Endo-perio(1).pdf

Perio – Endo Lesions Dr Shatha Abubotain, BDS, FRCDC  1. Intercommunication Between Pulpal and Periodontal Tissue 2. Influence of Pulpal Pathologic Condition on the Periodontium OUTLINE 3. Influence of Periodontal Inflammation on the Pulp...

Perio – Endo Lesions Dr Shatha Abubotain, BDS, FRCDC  1. Intercommunication Between Pulpal and Periodontal Tissue 2. Influence of Pulpal Pathologic Condition on the Periodontium OUTLINE 3. Influence of Periodontal Inflammation on the Pulp 4. Theoretic Pathways of Osseous Lesion Formation Primary Endodontic Lesions Primary Endodontic Lesions With Secondary Periodontal Involvement Primary Periodontal Lesions Primary Periodontal Lesions With Secondary Endodontic Involvement True Combined Lesions Concomitant Pulpal and Periodontal Lesions What is Perio- Endo Lesion Endodontic and periodontal diseases are both polymicrobial anarebic infections. The term ‘‘endo-perio’’ lesion describes diseases due to inflammatory products found in varying degrees in both the periodontium and the pulpal tissues. When inflammation presents on a tooth associated with both pulpal pathology and the periodontal tissues, it is classified as a perio-endo lesion. Intercommunication Between Pulpal and Periodontal Tissue Several possible channels between the pulp and periodontium that lead to the interaction of the disease process in both tissues. These include: Neural pathways Lateral canals Dentinal tubules (especially when the cementum is exposed) Palatogingival grooves (maxillary incisor teeth; especially lateral incisors) Periodontal ligament Alveolar bone Apical foramina (The most direct route of communication to the periodontium) Common vasculolymphatic drainage pathways Other ways of communication between the root canal system and the periodontal ligament includes Perforation. Vertical fractures. Caries invading through the floor of the pulp chamber.  Influence of pulpal pathologic condition on the periodontium Pulpal degeneration results in necrotic debris, bacterial by-products, and other toxic irritants that can move toward the apical foramen, causing periodontal tissue destruction apically and potentially migrating toward the gingival margin causing retrograde periodontitis. The nature and extent of periodontal destruction depends on: 1. The virulence of the irritating stimuli present in the root canal system (e.g., Microbiota, medications, foreign body reactions), 2. The duration of the disease 3. Host defense mechanism. Influence of periodontal inflammation on the pulp It is common to observe a stage 3 or 4 periodontitis spreading to the apical foramen. The pulp can be affected by: 1. Infection from a periodontal pocket spreading through exposed dentinal tubules or accessory canals. 2. Periodontal treatment, such as scaling, root planing, by altering the cementum layer. Although some studies have failed to confirm a direct correlation between periodontal disease and pulp tissue changes, the pulp usually do not degenerate as long as the main canal is not involved and the blood supply through the apical foramen remains intact. Theoretic pathways of osseous lesion formation The close relationship between pulpal and periodontal disease is established based on clinical and radiographic examination. Including: Medical history. Pulp vitality testing. Pocket and furcation probing. Tooth mobility. Critical examination of radiographs. Formulating a differential diagnosis 1. Consider both the periodontal and pulpal status of the affected tooth. 2. If an interrelationship in disease entities exists, appropriate treatment must be rendered to remove true causative factors and enhance the prognosis for tooth retention. 1. Primary endodontic lesions It involves inflammatory changes, such as caries, restorative procedures, and traumatic injuries. Bone will be resorbed apically and laterally. The inflammatory processes in the periodontium is localized at the apex and lateral aspect of the non vital tooth, or at the furcation in case of multi rooted tooth. TREATMENT: Adequate endodontic therapy. Clinical Findings related to Primary Endo Lesions 1. Negative reposes to cold test 2. Pain 3. Tenderness to palpation and percussion 4. Increased tooth mobility 5. Swelling of the marginal gingiva, mimic a periodontal abscess. 6. Sinus tract (when traced, it will probe down to the apex or the furcation area in mutli root tooth) 7. No probing depth / perio pockets 2. Primary endodontic lesions with secondary periodontal involvement When a lesion of endodontic origin is left untreated. Pathosis usually continues, leading to destruction of the periapical alveolar bone and progression into the interradicular area, causing breakdown of surrounding hard and soft tissues due to accumulation of plaque and calculus in the purulent pocket. TREATMENT Treating the primary cause (ENDO), followed by periodontal treatment. PROGNOSIS When the endodontic treatment is adequate, it will depend on the severity of periodontal involvement and the efficacy of periodontal therapy. Clinical Findings Related To Primary Endo Secondary Perio Lesions 1. Negative reposes to cold test 2. Pain 3. Tenderness to palpation and percussion 4. Increased tooth mobility 5. Swelling of the marginal gingiva, mimic a periodontal abscess. 6. Sinus tract (when traced, it will probe down to the apex or the furcation area in mutli-root tooth) 7. Plaque or calculus accumulation 8. Usually narrow based probing depth / perio pocket 9. Radiographs may show generalized periodontal disease with angular defects at the initial site of the endodontic involvement.  3. Primary Periodontal Lesions Periodontal disease has a progressive nature. May be due to local factors such as overhang restoration or trauma from occlusion. osseous defects in Loss of loss of lateral starts in the surrounding periodontal apex clinical aspects of sulcus bone and abscess attachment roots and in tissue furcation areas  Clinical Findings Related To Primary Perio Lesions Tooth respond to cold test (vital) Tooth mobility Broad-based pocket formation Accumulation of plaque and calculus The bony lesion is usually more widespread and generalized than those associated with endodontic lesions. TREATMENT: Depends on the extent of the periodontitis and on the patient’s ability to comply with potential long-term treatment and maintenance therapy.  4. Primary Periodontal Lesions With Secondary Endodontic Involvement It happens when periodontal disease progresses down the root surface and leads to an area of communication with the pulp. It differ from the primary endodontic lesion with secondary periodontal involvement only by the sequence of the disease processes. Radiographically, you cannot distinguish between these lesions and primary endodontic lesions with secondary periodontal involvement. TREATMENT: Adequate endodontic treatment followed by periodontal treatment. PROGNOSIS: Depends mainly on the periodontal status of the tooth and how it responds to treatment. 5. True Combined Lesions When both an endodontic and periodontal lesion developing independently and progressing concurrently which meet and merge at a point along the root surface. The periodontal lesion exists and progresses, whilst during the same period the tooth devitalizes, and the apical lesion progresses. 6. Concomitant Pulpal And Periodontal Lesions When both disease states exist, but with different causative factors and with no clinical evidence that either disease state has influenced the other. This situation often goes undiagnosed. Usually, treatment is rendered to only one of the diseased tissues in the hope that the other responds favorably. Ideally, the two disease processes must be treated concomitantly.