Endodontic-Periodontal Interrelationships PDF

Endodontic-Periodontal interrelationships Matthew Malek, DDS Diplomate, American Board of Endodontist Director of the Post Graduate Program in Endodontics Department of Endodontics NYU College of Dentistry 1. Pulpal 2. Periapical 3. Periodontal a) Asymptomatic apical periodontitis — Inflammation...

Endodontic-Periodontal interrelationships Matthew Malek, DDS Diplomate, American Board of Endodontist Director of the Post Graduate Program in Endodontics Department of Endodontics NYU College of Dentistry 1. Pulpal 2. Periapical 3. Periodontal a) Asymptomatic apical periodontitis — Inflammation and destruction of apical periodontium that is of pulpal origin, appears as an apical radiolucent area, and does not produce clinical symptoms. b) Symptomatic apical periodontitis — Inflammation usually of the apical periodontium, producing clinical symptoms including a painful response to biting and/or percussion or palpation. It might or might not be associated with an apical radiolucent area. (https://www.aae.org/specialty/clinical-resources/glossary-endodonticterms/) Periodontitis can be defined as the presence of gingival inflammation at sites where there has been a pathological detachment of collagen fibers from the cementum and the junctional epithelium has migrated apically. Inflammatory events associated with connective tissue attachment loss also lead to the resorption of coronal portions of tooth supporting alveolar bone. (Armitage 1995) Periodontal disease: a) Source of inflammation: extra-radicular b) If not treated, usually leads to apical migration of the attached gingiva and crestal bone loss c) Pulp status: usually vital Endodontic disease: a) Source of inflammation: usually the pulp b) If not treated, often leads to apical bone loss c) Pulp status: usually non-vital Dental pulp and periodontal tissues are intimately related. As the tooth develops and the root is formed, 3 main avenues for communication are created: 1.Dentinal Tubules 2.Apical Foramen 3.Lateral and Accessory Canals Dentin Tubules Exposed dentinal tubules in areas of exposed dentin may serve as communication pathways between the pulp and PDL. In the root, dentinal tubules extend from the pulp to the dentino-cemental junction. They range in size from 1 to 3 microns in diameter (bacteria and their toxins are smaller in size). Apical Foramen The apical foramen is the most direct route of communication to the periodontium. Bacterial and inflammatory byproducts may exit readily through the apical foramen to cause periapical pathosis. Lateral and Accessory Canals 30-40% of all teeth have lateral or accessory canals. Pulpal infection Necrotic debris and bacterial byproducts move toward apical foramen Periodontal tissue destruction Resorption of bone, cementum, and dentin (Periapical Radiolucency) Periodontal disease has negligible effect on the pulp, at least until it involves the apex. (Czarnecki & Schilder, ’79) Effect of perio disease on the pulp is degenerative in nature including an increase in calcifications, fibrosis and collagen resorption in the pulp. (Langeland et al ‘74 and Mandi ‘72) Any pulpal changes resulting from periodontal disease are more likely to occur when the apical foramen is involved. (Langland et al ’74) • Which lesion is periodontal, and which is endodontic in origin? • Which one has a better prognosis? • How would you treat these two teeth differently? Classification of Endo-Perio Lesions The following classification system was developed by Simon, Glick and Frank in 1972: 1) 2) 3) 4) 5) Primary Endodontic Lesions Primary Periodontic Lesions Primary Endodontic Lesions with Secondary Periodontic involvement Primary Periodontic Lesions with Secondary Endodontic involvement True Combined Lesions 1) Primary Endodontic Disease Tooth is (almost) always non-vital Possible signs and symptoms: Sensitivity to percussion and palpation Apical and lateral bone resorption Sinus tract, sometimes associated with gingival swelling and pocket. In multi-rooted teeth, a PDL sinus tract can drain off into the furcation area and resemble a periodontally-induced Grade III “through-andthrough” furcation defect. 