ENDO-PERIO LESIONS is one and both pulp and periodontal tissue are affected by disease progress

ENDO-PERIO LESIONS is one and both pulp and periodontal tissue are affected by diseas

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2. ENDO-PERIO LESIONs-diagnosis and management. Presented by- Dr. ANURADHA REDDY

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4. INTRODUCTION Understanding the interrelationship between endodontic and periodontal diseases is crucial for correct diagnosis, prognosis, and treatment decision-making. The dental pulp and periodontium are closely related, and the pathways of communication between these structures often determine the progress of disease in these tissues. Understanding the interrelationship between endodontic and periodontal diseases is crucial for correct diagnosis, prognosis, and treatment decision-making. The dental pulp and periodontium are closely related, and the pathways of communication between these structures often determine the progress of disease in these tissues. 4

5. The etiopathogenesis of endodontic–periodontic lesions. 5

6. Pathways for communications Dentinal Tubules. Lateral or Accessory canals. Apical foramen. 6

7. 7 DENTINAL TUBULES Exposed dentinal tubules in areas devoid of cementum may serve as communication pathways between the pulp and the periodontal ligament. Exposure of dentinal tubules may occur due to developmental defects, disease processes, or periodontal or surgical procedures.

8. 8 LATERAL AND ACCESSORY CANALS can be present anywhere along the root. The presence of patent accessory canals is a potential pathway for the spread of microorganisms and their toxic byproducts from the pulp to the periodontal ligament and vice versa, resulting in an inflammatory process in the involved tissues.

9. 9 APICAL FORAMEN Is the principal route of communication between the pulp and the periodontium. Bacterial byproducts and inflammatory mediators in a diseased pulp may exit readily through the apical foramen to cause periapical pathosis and vice versa.

10. Etiological FACTORS 10 PATHOGENIC FACTORS Among the live pathogens encountered in a diseased pulp that can cause lesions in the periodontal tissues are bacteria, fungi, and viruses.

11. 11 NON LIVING PATHOGENS The presence of certain foreign substances in situ may explain the emergence or persistence of some apical pathoses, substances such as dentin and cementum chips, amalgam, root canal filling materials, cellulose fibers from absorbent paper points, gingival retraction cords and calculus-like deposits. Mechanical or surgical removal of the foreign bodies is usually the treatment of choice. NON LIVING PATHOGENS The presence of certain foreign substances in situ may explain the emergence or persistence of some apical pathoses, substances such as dentin and cementum chips, amalgam, root canal filling materials, cellulose fibers from absorbent paper points, gingival retraction cords and calculus-like deposits. Mechanical or surgical removal of the foreign bodies is usually the treatment of choice.

12. 12 CONTRIBUTING FACTORS Inadequate endodontic treatment : Poor endodontic treatment allows canal re-infection, which may often lead to treatment failure. Endodontic failures can be treated either by orthograde or retrograde retreatment with good success rates. Trauma: Trauma to teeth and alveolar bone may involve the pulp and the periodontal ligament.

13. 13 Coronal leakage : Coronal leakage is the leakage of bacterial elements from the oral environment along restoration margins to the endodontic filling. Ray & Trope reported that defective restorations and adequate root canal fillings had a higher incidence of failures than teeth with inadequate root canal fillings and adequate restorations. (Ray HA, Trope M. Periapical status of endodontically treated teeth in relation to the technical quality of the root canal filling and the coronal restoration. Int Endod J 1995;28:12-8 .)

14. 14 Perforations: When root perforation occurs, communications between the root canal system and either peri-radicular tissues or the oral cavity may often reduce the prognosis of treatment. It has been recognized that treatment success depends mainly on immediate sealing of the perforation and appropriate infection control.

15. 15 Developmental malformations : Teeth with developmental malformations are directly associated with an invagination or a vertical developmental radicular groove. These grooves are usually seen in central fossa of maxillary central and lateral incisors. This fissure-like channel provides a nidus for the accumulation of bacterial biofilm and an avenue for the progression of periodontal disease that may also affect the pulp.

16. 16 Resorptions: Root resorption is a condition associated with either a physiologic or a pathologic process resulting in a loss of dentin, cementum, and or bone. Non-infective Root Resorption This process occurs as a result of a tissue response to non-microbial stimuli in the affected tissues. It includes Transient root resorption, Pressure-induced root resorption, Chemical-induced root resorption, and Replacement resorption.

