Endodontic Periodontic Lesions copy.pptx

Endo Perio lesions

1. Submitted by: ENDODONTIC-PERIODONTIC LESION

2. INTRODUCTION Health of periodontium is important for normal physiology of the tooth . Periodontium is anatomically inter related with pulp by virtue of apical foramina and lateral canals which create a pathway for exchange of noxious agents between these two tissues .Not only the interaction between periodontium and pulp produces or aggrevate the existing lesion ,but also presents challenges in deciding the direct cause of an inflammatory condition.

3. DEFINITION An endo-perio lesion is one where both pulp and periodontal tissues are affected by the disease program.

4. PHYSIOLOGICAL PATHOLOGICAL MISCELLANEOIUS Apical foramen Perforation Iatrogenic Lateral & accessory canals Vertical root fracture -Perforation during endodontic therapy Atypical anatomical factors: Loss of cementum -Root fracture during root canal therapy - Palatogingival groove Pathological exposure of lateral canals -Exposure of dentinal tubules during root planning -Cervical enamel projection Trauma from occlusion-crown fracture Sys temi c Dentinal tubules Systemic disease like diabetes mellitus PATHWAYS OF COMMUNICATION BETWEEN PULP AND PERIODONTIUM

5. PATHWAY OF COMMUNICATION BETWEEN PULP AND PERIODONTIUM. PHYSIOLOGICAL PATHWAY APICAL FORAMEN I t is one of the major pathway of communication between dental pulp and periodontium. Inflammatory factors exit through apical foramen and irritate periodontium. LATERAL OR ACCESSORY CANALS Majority of lateral canals or accessory canals are found in apical third and furcation area of the root. As periodontal disease progresses down the root surface,accessory and lateral canals get exposed to oral cavity. It is difficult to identify lateral canals or radiografhs . PALATOGINGIVAL GROOVE It is development anomaly commonly seen in maxillary lateral incisor.Groove begins in the central fossa,crosses the cingulum and extends apically at varying distance. CERVICAL ENAMEL PROJECTIONS These are flat ectopic extension of enamel that extends beyond normal contours of cementoenamel junction.They interfere with the attachment apparatus and are important in periodontal disease.

6. Palatogingival groove Enamel pearl Cervical enamel projection Perforation of root creates communication between root canal system & periodontium Perforation during endodontic treatment

7. PATHOLOGICAL PATHWAY 1.PERFORATION OF ROOT Perforation creates an artificial communication between the root canal system and periodontium.Closer is the perforation to gingival sulcus,greater is the chance of apical migration of gingival epithelium in initiating a periodontal lesion . 2.VERTICAL ROOT FRACTURE It forms a communication between root canal system and periodontium 3.LOSS OF CEMENTUM Loss of cementum can occur due to gingival recession,presence of inadequate attached gingiva,abrasion , periodontal surgery. 4.PATHOLOGICAL EXPOSURE OF LATERAL CANALS Infrabony pocket or furcation bone loss can result in pulp exposure by exposing the lateral canals to oral environment MISCELLANEOUS PATHWAY IATROGENIC 1.Perforation during endodontic therapy 2.Root fracture during root canal therapy 3.Exposure of dentinal tubules during root planning

8. IMPACT OF PULPAL DISEASES ON THE PERIODONTIUM Pulpal infection may cause a tissue destructive process which may progress from apical region to the gingival margin, termed as RETROGRADE PERIODONTITIS . Restorative procedures and traumatic injuries cause inflammatory changes in the pulp,though it is still vital.Though a vital pulp does not affect the periodontium,necrosed pulp is seen associated with periodontal problem.Inflammatory lesions may develop from a root canal infection through lateral and accessory canals. Retrograde Periodontitis

9. IMPACT OF PERIODONTAL DISEASE ON PULPAL TISSUE Pathogenic bacteria and inflammatory products of periodontal diseases may enter in to root canal system via accessory canals,lateral canals,apical foramen,dentinal tubules resulting in retrograde pulpitis . As periodontal disease extends from gingival sulcus towards apex, the auxillary canals get affected which results in pulpal inflammation.It becomes more serious if these canals get exposed to oral cavity because of loss of periodontal tissues by extensive pocket depth.