1) Primary Endodontic Disease Pre-op #30 Post-op #30 2 Years follow-up #30 1) Primary Endodontic Disease Pre-op #30 1 Year follow-up #30 1) Primary Endodontic Disease Q- How can we determine whether the pocket is due to a periodontal disease or an endodontic disease? 1) Perform sensibility test 2) Probe all around the tooth: In endodontic diseases, usually the pocket is deep and narrow In periodontal the pocket is shallow and wide. 1) Primary Endodontic Disease Two years post-op 1) Primary Endodontic Disease Q- How can we determine whether a furcation involvement is due to a periodontal disease or an endodontic disease? 1) Perform sensibility tests 2) Radiographically, if the crestal bone level, mesial and distal to the tooth appear relatively normal, the defect is most likely due to an endodontic disease. 1) Primary Endodontic Disease Pre-op Three years follow-up 1) Primary Endodontic Disease Courtesy of Dr. Marie Mora Pre-op 6-month F/U Post-op 20-month F/U Courtesy of Dr. Marie Mora 2) Primary Periodontal Disease Tooth is (usually) vital Possible signs and symptoms: Gingival swelling associated with plaque and calculus Loss of crestal bone and supporting periodontal soft tissues Loss of clinical attachment 2) Primary Periodontal Disease Crestal bone loss + no periapical lesion + wide shallow pocket + vital tooth These teeth require periodontal evaluation prior to initiation of endodontic treatment. A periapical lesion of endodontic origin usually will not occur in the presence of a normal vital pulp!!! 3) Primary Endo with Secondary Perio Untreated suppurating primary endodontic disease, resulting in periodontal breakdown. Plaque formation at the gingival margin of the sinus tract leads to plaque-induced periodontitis. The involved tooth requires both endodontic and periodontal treatments. Root fractures and perforations may also present as primary endodontic with secondary periodontal involvement. 4) Primary Perio with Secondary Endo The apical progression of a periodontal pocket continues until the apical tissues are involved. The pulp may become necrotic as a result of infection entering via the apical foramen (?). Rare case. Usually the treatment is extraction. 5) True Combined Lesions True combined endo/perio disease occurs less frequently than other endo/perio problems. Very rare case and treatment is usually extraction. It is formed when an endodontic disease and a periodontal disease exist concomitantly, whether they join or not. 5) True Combined Lesions 5) True Combined Lesions Grade 1 mobility Pockets all around the tooth up to 5mm Respond normally to sensibility tests and percussion and bite. No mobility Deep pocket in the distal Normal response to cold and EPT Primary Perio No mobility No deep pockets Not sensitive to perc/palp No mobility No probable pocket No response to cold and EPT No mobility No response to cold and EPT Pain to percussion Diagnosis A thorough clinical and radiographic examination is imperative for developing a diagnosis Data Collected must include: pulp sensibility testing: cold, EPT, cavity test periapical radiographs pocket probing percussion palpation sinus tract tracing cracked tooth testing: bite test with Q-tips / bite stick / tooth-sleuth, visualization under magnification and transillumination Differential Diagnosis Between Pulpal and Periodontal Disease CLINICAL Etiology Vitality Restorative Plaque/calculus Inflammation Pockets Microbial RADIOGRAPHIC Pattern Bone loss Periapical Vertical bone loss HISTOPATHOLOGY Junctional epithelium Granulation tissues Gingival margin THERAPY Treatment Pulpal Periodontal Pulp infection Nonvital Deep or extensive Not related Acute Single, narrow Few Periodontal infection Vital Not related Primary cause Chronic Multiple, wide coronally Complex Localized Wider apically Radiolucent No Generalized Wider coronally Not often related Yes No apical migration Apical migration Apical Normal Coronal Some recession Root canal therapy Periodontal treatment Treatment Decision-Making and Prognosis Combined lesions should be treated with endodontic therapy first. Treatment should be evaluated in 2-3 months, and only then should periodontal treatment be considered. Prognosis depends on the periodontal involvement and treatment. Cases of True Combined disease usually have an unfavorable prognosis. Thank you!