17. 17 Infective Root Resorption: This process occurs due to a vascular response to microorganisms invading the affected tissues. It may be located either within the root canal space (internal resorption) or on the external root surface of the root (external resorption). Practically, almost all teeth with apical periodontitis will exhibit a certain degree of root resorption. If allowed to progress, the resorptive process can destroy the entire root.

18. 18 Difference Between Endodontic and Periodontal Lesions

19. CLASSIFICATION 19 SIMON’S CLASSIFICATION Simon et al proposed a classification based on the etiology and subsequent progression of the disease process. Primary Endodontic Lesion Primary Endodontic Lesions With Secondary Periodontal Involvement Primary Periodontal Lesion Primary Periodontal Lesion With Secondary Endodontic I nvolvement True combined lesion Concomitant endodontic and periodontal lesion (added by belk and guttmann )

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21. ACCORDING TO WEINE: Tooth in which symptoms clinically and radiographically simulate periodontal disease but are due to pulpal inflammation Tooth that has both pulpal and periodontal disease concomitantly Tooth has no pulpal problem but requires endodontic therapy plus root amputation to gain periodontal healing Tooth that clinically and radiographically simulated pulpal or periapical disease but in fact has periodontal disease 21

22. 22 Type 1 Lesion requiring endodontic treatment only. tooth with necrotic pulp reaching apical periodontium Root perforations Root fractures Chronic periapical abscess with sinus tract Reimplants Transplants Teeth requiring hemisection . Type 2 Lesion that require periodontal treatment only Occlusal trauma causing reversible pulpities supra/infra bony pockets caused during periodontal treatment resulting in pupal inflammation Occlusal trauma and gingival inflammation resulting in pocket formation Type 3 Lesions that require combined endodontic and periodontal treatment Any lesion of type 1 which result in irreversible reaction to periodontium requiring periodontal treatment Any lesion of type 2 which results in irreversible damage to pulp tissue requiring endodontic therapy Oliet and Pollock’s Classification This Classification Is Based On Treatment Protocol.

23. Clinical diagnostic aids VISUAL EXAMINATION The alveolar mucosa and the attached gingiva are examined for the presence of inflammation, ulcerations, or sinus tracts. PERCUSSION An abnormal positive response indicates inflammation of the periodontal ligament that may be either from pulpal or periodontal origin. PULP TESTING The most commonly used pulp vitality tests are cold test, electric test, blood flow tests and cavity test. The same degree of confidence cannot be ascribed to positive pulp test responses in a tooth with multiple canals. 23

24. 24 MOBILITY Tooth mobility is directly proportional to the integrity of the attachment apparatus or to the extent of inflammation in the periodontal ligament. In cases of primary endodontic pathology, the mobility resolves within a week of initiating endodontic therapy. RADIOGRAPHS Interpretation of discrete periapical/lateral lesion- suggest cause of lesion Radiograph is of little value when bone loss extends from crestal bone to/near apex

25. FISTULA TRACKING Endodontic or periodontal disease may sometimes develop a fistulous sinus tract. Fistula tracking is done by inserting a semirigid radiopaque material into the sinus track until resistance is met. Commonly used materials include gutta-percha cones or pre-softened silver cones. A radiograph is then taken, which reveals the course of the sinus tract and the origin of the inflammatory process  25

26. 26 Salient Features of Endodontic–Periodontic Lesions

27. Primary Endodontic Lesions 27 Typically, endodontic lesions resorb bone apically and laterally and destroy the attachment apparatus adjacent to a nonvital tooth. Inflammatory processes in the periodontium occurring as a result of root canal infection not only may be localized at the apex but also may appear along the lateral aspects of the root and in furcation areas of two- and three-rooted teeth. The emergence of these processes may be associated with clinical signs of inflammation: pain, tenderness to pressure and percussion, increased tooth mobility, and swelling of the marginal gingiva, simulating a periodontal abscess.

28. Clinically, endodontic testing procedures should reveal a necrotic pulp or, in multirooted teeth, at least an abnormal response, indicating the pulp is degenerating. Because the primary lesion is an endodontic problem that has merely manifested itself through the periodontal ligament, complete resolution is usually anticipated following nonsurgical endodontic therapy without any periodontal treatment.