10. ETIOLOGY OF ENDODONTIC-PERIODONTAL LESIONS. Primary etiologic agent in periodonditis is bacterial plaque.Besides this primary factor,there are secondary factors which contribute to the disease process either by increasing the chances of plaque accumulation or by the altering the response of host to the plaque .Pulpal diseases can result in periodontal problems and vice versa. ETIOLOGICAL EFFEC T S BACTERIAL PLAQUE : Commonly associated microorganism associated with endodontic-periodontal lesion are Actinomyces spp,F.nucleatum , P.intermedia , P.gingivalis ,and Treponema spp.Sometimes C.albicans , viruses like herpes simplex,cytomegalovirus and EBV have also shown to play an important role in periapical lesion. FOREIGN BODIES Foreign bodies like amalgam filling, root canal filling material , dentin or cementum chips , calculus deposits can irritate pulp and periodontium. Contributing factors resulting in combined Endodontic-Periodontal lesions Malpositioned teeth causing trauma Presence of additional canals in teeth Cervical enamel projects into furcation of multirooted teeth Large number of accessory and laterals canals Trauma combined with gingival inflammation

11. CLASSIFICATION OF ENDODONTIC PERIODONTAL LESION According to weine :Based on etiology and treatment plan : Class I:Tooth which clinically and radiographically simulates the periodontal involvement but it is due to pulpal inflammation or necrosis. Class II :Tooth has both pulpal and periodontal disease occurring concomitantly. Class III: Tooth has no pulpal problem but require endodontic therapy plus root amputation for periodontal healing. Class IV: Tooth that clinically and radiographically simulates pulpal or periapical disease but has periodontal disease. According to Simon et al: Based on etiology,diagnosis,prognosis and treatment : Type I: Primary endodontic lesion Type II:Primary endodontic lesion with secondary periodontal involvement Type III: Primary periodontal lesion Type IV:Primary periodontal lesion with secondary endodontic involvement. Type V:True combined lesion

12. DIAGNOSIS OF ENDODONTIC-PERIODONTAL LESION A growing periapical lesion with secondary involvement of the periodontal tissue may have the similar radiographic apperarence as a appearance as a chronic periodontal lesion which has reached to apex. Chief complaint of patient : Patient may tell the pain indicating pulpal or periodontal type.History of patient may reveal previous pulpal exposure or any periodontal treatment. Associated Etiology: For pulpal disease,caries ,trauma ,or pulpal exposure is common etiology whereas for periodontal disease is associated with plaque ,history of bleeding,or bad odour . Clinical tests: Different signs and symptoms can be assesses by visual examination , palpation,and percussion ,presence of carious tooth,recession,swelling of gingiva, increased pocket depth may indicate endo perio lesion.

13. Tracking sinus or fistula Gutta percha is inserted slowly through the sinus and x-ray is taken to track it.Being radiopaque ,Gutta percha helps in determining and differentiating the source of infection . Pocket probing Pocket probing helps to know the location and depth of pocket and furcation involvement . Microbiological Examination Microbiological analysis provide important information regarding the main source of problem. Distribution : Pulpal pathology is usually localized in nature,whereas periodontal condition is generalized. Bone loss: In pulpal disease ,bone loss is generally localized and wider apically.It is not associated with vertical bone loss.In periodontal disease , bone loss is generalized which is wide coronally.It may be associated with vertical bone loss. Pain: Pain in pulpal pathology is acute and sharp and patient cannot identify the offending tooth. In periodontal pathology pain is dull in nature and patient can identify offending tooth. Swelling; If swelling is seen on apical region ,it is usually associated with pulpal disease.swelling is usually associated with periodontal disease.

14. PRIMARY ENDODONTIC LESION Acute exacerberation of chronic apical lesion in a nonvital tooth may drain coronally through periodontal ligament in to gingival sulcus, thus resembling clinical picture of periodontal abscess.The lesion presents as an isolated pocket or swelling on side of tooth . ETIOLOGY Dental caries Deep restoration to pulp Traumatic injury Poor root canal treatment CLINICAL FEATURES Patient is usually asymptomatic , but history of acute exacerbration may be present. Since tooth is associated with necrotic pulp, pulp does not show response to virality test Sinus tract may be seen from apical foramen,lateral canals or the furcation area. Probing shows true pocket. Pocket is associated with minimal plaque or calculus. DIAGNOSIS 1 .Necrotic pulp draining through PDL into gingival sulcus. 2.Isolated pocket on side of tooth. 3.Pocket associated with minimal amount of plaque .

