BDS 11136 Endodontic-Periodontic Relationship PDF

Endodontic-periodontal interrelationship BDS 11136 Date : xx / xx / xxxx Aims: The educational aims of this lecture are: 1. To explain the relationship between endodontics and periodontium 2. To explain how to differentiate between endodontic and periodontal lesions 3. To explain how to manage di...

Endodontic-periodontal interrelationship BDS 11136 Date : xx / xx / xxxx Aims: The educational aims of this lecture are: 1. To explain the relationship between endodontics and periodontium 2. To explain how to differentiate between endodontic and periodontal lesions 3. To explain how to manage different lesions based on their origin Objectives: On completion of this lecture, the student should have: 1. An understanding of how to diagnose endodontic, periodontal or combined lesions 2. An understanding of how the origin of a lesion affects the treatment plan I- Intercommunication between pulpal & periodontal tissues I- Intercommunication between pulpal & periodontal tissues Physiological causes ABCD- Apical foramen Lateral (accessory) canals Dentinal tubules Palatogingival groove Non-Physiological causes A- Root perforations B- Vertical root fracture Physiological Causes 1- Apical foramen Main Pathway: Ingress of irritants from necrotic pulp through apical foramen into peri- radicular tissue initiates an inflammatory response. Or: If plaque covers the root & reaches the apical vessels pulpal inflammation pulp necrosis 2- Lateral (accessory) Canals Carry toxic substances from pulp to periodontium or vice versa Formed due to: • Breakdown of epith root sheath of Hertwig before root dentin formation. • Blood vessels persistance between dental papilla & dental sac. - Common sites: Posterior teeth, furcation of molars In apical portions of roots. Non physiological causes A- Root perforations: • An artificial communication between root canal system and periodontium • The closer the perforation to the gingival sulcus , the Greater chances for apical migration of the gingival epithelium in initiating periodontal lesions. B- Vertical root fracture: • Can form a communication between the root canal system and the periodontium. • Fracture site provides an entry of the bacteria and their toxic products from root canal system to the surrounding periodontium. The J-shaped radiographic lesion is the classical sign of a longstanding root fracture, usually in the mesiodistal plane I- Intercommunication between pulpal & periodontal tissues. II- Influence of pulpal disease and endodontic procedures on the periodontium. III- Influence of periodontal inflammation & procedures on the pulp. IV- Endo-perio lesions V- Differential diagnosis of endo-perio lesions. VI- Treatment alternatives. II- Influence of Pulpal disease & Endodontic procedures on the Periodontium A-Pulpal disease: • Irritant from necrotic pulp, lateral canals & apical foramen. • Inflammation in the periodontium. • It is a reversible condition , if successful RCT is done. • Periodontal tissue destruction starts apically and migrates toward the gingival margin, thus termed Retrograde periodontitis. • While Marginal periodontitis in which the disease proceed from the gingival margin to root apex. B- Endodontic Procedures: Pulp extirpation. Cleaning & shaping of R.C. - Post space preparation perforations. Extension of files, reamers or materials. B- Endodontic Procedures: Perforation of pulp chamber floor. Vertical root fracture. Perforation of root during cleaning & shaping. I- Intercommunication between pulpal & periodontal tissues II- Influence of pulpal disease and endodontic procedures on the periodontium. III- Influence of periodontal inflammation & procedures on the pulp IV- Endo-perio lesions. V- Differential diagnosis of endo-perio lesions. VI- Treatment alternatives. III- Influence of periodontal Inflammation & procedures on the pulp A- Periodontal disease: Progressive periodontal disease leads to apical migration of epithelial attachment. Root surface exposure to oral cavity & to irritants (bacterial plaque) B- Periodontal Procedures - - Deep curettage severe apical vessels - - Scaling & planning of root surfaces removes cementum. opens D.T & lateral canals. leading to pulp necrosis. Chemicals and medicaments used during periodontal therapy may cause pulpal damage. I- Intercommunication between pulpal & periodontal tissues II- Influence of pulpal disease and endodontic procedures on the