29. Primary Endodontic Lesions With Secondary Periodontal Involvement 29 When a lesion of endodontic origin is not treated, usually pathosis will continue, leading to destruction of the periapical alveolar bone and progression into the interradicular area, causing breakdown of surrounding hard and soft tissues. As drainage persists through the gingival sulcus , accumulation of plaque and calculus in the purulent pocket results in periodontal disease and further apical migration of the attachment. When this occurs, not only does the diagnosis become more difficult, but the prognosis and treatment may be altered. Diagnostically, these lesions have a necrotic root canal and plaque or calculus accumulation, demonstrable by a probe and radiograph.

30. Radiographs may show generalized periodontal disease with angular defects at the initial site of the endodontic involvement. Resolution of the primary endodontic and secondary periodontal lesion relies on treatment of both conditions When only endodontic therapy is provided, only part of the lesion can be expected to heal. If endodontic therapy is adequate, the prognosis depends on the severity of periodontal involvement and efficacy of periodontal therapy. 30

31. 31 Primary endodontic lesion with secondary periodontal involvement in relation to the distal root necessitating endodontic therapy of the lower first molar followed by periodontal therapy. (b) Seven-year follow-up showing complete healing of both endodontic and periodontal lesions.

32. Primary Periodontal Lesions 32 Periodontal disease has a progressive nature. It begins in the sulcus and migrates to the apex as deposits of plaque and calculus produce inflammation, causing loss of surrounding alveolar bone and supporting periodontal soft tissues. This leads to a loss of clinical attachment and formation of a periodontal abscess during the acute phase of destruction. The progression of periodontal disease to the formation of osseous defects and subsequent radiographic appearance along lateral aspects of roots and in furcation areas is seen.

33. These defects may or may not be in association with trauma from occlusion, which can often be the cause of an isolated periodontal problem. Osseous lesions of periodontal origin are usually associated with tooth mobility, and the affected teeth respond positively to pulp testing. In addition, careful periodontal examination will usually reveal broad-based pocket formation and an accumulation of plaque and calculus. The bony lesion is usually more widespread and generalized than lesions of endodontic origin . 33

34. The prognosis for those teeth affected by periodontitis worsens as the disease process and periodontal destruction progress. Treatment depends on the extent of the periodontitis and on the patient’s ability to comply with potential long-term treatment and maintenance therapy. Because this is purely a periodontal problem, the prognosis depends exclusively on the outcome of periodontal therapy. 34

35. Primary periodontal disease in a maxillary second premolar (A)Radiograph showing alveolar bone loss and a periapical radiolucency . Clinically, a deep narrow pocket was found at the mesial aspect of the root. There was no evidence of caries and the tooth responded normally to pulp sensitivity tests. (B) Radiograph showing pocket tracking with gutta-percha cone to the apical area. It was decide to extract the tooth. (C) Clinical view of the extracted tooth with the attached lesion. Note a deep mesial radicular development groove . 35

36. Primary Periodontal Lesions With Secondary Endodontic Involvement 36 periodontal disease can have an effect on the pulp through dentinal tubules, lateral canals, or both. Primary periodontal lesions with secondary endodontic involvement differ from the primary endodontic lesion with secondary periodontal involvement only by the temporal sequence of the disease processes. The tooth with primary periodontal and secondary endodontic disease exhibits deep pocketing, with a history of extensive periodontal disease and, possibly, past treatment. When the pulp becomes involved, the patient often reports accentuated pain and clinical signs of pulpal disease.

37. This situation exists when the apical progression of periodontal disease is sufficient to open and expose the pulp to the oral environment by way of lateral canals or dentinal tubules. On radiographs, these lesions may be indistinguishable from primary endodontic lesions with secondary periodontal involvement. The prognosis depends on continuing periodontal treatment subsequent to endodontic therapy. Primary periodontal disease with secondary endodontic involvement in a maxillary premolar. (A) Radiograph showing bone loss in one third of the root and separate periapical radiolucency . The crown was intact but pulp sensitivity tests were negative and the pulp was necrotic on entry. (B) Radiograph taken immediately after root canal therapy showing sealer in lateral canal that was exposed due to the bone loss. 37

38. True Combined Lesions 38 In certain cases, the signs and symptoms of pulpal and periodontal involvement are such that it is clinically not possible to differentiate which started first. Such a chronic lesion with gross pulpal and periodontal destruction is referred to as a true combined lesion. The prognosis in such cases is typically guarded by the chronic nature of the periodontal disease process. These are typical cases which might need endodontic therapy followed by radisection / hemisection in order to improve the prognosis of the affected tooth.

