Endodontic-Periodontic Lesions-ediated.pptx

endo perio lesion

1. Treatment of EPLs Department of Periodontology Dr.Mohammad Eissa Ahmadi

2. Definition When inflammation presents on a tooth which is associated with both pulpal pathology and the periodontal tissues, it is classed as a perio-endo lesion.

3. Nargis soNde, MalcolM edwards Prim Dent J. 2020;9(4):45-51 Perio-enDo lesions: a guiDe to Diagnosis anD clinical managemen Sources of communication between the pulp and periodontium. A: Apical foramen B: lateral canals c: Dentinal tubules D: perforations e: fractures f: Developmental Anomalies

4. Pathways of Communication between Pulp and Periodontium Apical Foramen Physiological Pathways : Lateral or Accessory Canals Palato-gingival Groove Cervical Enamel Projections Dentinal Tubules

5. Pathological Pathways Perforation of the Root Vertical Root Fracture Loss of Cementum Pathological Exposure of Lateral Canals Infra bony pocket or furcation bone loss can result in pulp exposure by exposing the lateral canals to the oral environment

6. Miscellaneous Pathways Iatrogenic Perforation during endodontic therapy : It produces mechanical or pathological communication between root canal system and external tooth surface. Root fracture during root canal therapy: Root fracture can occur due to excessive dentin removal during biomechanical preparation and weakening of tooth during post space preparation. Fracture site provides entry for bacteria and their toxic products from root canal system to the surrounding periodontium. Exposure of dentinal tubules during root planning: It can result in communication between pulpal and periodontal space.

7. 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

8. Impact of Periodontal Disease on Pulpal Tissue Pathogenic bacteria and inflammatory products of periodontal diseases may enter into the root canal system via accessory canals, lateral canals, apical foramen, dentinal tubules resulting in retrograde pulpitis. As periodontal disease extends from gingival sulcus toward apex, the auxiliary 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. Periodontal therapy using ultrasonic scalers, vibrators, curettes and chemicals may harm the pulp specially if remaining dentin thickness is <2 mm.

9. Etiology of Endodontic– Periodontal Lesions EPLS

10. Etiopathogenesis of endo-perio lesions Etiological factors Contributing factors

11. Classification of Endodontic– Periodontal Lesions According to Weine: Based on etiology and treatment plan

12. According to Grossman et al.: Oliet and Pollock’s classification based on treatment protocol Type III Type II Type I Lesions that require combined endodontic and periodontal treatment Lesion that require periodontal treatment only Lesions requiring endodontic treatment only any lesion of type I which result in irreversible reaction to periodontium requiring periodontal treatment • Occlusal trauma causing reversible pulpitis • Tooth with necrotic pulp reaching periodontium • Root perforations • Suprabony or infrabony pockets caused during periodontal treatment resulting in pulpal inflammation • Root fractures Any lesion of type II which results in irreversible damage to pulp tissue requiring endodontic therapy • Chronic periapical abscess with sinus tract • Replants • Occlusal trauma and gingival inflammation resulting in pocket formation • Transplants • Teeth requiring hemi section

13. Based on the primary cause of the disease, Simon et al. has given classification of endodontic periodontal lesion as [2,5,22,23]

14. Diagnosis of Endodontic– Periodontal Lesion

15. Test Primary endodontic lesion Primary periodontal lesion Primary endodontic secondary periodontal Primary periodontal secondary endodontic True combined lesions Visual Presence of decay/ incorrect restorations/ erosion/ abrasion Inflammation/ recession of gingiva Presence of plaque/ calculus Intact teeth Plaque/ calculus at the gingival margin Root perforation/ fracture Plaque/ calculus And swelling around multiple teeth Puss + exudate Periodontitis around single or multiple teeth Puss + exudate Pain Sharp Usually dull ache Usually sharp Usually dull ache Usually dull ache, sharp only in acute condition Palpation Not conclusive Pain on palpation Pain on palpation Pain on palpation Pain on palpation Percussion Normally tender Tender on percussion Tender on percussion Tender on percussion Tender on percussion Mobility Present only in fractured or traumatized teeth Localized/ generalized mobility Localized mobility Generalized mobility Generalized Higher grade mobility on involved tooth Pulp vitality Lingering or no response Positive Negative Positive Usually negative Pocket probing Solitary narrow pocket Multiple wide and deep pockets Solitary wide pocket Multiple wide and deep pockets Typical conic periodontal type of probing Sinus tracing Radiograph with gutta-percha points to apex/furcation At lateral aspect of the root Mainly at the apex/ furcation area At lateral aspect of the root Difficult to trace X-rays Periapical radiolucency Vertical bone loss Wider bone loss coronally Wide based apical radiolucency Angular bone loss in multiple teeth Similar to a vertically fractured tooth Cracked tooth testing Painful when chewing No symptoms Painful when chewing No symptoms Painful when chewing

16. Primary Endodontic Lesions Sometimes an acute exacerbation of chronic apical lesion in a nonvital tooth may drain coronally through periodontal ligament into the gingival sulcus, thus resembling clinical picture of periodontal abscess. The lesion presents as an isolated pocket or the swelling on the side of the tooth. Etiology

17. Clinical Features

18. Prognosis after endodontic therapy is excellent. In fact, if periodontal therapy is performed without considering pulpal problem, prognosis becomes poor. Diagnosis Treatment Root canal therapy Good prognosis

19. Primary Endodontic Lesion with Secondary Periodontal Involvement 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.

