is felt

39. Radiographic evaluation Root fractures Perforations Resorptions Restoration margins Extension of bone loss Adequacy of obturation

40. Management Of Endo Perio Lesions Estimation of prognosis Treatment of endo perio cases

41. PROGNOSIS: Depends on Patients oral hygiene The amount of attachment loss Endodontic status Effectiveness of the periodontal treatment accomplished Primary endo -- Good to excellent prognosis Primary perio -- Depends on periodontal therapy Combined lesion -- Poor prognosis Periodontology 2000, Vol. 34, 2004, 165–203

42. Treatment : RCT Primary Endodontic Periodontal therapy Primary Periodontal RCT + Periodontal therapy immediately/later Primary Endodontic Secondary Periodontal Scaling + Immediately followed by cleaning and shaping  Follow up & observe pocketing  Obturation Primary Periodontal and Secondary Endodontic RCT + periodontal therapy True Combined lesion

43. Removal of underlying cause Check endodontic status If Root canal treated Evaluate adequacy Preparation: Under prepared Over prepared Perforation Zipping ledges Obturation : Under filled Overfilled Poor adaptation Is root canal re-treatment feasible?

44. If Yes Do first stage endo Clean and shape canals Dress with calcium hydroxide Resolution? Yes No Extract

45. Elimination of palatogingival groove

46. Management of cervicoenamel projection Should be eliminated down to the crestal bone level by saucerization osteoplasty or regenerative procedures may required to treat the osseous defect

47. Management of internal resorption Extirpation of pulp Routine endodontic treatment and Obturation with Thermoplasticized guttapercha If the root is perforated MTA is used to repair the defect

48. Management of external resorption If due to pulpal disease -root canal therapy If it is due to orthodontic appliances Reducing the forces In case of external cervical root resorption -surgical exposure of the defect and restoration with suitable material

49. Management of trauma from occlusion Occlusal adjustments Orthodontic tooth movement Management of parafunctional habits `

50. ALTERNATIVE TREATMENT MODALITIES : When traditional endodontic and periodontal treatments prove insufficient to stabilize affected teeth, the clinician must consider other treatment alternatives like: Root Amputation : Removal of one or more roots of a multi rooted tooth while the others are retained Hemisection : Removal or separation of root with its accompanying crown portion of mandibular molars Radisection : Newer terminology for removal of roots of maxillary molars Bicuspidization : Separation of mesial and distal roots of mandibular molar along with its crown portion, where both segments are then retained individually

51. Indications for Resections and hemisection Periodontal indications Severe vertical bone loss involving only one root of a multi rooted tooth Through and through furcation destruction Unfavorable proximity of roots of adjacent teeth, preventing adequate hygiene maintenance in proximal areas Severe root exposure due to dehiscence

52. Restorative and endodontic indications : Endodontic failure: perforations, over extension , obstructed canals, separated instrument , root resorption Vertical fracture of one root Restorative reasons: sub gingival caries, erosion of large part of crown and root, traumatic injury Combination of these

53. Contraindications Root fusion making separation impossible Angulation or position of tooth in the arch: if the tooth is buccally or lingually , mesially or distally cannot be resected When the loss of bone involves more than one root Improperly shaped occlusal contact may convert occlusal forces in to destructive forces and cause failure of hemisection

54. Surgical exposure of Furcation prior to sectioning of disto buccal root Initial cut with a diamond instrument Widened cut to allow instrumentation ROOT RESECTION

55. Elevation of disto buccal root Surgical closure Appearance of tooth following the removal of disto buccal root

56. HEMISECTION Refers to sectioning of molar teeth with removal of one half crown and its supporting root structure

57. BICUSPIDIZATION Bicuspidization is a surgical procedure carried out exclusively on the mandibular molars Where the mesial and distal roots are seperated with their respective crowns and retention of both halves This seperation eliminates the existance Of furcation and makes it easy for the patients to maintain hygiene

58. CONCLUSION : The endodontic periodontal problems are responsible for more than 50% mortality today. They present challenges to the clinicians as far as the diagnosis and prognosis of the involved teeth. The treatment rendered and the subsequent success or failure of that treatment, is directly dependent on making an accurate diagnosis of the lesion.

59. REFERENCES : Seltzer – Biologic considerations in endodontic practice, 4 th edition Grossman Endodontic Practice, 13th Edition Cohen Pathways of the pulp, 9th Edition Franklin S.Weine endodontictherapy ,4 th edition Nisha garg ,text book of endodontics ,3 rd edition Carranza text book of periodontics ,11 th edition