ENDO PERIO RELATION
INDIAN DENTAL ACADEMY Leader in continuing dental education
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Comparison of presentation of apical and marginal periodontitis Causes for attachment loss Pathways of communication between pulp and periodontium * Lateral and accessory canals *Dentinal tubules *Developmental defects *Cementum defects *Iatrogenic perforations and root fracture www.indiandentalacademy.com
Diagnosis of endo perio lesions *history of dentinal pulpal and periapical pain *history of periodontal symptoms *signs and symptoms of pulpal or periapical disease *periodontal charting(probing profile) *radiographic pattern of bone loss Possible causes of endo perio lesions Definition and classification of endo perio lesions Single isolated endo perio lesions Multiple endo perio lesions Management of endo perio lesions *estimation of prognosis *treatment of endo perio cases *root resection *role of regenerative techniques www.indiandentalacademy.com
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Periodontal ligament supporting teeth
Junctional epithelium
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Loss of marginal attachment www.indiandentalacademy.com
Differential Diagnosis Clinical Pulpal Cause : pulp infection Vitality :non vital Restorative :deep or extensive Plaque /calculus: not related Inflammation :acute Pockets :single and narrow
pH value :acidic Trauma :primary or secondary Microbial :few www.indiandentalacademy.com
Periodontal
:periodontal :vital :not related :primary cause :chronic :multiple and wide coronally :alkaline :contributing factor :complex
Radiographic
Pulpal
Pattern :localized Bone loss :wider apically Periapical :radiolucent Vertical bone loss: no
periodontal :generalized :wider coronally :not related :yes
Histopathology Junctional epithelium :no apical migration :present Granulation tissues : apical (minimal) :coronal (larger) Gingival :normal :recession Treatment Therapy :RCT :Periodontal therapy www.indiandentalacademy.com
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pathways www.indiandentalacademy.com
Case report I: primary endo lesion with secondary perio lesion
Abscess irt 23 Radiolucency irt 23
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Flap reflected, curettage done
Bone graft placed
Post treatment view after augmentation of 23 with composite
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Post surgical radiograph
Case report II: Primary perio lesion with secondary endo lesion
Bone loss up to apex of 44
Pre operative probing
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Flap reflected, curettage done
Bone graft placed
Post operative probing after 9 months
Post operative radiograph after 9 months
Case report III: True combined periodontal endodontic lesion www.indiandentalacademy.com
Per operative probing
Horizontal bone loss and periapical radiolucency
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Flap reflected, curettage done
Bone graft placed
Post operative after 6 months Post operative radiograph after 6 months
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Combined lesions: Two separate lesions: “pulpo periapical” and “periodontal with no communication between them Single lesion that involves both endodontic and periapical problem Separate endodontic and periodontal lesion that later communicate “concomitant pulpo periapical lesion” www.indiandentalacademy.com
Early periodontal lesion
Advanced periodontal destruct
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Horizontal bone loss
After 4 yrs
Vertical bone loss
After 12 yrs
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Bone loss encroaching the bone apices
Periodontal bone loss involving the mesial root of 36
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Lateral periodontal bone loss of pulpal origin
Resolution following RCT
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Early periradicular bone loss in 32
Further apical and marginal bone loss over a 10 yr period
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Pathways of communication between pulp and periodontium ďƒ˜Lateral canals and accessory canals
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Dentinal tubules
Microorganisms within dentinal tubules of infected tooth www.indiandentalacademy.com
Development defects
Palatogingival groove in the maxillary central incisor Cementum defects Iatrogenic perforations and
root fractures www.indiandentalacademy.com
After infilling of bony defect
Effect of pulp disease and its treatment on the periodontium
ď ś Periodontal inflammation and bone loss
Sub marginal bone loss Horizontal bone loss Furcation involvement ď ś Periodontal wound healing
Gingival tissue thickness Alveolar bone level Surgical trauma to flap Effective flap repositioning Root canal treatment
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This is why many periodontist’s insist on RCT on teeth with “ doubtful" pulp status when regenerative surgery is planned…….the rationale is to eliminate possible sources of infection to maximize the potential for successful outcome
Extrusion of root filling material causing delayed healing www.indiandentalacademy.com
ď ś Effect of iatrogenic problem
Perforations
Reparative dentine defending the pulp space