periodontium. III- Influence of periodontal inflammation & procedures on the pulp IV- Endo-perio lesions. V- Differential diagnosis of endo-perio lesions. VI- Treatment alternatives. Primary Endo Lesions. Primary Endo with Secondary Perio involvement Endo-Perio Lesions True Combined Lesions Primary Perio with Secondary Endo involvement Primary Perio Lesions Concomitant pulp & perio disease 22 1- Primary Endodontic Lesions • Resorb bone apically and laterally and destroy the attachment apparatus adjacent to a nonvital tooth. • Causes: Caries, restoration, traumatic injury • Sometimes an acute exacerbation of a chronic apical lesion in a non vital tooth ,may drain coronally through the periodontal ligament into the gingival sulcus, thus mimic clinically the presence of a periodontal abscess. • A sinus tract may open into the gingival sulcus so a pocket can be easily traced with a gutta-percha cone or a periodontal probe. • There is no increased probing depth existing around the tooth. • In multirooted teeth the sinus tract may drain into the furcation area. • Resembling a grade III through-and- through furcation defect resulting from a periodontal disease. Radiographically: Radiolucent area but Localized osseous destruction Clinically: • Pain or asymptomatic. • Tenderness to pressure and percussion. • Slight tooth mobility may occur. • Swelling of the marginal gingiva, simulating a periodontal abscess. • Negative pulp tests. Treatment: Root canal treatment without any periodontal treatment. Periodontal treatment alone would fail! Prognosis: Good if proper root canal treatment is done . 2- Primary Endo with Secondary Perio involvement • Endodontic lesion not treated → destruction of periapical bone • Accumulation Of plaque & calculus apical migration of attachment epithelium. Clinically: • Isolated deep pockets • Necrotic pulp • Plaque & calculus • TTT: Both RCT & Periodontal TTT • Prognosis: depends on the severity of periodontal involvement and efficacy of endodontic treatment. 3- Primary Periodontal lesions • Begins in the sulcus & migrates to the apex due to accumulation of plaque • Loss of clinical attachment & periodontal abscess. • Characteristics: 1- Wide spread generalized bony lesion 2- Tooth mobility 3- +ve pulp testing • Treatment: Periodontal TTT • Prognosis: Depends exclusively on the outcome of periodontal treatment. 4- Primary Periodontal with Secondary Endo involvement • May be indistinguishable from 1ry endodontic lesions with 2ry periodontal involvement. • Deep pockets & extensive periodontal disease. • When pulp becomes involved → pain (S&S of pulpal disease) • Treatment: RCT & periodontal TTT • Prognosis: Depends on periodontal TTT 5- Concomitant pulp and periodontal Lesions -Both diseases exist but no evidence that either disease has influenced the other. -Periodontal & endodontic problem exists but with no communication. Treatment : Both lesions must be treated consequently. Prognosis : Slightly better than true combined lesions. 6- True combined Lesions - Pulpal & periodontal disease may occur independently or concomitantly in & around the same tooth, where merging of apical pulpal lesion and progressive apical extension of periodontal pocket. ( Endodontic and Periodontal coalesce) . TTT: Both; RCT & perio treatment. Prognosis: Poor lesions I- Intercommunication between pulpal & periodontal tissues II- Influence of pulpal disease and endodontic procedures on the periodontium. III- Influence of periodontal inflammation & procedures on the pulp IV- Endo-perio lesions. V- Differential diagnosis of endo-perio lesions. VI- Treatment alternatives. How to differentiate between Endodontic and Periodontal Lesions V- Differential diagnosis of endo-perio lesions 1- Subjective signs and symptoms 2- Radiographic findings 3- Clinical tests 1- Subjective S&S: - Little or no pain → Periodontal - Acute pain → Pulpal & periradicular lesions 2- RG findings: - Periodontal → Generalized, angular bone loss (from cervical to periapical) - Periapical → Damage to apical periodontium (may extend cervically) (4P V T) Pulp testing. Periodontal Probing Tracing of sinus tract 3-Clinical Tests Visual examination Palpation Percussion 3- Clinical tests: (4P V T) A- Pulp Testing Perio Positive 1ry Perio Positive 1ry Endo No response Combined No response 3- Clinical tests: (4P V T) B- Periodontal probing Periodontal Wide & do not extend apically Endodontic Narrow & extend to apical foramen or lateral canals C- Palpation • A positive response to palpation may indicate active periradicular inflammatory process. • However, this test does not indicate whether the inflammatory process is of endodontic or periodontal origin. In early stages may help, but in advanced stages it is of no value . D- Percussion Unreliable because both perio & endo lesions cause inflammation in periodontal ligament. 