39. True combined endodontic and periodontal lesion in a mandibular molar. Note the proximal decay involving the pulp causing a periradicular radiolucency in the distal root indicative of the endodontic lesion which is combined with the angular bone loss caused by the periodontal lesion.

40. Concomitant Pulpal and Periodontal Lesions 40 This arises due to the presence of distinct etiological factors of pulpal and periodontal diseases which do not influence one another. The signs and symptoms of both the diseases are evident independent of each other. Usually treatment is rendered to only one of the two diseases in a hope that the other would subside. However, resolution of this lesion would occur when both the diseases are treated independently.

41. 41 Concomitant endodontic and periodontal lesion in a maxillary premolar. Note the proximal decay involving the pulp causing a periradicular radiolucency indicative of the endodontic lesion which is independent of the horizontal bone loss caused by the periodontal lesion.

42. Treatment alternatives: Endodontic lesions should be treated before the management of the periodontal lesions because of the following reasons: ŠŠEndodontic treatment is highly predictable. ŠŠPeriodontal component cannot resolve till the endodontic lesion is present. ŠŠProgress of periodontitis is slow, with the exception of acute disease. Therefore, prompt management of the pulpal lesion is the primary concern. When traditional endodontic and periodontal treatments prove insufficient to stabilize an affected tooth, the clinician must consider treatment alternatives. Generally, a localized periodontal defect associated with an endodontically untreatable tooth or an iatrogenic tooth problem is reason to explore other treatment options. 42

43. 43 Alternate treatments often consist of resection or regenerative approaches. Resection techniques focus on eliminating the diseased roots or teeth; regenerative efforts are aimed at restoring lost biologic structures. Resection methods involve removal of affected roots or extraction of involved teeth. Bone replacement grafts using guided-tissue and bone-regeneration techniques are ways to reestablish biologic structures that were lost during this disease process. Root resection is the removal of a root, with accompanying odontoplasty before or preferably after endodontic treatment. Formerly it was used when root canal therapy was considered too difficult, but now its indications are restricted to multirooted teeth in which one or more roots cannot be saved.

44. 44 The indications for root resection often include (but are not limited to) root fracture, perforation, root caries, dehiscence, fenestration, external root resorption involving one root, incomplete endodontic treatment of a particular root, severe periodontitis affecting only one root, and severe Grade II or III furcation involvement. Factors such as occlusal forces, tooth restorability, and the value of the remaining roots must be examined before treatment. Proper reshaping of the occlusal table and restoration of the clinical crown are essential, and the root surface must be recontoured to remove the root stump, thus preventing formation of a potential food trap.

45. 45 Retrospective longitudinal studies have observed the fate of sectioned teeth for time frames ranging from 3 to 12 years and have reported success rates ranging from 62% to 100%, with a low incidence (i.e., 10%) of periodontal breakdown. However, as most long-term studies will point out, the major cause of failure of resection procedures resides in failure of the endodontic and restorative components. Unique anatomic features, such as root length, curvature, shape, size, position of adjacent teeth, and bone density, may influence the end result. The removal of roots purely to eliminate a resorptive or traumatic perforation defect, fractured root, or endodontically inoperable root usually results in definitive treatment.

46. 46 The final restoration of root- resected teeth will depend significantly on the nature of the resection, the amount of remaining tooth structure, the periodontal status, and the patient’s occlusion. The prosthetic aspects of tooth restoration must be carefully assessed and integrated into the anticipated surgical procedure to ensure proper positioning of tooth margins relative to the osseous crest and also to manage the anticipated changes in occlusal relationships and masticatory forces. Controversy has also existed regarding the benefits and need for endodontic therapy before root resection. Instances develop in which exploratory surgery is necessary; should the

47. 47 periodontal problem be more extensive than that determined presurgically , the removal of a root should be carried out at that time. In these instances, removal of the involved root without endodontic treatment would be acceptable, but root canal therapy should be performed as soon as possible after root removal. After resection of a vital root, the pulpal opening in the crown may be sealed and restored with a permanent amalgam restoration or sedative base material (e.g., Dycal ) as a temporary solution it is generally agreed that whenever possible, endodontics should be performed in advance (before root resection).