15. Treatment 1.Root canal therapy 2.Good prognosis Prognosis Progniosis after endodontic therapy is excellent . Spread of infection can occur-Apical foramen To gingival sulcus via periodontium, from lateral canal to pocket, from lateral canal to furcation,from apex to furcation

16. PRIMARY ENDODONTIC LESION WITH SECONDARY PERIODONTAL INVOLVEMENT This lesion appears if primary endodontic lesion is not treated. In such caes the endodontic disease continues resulting in destruction of periapical alveolar bone,progress into interradicular area and finally causing breakdown of surrounding hard and soft tissues. Clinical features Isolated deep pockets are seen though there may be the presence of generalized periodontal disease In such cases endodontic treatment will heal part of the lesion but complete repair will require periodontal therapy . Diagnosis Continuous irritation of periodontium from necrotic pulp from failed root canal treatment Isolated deep pockets Periodontal breakdown in the pocket Treatment Root canal treatment to remove irritants from pulpal space Retreatment of failed root canal therapy Extraction of teeth with vertical root fracture if prognosis

17. PRIMARY ENDODONTIC LESION WITH SECONDARY PERIODONTAL INVOLVEMENT

18. PRIMARY PERIODONTAL LESIONS Primarily this lesion is caused by periodontal disease .pulp may be normal in most of the cases but as disease progress pulp may become affected. Etiology Plaque Calculus Trauma Clinical features 1 .Periodontal probing may show presence of plaque and calculus within the periodontal pocket. 2.Due to attachment loss tooth may become visible. 3.Usually generalised periodontal involvement is present. Diagnosis 1.Periodontal destruction associated with plaque or calculus 2.Patient experience periodontal pain 3.Pulp may be normal in most cases Treatment 1.Oral prophylaxis and oral hygiene instructions 2.Scaling and root planning 3.Periodontal surgery root amputation may be required in advanced cases

19. PRIMARY PERIODONTAL LESION

20. PRIMARY PERIODONTAL LESION WITH SECONDARY ENDODONTIC INVOLVEMENT Periodontal disease affect pulp via accessory canal and lateral canal ,apical foramen ,dentinal tubules, during iatrogenic errors. Etiology: Periodontal procedure such a scaling ,root planning and curettage may open up lateral canals and dentinal tubules to the oral environment, resulting in pulpal inflammation. Clinical features 1.Oral examination of patient reveals presence of generalized periodontal disease 2.Tooth is usually mobile 3.If severe periodontal destruction exposes the root surface ,irreversible pulpal damage can result. 4.Radiographically,these lesion become indistinguishable from primary endodontic lesion with secondary periodontal involvement.

21. Diagnosis 1.Periodontal destruction associated with nonvital tooth 2.Generalised periodontal disease present. 3.Patient may complain sensitivity after routine periodontal therapy 4.Usually the tooth is mobile 5.Pocket may show discharge on palpation. Treatment 1.Root canal treatment 2.Periodontal surgery PRIMARY PERIODONTAL LESION WITH SECONDARY INVOLVEMENT

22. INDEPENDENT ENDODONTIC PERIODONTAL LESION WHICH DO NOT COMMUNICATE Clinical features 1. periodontal examination may show periodontal pocket associated with plaque or calculus. 2.Tooth is usually non vital 3.Though both lesion are present concomitantly they cannot be designed as true combined endo- perio lesion Treatment Root canal treatment periodontal therapy

23. True combined Endo perio lesion They are produced when one of these lesion which are present in and around the same tooth coalesce and become clinically indistinguishable. Clinical features Periodontal probing reveals conical periodontal type of probing and at base of periodontal lesion the probe drops farther down the root surface Radiograph may show bone loss from crestal bone extending down the lateral surface of root. Treatment 1.First see whether periodontal condition is treatable.If promising and then go for endodontic therapy. Endodontic therapy is completed before initiation of periodontal therapy. 2.After completion of endodontic therapy periodontal therapy is started which may include scaling, root planning and surgery.

24. TRUE COMBINED ENDO-PERIO LESION

25. CONCLUSION Endodontic periodontal lesions present a diagnostic and treatment dilemma which can have a diverse pathogenesis.To reach correct diagnosis ,the operator should have a thorough understanding and scientific knowledge of these lesion.Treatment of combined endodontic and periodontal lesion does not differ from the treatment given when the two disorders occurs separately.

26. REFERENCE Textbook of Endodontics- Nisha Garg Amit Garg