3- Clinical tests: (4P V T) E- Visual examination 1ry Endo 1ry Perio Caries, extensive or fractured restoration, trauma or attrition Plaque or calculus deposition, generalized gingivitis or periodontitis F- Tracing of sinus tract Pulpal Periodontal Clinical Etiology Pulp infection Periodontal infection Vitality Nonvital Vital Restoration Deep or extensive Not related Plaque/calculus Not related Primary cause Inflamation Acute Chronic Pockets Single, narrow Multiple, wide coronally Radiograph Pattern Localised Generalized Bone loss Wider apically Wider coronally Vertical bone loss No Yes Periapical bone Radiolucent Not often related Histopathology Junctional epithelium No apical migration Apical migration Granulation tissue Apical (minimal) Coronal (larger) Gingiva Normal Recession I- Intercommunication between pulpal & periodontal tissues II- Influence of pulpal disease and endodontic procedures on the periodontium. III- Influence of periodontal inflammation & procedures on the pulp IV- Endo-perio lesions. V- Differential diagnosis of endo-perio lesions. VI- Treatment alternatives. VI- Treatment alternatives Treatment Endo & Perio TTT Resective approaches Regenerative approach Resective approaches Root amputation Hemisection Bicuspidization Regenerative approach It is a technique that prevent apical migration of gingival epithelium and allowing tissue derived from the periodontal ligament to repopulate the space adjacent to the denuded root surface. Bone missing from a disease Suturing of the flap Case A 42 years old male patient came with a history of acute localized pain and localized swelling in the left mandibular molar area. The patient said that he suffered from severe throbbing pain since 1month. Radiographic examination presented severe bone loss around the distal root of lower 2nd molar. The rest of the dentition had normal periodontal values. The lower 2nd molar was nonresponsive to vitality tests. 1- What is the diagnosis of such a case? 2- What is the cause of bone loss around the distal root? 3- What is the treatment plan? 1- Primary periodontal disease with 2ry endodontic involvement 2- Inaccessible space between lower 7 & 8 3- RCT , periodontal ttt and extraction of wisdom tooth. Case: A 52-year-old male was seen for recurrent local swelling and drainage in the area of the maxillary right second premolar. Clinical examination revealed a draining sinus tract in the attached gingiva near the second premolar. A radiograph indicated that there was a widened apical periodontal ligament space consistent with a developing periapical lesion in addition to a deep periodontal defect interproximally on the distal aspect. At this point, the origin of the sinus tract was unknown. Sensitivity testing: No responses were obtained from the second premolar, and the first molar previously had root canal treatment. No communication between the two lesions was evident on the film, and none was found during probing. Diagnosis Concomitant Endo Periodontal lesion Aims: The educational aims of this lecture are: 1. To explain the relationship between endodontics and periodontium 2. To explain how to differentiate between endodontic and periodontal lesions 3. To explain how to manage different lesions based on their origin Objectives: On completion of this lecture, the student should have: 1. An understanding of how to diagnose endodontic, periodontal or combined lesions 2. An understanding of how the origin of a lesion affects the treatment plan Reading material: Students are advised to read details at: 1. Cohen`s pathways of the pulp, 11th edition, 2016, Kenneth M. Hargreaves and Louis H. Berman. (chapter 25) 2. Endodontic science (two volumes), 2nd edition, 2009, Carlos Estrela. 3. Problems in endodontics, Etiology, diagnosis and treatment, 2009, Michael Hulsmann and Edgar Schafer. (chapter 16) 4. Endodontology, an integrated biological and clinical view, 2013, Domenico Ricucci and Jose F. Siqueira Jr. (chapter 10) 5. Clinical endodontics, 3rd edition, 2009, Leif Tronstad. (chapter 6) Thank You