20. Cont. . Diagnosis: Continuous irritation of periodontium from necrotic pulp or from failed root canal treatment Isolated deep pockets Periodontal breakdown in the pocket Treatment Root canal treatment to remove irritants from pulp space Retreatment of failed root canal therapy Concomitant periodontal therapy Extraction of teeth with vertical root fracture if prognosis is poor Good prognosis. Prognosis: In case vertical root fracture is causing the endo–perio lesions, tooth is extracted, otherwise the prognosis is good.

21. Primary Periodontal Lesions Etiology: Plaque Calculus Trauma Clinical Features Periodontal probing may show presence of plaque and calculus within the periodontal pocket Due to attachment loss, tooth may become mobile Usually generalized periodontal involvement is present

22. Diagnosis , Treatment, Prognosis , Diagnosis Periodontal destruction associated with plaque or calculus Patient experiencing periodontal pain Pulp may be normal in most of the cases. Treatment Oral prophylaxis and oral hygiene instructions Scaling and root planning Periodontal surgery, root amputation may be required in advanced cases. Prognosis Prognosis becomes poor as the disease advances

23. Primary Periodontal Lesions with Secondary Endodontic Involvement

24. Clinical Features , Diagnosis , Treatment , Prognosis Clinical Features Oral examination of patient reveals presence of generalized periodontal disease Tooth is usually mobile when palpated If severe periodontal destruction exposes the root surface, irreversible pulpal damage can result Radiographically, these lesions become indistinguishable from primary endodontic lesions with secondary periodontal involvement. Diagnosis Periodontal destruction associated with nonvital tooth Generalized periodontal disease present Patient may complain sensitivity after routine periodontal therapy Usually the tooth is mobile Pocket may show discharge on palpation. Treatment Root canal treatment Periodontal surgery in some case Prognosis : Prognosis depends on the periodontal problem.

25. True Combined Endo–Perio Lesions True combined lesions are produced when one of these lesion (pulpal or periodontal) which are present in and around the same tooth coalesce and become clinically indistinguishable. These are difficult to diagnose and treat.

26. Clinical Features Periodontal probing reveals conical periodontal type of probing and at base of the periodontal lesion the probe abruptly drops farther down the root surface and may extend to the apex. Radiograph may show bone loss from crestal bone extending down the lateral surface of root

27. Treatment First see whether periodontal condition is treatable, if promising and then go for endodontic therapy. Endodontic therapy is completed before initiation of definitive periodontal therapy After completion of endodontic treatment, periodontal therapy is started which may include scaling, root planning, and surgery along with oral hygiene instructions Prognosis It depends upon prognosis of the periodontal disease.

28. Different between combined lesions and concomitant lesion Concomitant lesion Combined lesions Acute and localized in nature • Chronic and generalized in nature They may not be communication between pulpal and periodontal lesion when seen clinically and radiographically • There is communication between pulpal and periodontal lesion when seen clinically or radiographically

29. Differential diagnosis between pulpal and periodontal disease Pulpal Periodontal Features Pulpal infection Periodontal infection Etiology No relation Commonly seen Plaque and calculus Nonvital Tooth is vital Tooth vitality Usually show deep and extensive restoration No relation Restorations If present single, isolated Usually present and generalized Periodontal destruction Normal Recession of gingival with apical migration of attachment Gingiva and epithelial attachment Localized Generalized Pattern of disease Periapical radiolucency Usually not related Radiolucency Commonly seen on apical part of toot Usually present on coronal part of tooth Inflammatory and granulation tissue Root canal therapy Periodontal therapy Treatment Few Complex Microbial Wider apically Wider coronally Bone loss Localized Generalized Pattern Normal Some recession Gingiva Often acidic Often alkaline pH of saliva

30. Conclusion Endodontic periodontal lesions present a diagnostic and treatment dilemma which can have a diverse pathogenesis ranging from quite simple to complex. To reach at correct diagnosis, the operator should have a thorough understanding and scientific knowledge of these lesions. Treatment of combined endodontic and periodontal lesions does not differ from the treatment given when the two disorders occur separately. Even though dentistry is divided into the multiple fields of specialization, to achieve the best outcome for endo– perio lesions, a multi-disciplinary approach should be involved, though some cases may require only endodontic therapy or periodontal treatment and others may require the combined approach.

31. Reference Text books : Newman carrenza 2020 linda 2021 Textbook of Endodontics, 4E (Nisha & Amit Garg) (2019) [PDF] [ UnitedVRG ] Articles : Journal of Research in Medical and Dental Science (Endodontic Periodontal Lesion Diagnosis and Treatment Decision Analysis Keerthika R, Nivedhitha MS) Treatment of an Endo-Perio Lesion with Ozone Gas in a Patient with Aggressive Periodontitis: A Clinical Case Report and Literature Review (This article was published in the following Dove Press journal)