48. 48 If this is not possible, the endodontic treatment should be performed as soon as possible after vital-root amputation. Otherwise, pulpal complications such as internal resorption , pulpal inflammation, and necrosis may occur. The concepts of guided tissue regeneration (GTR) or guided bone regeneration (GBR) have been used to promote bone healing after endodontic surgery. Theoretically, the GTR barrier prevents contact of connective tissue with the osseous walls of the defect, protecting the underlying blood clot and stabilizing the wound. The quality and quantity of the regenerated bone were superior with adjunctive use of the membrane than without such use.

49. 49 With the introduction of the GTR concept, a combination of bone replacement graft and GTR membrane has shown promising results.

50. RESTORATIVE – PERIODONTICS INTER-RELATION 50 DR. ABDUL KADIR 3 RD YEAR MDS

51. The long term success of a restored tooth depends on the preservation of a healthy periodontium There has been a difficulty in placement of restorative margins and prosthetic replacement of periodontally compromised patients. Many treatment failures were attributed to poor handling of periodontal tissues but blamed on poor oral hygiene/ cooperation by the patient. The actual reason for these incidents is the violation of biologic width due to improper margins. 51

52. BIOLOGIC WIDTH 52 BIOLOGIC WIDTH is defined as the physiologic dimension of the junctional epithelium and connective tissue attachment. (Glossary of Periodontal Terms, 2001) It acts as a biologic seal surrounding the teeth to protect the subgingival connective tissue from microbes and simultaneously support the alveolar bone. The dimension of biologic width can vary based on tooth position, from tooth to tooth or surface to surface on the same tooth, but it is present in all healthy dentition. It varies in different individuals. The biologic width follows the architecture of the bone crest which follows the scalloped shape of CEJ .

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55. 55 SUPRAGINGIVAL MARGINS: Advantages of supragingival restorations: ♦ Ease of impression making ♦ Ease of cleansing ♦ Least gingival inflammation ♦ Detection of secondary caries ♦ Maintenance of probing depths. The clinician can place supragingival, equi -gingival (even with the tissue) and subgingival margins. It is always advisable to place supragingival margins.

56. 56 EQUI-GINGIVAL MARGINS: Equi -gingival margins were not preferred due to increased plaque accumulation and gingival inflammation. However, with superior finishing techniques, it can be used to get a smooth polished interface at gingival margin. It is also well-tolerated by the periodontium, provided it is above the crest.

57. 57 SUBGINGIVAL MARGINS: ♦ They can at instances cause direct operative trauma to the tissues. ♦ They facilitate increased plaque accumulation subgingivally which leads to accelerated periodontal breakdown and recurrent caries. ♦ In thin gingival biotypes, the inflammatory response to plaque accumulation results in gingival recession. ♦ In thick gingival biotypes, crestal bone loss, loss of connective tissue attachment and deep pocket formation can be seen. ♦ Gingival hyperplasia and minimal bone loss or a combination of these presentations can also be seen at times.

58. 58 USE OF SULCULAR DEPTH AS A GUIDE: If the sulcus depth is 1.5mm or less, the restoration margin should be 0.5mm below the gingival crest. It is important on the facial aspect to maintain the biologic width if the patient is at high risk for recession. If the sulcus depth is more than 1.5mm, place the margin approximately 0.75mm/ half the sulcus depth, so that it is still under the tissue if the patient is at high risk for recession. If sulcus depth is >2mm especially on the facial aspect, evaluate whether gingivectomy could be performed to create a 1.5mm sulcus and treat the patient using first rule.

59. Restoration overhangs: Overhanging restorations are considered to be a contributing factor for gingivitis and attachment loss --- due to retention of bacterial plaque and increase in periodontal pathogens within the bacterial plaque. Jeffcoat & Howell correlated severity of overhang with periodontal destruction. They classified overhangs into 3 categories based on their space occupied- Small - 51% of the interproximal space Medium – 20 to 50% of interproximal space Large- >51% of the interproximal space 59

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61. Conclusion: Periodontal health is dependent on the integrity of the restoration given. A minimum of 3mm space is needed between restorative margin and alveolar crest to allow 2mm for biologic width and 1mm for sulcus depth. Overhanging restorations and open inter-proximal contacts should be removed during disease control phase of therapy. It is preferable to place supragingival margins. If subgingival margins are indicated, then crown-lengthening should be performed either surgically or orthodontically to provide adequate biologic width. 61

62. REFERENCES 62 COHEN’S, Pathways of the pulp. 11 th edition. Ingle’s Endodontics . 6 th edition. Grossman’s endodontic practice, 14 th edition.