Endodontic and Periodontal Interrelationships.pptx

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.

1. Endodontic and Periodontal Interrelationships PRESENTED BY – Dr DHEERAJ GUPTA PG II nd Year

2. INTRODUCTION Dental pulp and surrounding periodontium have embryonic, anatomic and are interrelated and influence each other during function and disease and it is common to consider them as single entity from diagnostic and treatment perspective.

3. Pathways of Communication between Pulp and Periodontium Developmental Apical foramen Accessory and lateral canals Congenital absence of cementum Deep developmental grooves Enamel projections Pathological Vertical tooth fracture Idiopathic resorption: internal or external Loss of cementum: due to external irritants Acute and chronic pulp disease Root caries Traumatic occlusion Iatrogenic Factors Exposure of dentinal tubules during root planning Accidental lateral perforation during root canal treatment Root fracture during endodontic treatment

4. Pathways of Communication between Pulp and Periodontium

5. Classification of Endodontic–Periodontal Lesions Simon and Glick’s classification (1972) – classification based on aetiology, diagnosis, prognosis and treatment Primary endodontic lesions Primary endodontic lesions with secondary periodontal involvement Primary periodontal lesions Primary periodontal lesions with secondary endodontic involvement True combined lesions

6. Classification of Endodontic–Periodontal Lesions Weine’s classification (1972) – classification based on etiology and treatment plan Class I: Tooth that clinically and radiographically simulates the periodontal involvement, but it is due to pulpal inflammation or necrosis. Class II: Tooth that has both pulpal and periodontal disease occurring concomitantly. Class III: Tooth that has no pulpal problem but requires endodontic therapy with root amputation to achieve periodontal healing. Class IV: Tooth that clinically and radiographically simulates pulpal or periapical disease but, in fact, has periodontal disease.

7. Classification of Endodontic–Periodontal Lesions Grossman’s classification – based on treatment Lesions that require endodontic treatment procedures only Lesions that require periodontal treatment procedures only Lesions that require combined endodontic– periodontic treatment procedure Simon and Glick’s classification is the most commonly used classification

8. Primary Endodontic Lesions Causes Caries Restorative procedures Traumatic injuries Clinical features Severe pain which can intensify in the night (lying down) Tenderness on percussion Swelling in the marginal gingiva Abscess draining (sinus tract) through narrow pseudo-periodontal pocket present on any isolated area of the involved teeth On exploring the sinus tract with gutta-percha point reveals the involvement of periapical region Walking the periodontal probe around the gingival sulcus of involved tooth results in sudden loss of resistance indication a pocket which lacks width Analgesics will not reduce pain and will require root canal therapy Diagnosis Pulp vitality: Nonvital Radiographic finding: Caries or non-carious lesion involving the pulp Treatment Endodontic therapy of the tooth involved. Complete resolution of infection is generally anticipated without any periodontal treatment.

9. Primary Endodontic Lesions with Secondary Periodontal Involvement Causes Long-standing untreated endodontic lesion leads to destruction of the periapical alveolar bone. This destruction progresses into interradicular area, causing the breakdown of surrounding hard and soft tissues. Clinical features Pain which can increase during lying down (night) Tenderness on percussion Tooth mobility Swelling in the marginal gingiva Abscess draining through the periodontal pocket On exploring the sinus tract with gutta-percha point reveals the involvement of periapical region The pocket is extensive due to long-term existence of the lesion but seen only around the involved teeth; calculus may or may not be seen Analgesics will not reduce pain and will require root canal therapy Diagnosis Pulp vitality: Nonvital Radiographic finding: Caries or non-carious lesion involving the pulp Presence of large radiolucent region in the periapical and peri-radicular region Treatment Endodontic treatment Occasionally debridement of the pocket maybe necessary to remove calculus if any Heals within a short period and prognosis is good

10. Primary Periodontal Lesions Causes Plaque Calculus Trauma (fall or from occlusion) Spread of lesion from adjacent teeth Clinical features May or may not have pain which is dull and chronic in nature (due to constant drainage through the sulcus) Bleeding on probing Presence of calculus Broad-base pocket formation Mobility Widespread bone loss Patient usually has generalized periodontitis Swelling when present involves attached gingiva and not mucogingival region No facial swelling Diagnosis Pulp vitality: Vital Radiographic finding: Caries or non-carious lesion may or may not be present and does not involve the pulp Multiple areas of horizontal bone loss seen indicating generalized periodontitis Bone loss (pocket) is wider at the alveolar crest and gets narrow as it progresses apically Treatment Periodontal treatment Prognosis depends on the extent of periodontitis and patients ability to comply with potential long-term treatment and maintenance therapy

11. Primary Periodontal Lesions with Secondary Endodontic Involvement Causes Inflammation from periodontal tissues extends into the pulp through Dentinal tubules Accessory canals and lateral canals Congenital absence of cementum Developmental deep grooves (palato-gingival groove) Enamel projections Clinical features Deep pocket History of periodontal disease Pain due to pulpal involvement Diagnosis • Pulp vitality: Nonvital • Radiographic finding: Caries or non-carious lesion may or may not be present and does not involve the pulp Multiple areas of horizontal bone loss seen indicating generalized periodontitis Bone loss (pocket) is wider at the alveolar crest and gets narrow as it progresses apically Radiolucent areas in the periodontium has involved lateral canal or apical foramen Treatment Endodontic treatment followed by periodontal treatment Prognosis depends on periodontal treatment.

12. True Combined Lesions Causes Pulpal and periodontal disease may occur independently or concomitantly in and around the same tooth. When both lesions coalesce, they may become clinically indistinguishable Prognosis of the teeth depends on the extent of destruction caused by periodontal component. Clinical features Deep pocket History of periodontal disease Pain due to pulpal involvement Diagnosis Pulp vitality: Nonvital Radiographic finding: Caries or non-carious lesion involving the pulp Bone loss (pocket) is wider at the alveolar crest and gets narrow as it progresses apically. Radiolucent area seen at the periapical region and is in continuity with the periodontal lesion but may or may not influence each other Treatment Endodontic treatment is done. Periodontal treatment is done after a month so that endodontic lesion would have healed to some extent. When endodontic and periodontal treatment is insufficient to stabilize an affected tooth, alternative treatment should be considered such as resection or regenerative approaches.

13. CONCLUSION There is a strong interrelationship between pulpal and periodontal disease. Thorough knowledge of pathogenesis and microbes involved is essential for proper diagnosis and treatment planning. When pulp is involved, it is recommended to complete endodontic treatment and wait for 3 months before initiating any periodontal therapy unless it is the primary cause of infection.