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Effect of periodontal disease and its treatment on the pulp ď ś Effect of periodontal disease on the pulp
Pulpal and periodontal involvement of maxillary premolar
Progression of the two separate lesion to give a combined
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Effect of periodontal disease and its treatment on the pulp ď ś Effect of periodontal treatment on the pulp
Scaling and root planning may sometimes result in removal of excessive cementum and exposure of the dentinal tubules, leading to pulp inflammation
--Micro flora --Host defense Pulpal inflammation adjacent to open dentinal tubules www.indiandentalacademy.com
Endo perio lesions
Definition
An isolated, usually narrow, deep probing depth of pulpal or periodontal origin Lesion with sub marginal or intrabony periradicular bone loss of pulpal and/or periodontal origin that communicates with the oral cavity via probing defect A localized periodontal probing depth of pulpal or periodontal origin www.indiandentalacademy.com
ďƒ˜Classification
According to SIMON GLICK FRANk (cohen) Primary endodontic lesion Primary endodontic lesion with secondary periodontal involve Primary periodontal lesion Primary periodontal lesion with secondary endodontic involve rue combined lesion
According to WEINE I. Tooth in which symptoms clinically and radiographically simulate periodontal disease but are due to pulpal inflammation II. Tooth that has both pulpal and periodontal disease concomitantly III.Tooth has no pulpal problem but require endodontic therapy plus root amputation to gain periodontal healing www.indiandentalacademy.com
According to OLIET, POLLOCK (Grossman
Lesions that require endodontic procedures onl necrotic pulp and apical granulomatous tissue replacing periodontium with or without sinous tract Chronic periapical abscess with sinus tract Longitudinal and horizontal root fractures Pathologic and iatrogenic root perforations Teeth with incomplete apical root development Endodontic implants Teeth that require hemisection Root submergence www.indiandentalacademy.com
II.Lesions that require periodontal procedures only
Occlusal trauma causing reversible pulpitis Occlusal trauma plus gingival inflammation resulting in pocket formation and reversible pulpitis Suprabony or infrabony pocket formation treated with overzealous root planning and curettage leading to pulpal sensitivity Extensive infrabony pocket formation extending beyond the root apex and sometimes coupled with lateral or apical resorption yet with pulp that responds with in normal limits to clinical testing www.indiandentalacademy.com
III. lesions that require combined endodontic and periodontic treatment Any lesion in Group I That results in irreversible reactions in the attachment apparatus and requires periodontal treatment Any lesion in Group II that results in irreversible reactions to the pulp tissue and also requires endodontic treatment
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Diagnosis of endo perio lesions History of dentinal / pulpal pain History of periodontal symptoms (bleeding, mobility) Signs and symptoms of pulpal / periapical disease (vitality) Periodontal charting (probing profile) Radiographic pattern of marginal and periradicular bone loss www.indiandentalacademy.com
Diagnosis of endo perio lesions
Distopalatal
Midpalatal
Mesio palatal
Three point probing depths www.indiandentalacademy.com
Periodontal probing
Continuous probing around maxillary molar showing sudden changes in probing depths www.indiandentalacademy.com
Charting continuous probing profile of a single tooth
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Long narrow pockets: endodontic origin
“Blow out� lesion www.indiandentalacademy.com
Lateral endodontic abscess: wide and deep pocket
Radiographic patterns
( angularity and presence of marginal bone) Bone loss and absence of periodontal ligament space www.indiandentalacademy.com
Possible causes of endo perio lesions ď Ź
Single isolated endo perio lesions
Bone loss on one side because of lateral canal Resolution after re treatment www.indiandentalacademy.com
GP points used to trace localized deep probing defects www.indiandentalacademy.com
Fractures in teeth with vital pulp ď Ź
Definitive treatment is placement of cusp covered cast restoration
Suspected cuspal fracture
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Tooth preparation with occlusal reduction
Root Fractures
Bucco palatal fracture Mesio distal fracture
Following removal of fractured root
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Fracture of mesial root of vital molar
Bone loss related to fracture of mesial root of vital molar
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Fracture at middle third
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RCT of whole incisor
Horizontal fracture at middle third RCT till fracture line
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Root perforations
Perforation with furcal and periapical bone loss www.indiandentalacademy.com
Coronal third perforation Crown lengthening with RCT and new post retained restoration
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Lateral perforation www.indiandentalacademy.com
Management of perforations
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Radiograph following sealing www.indiandentalacademy.com
3 yrs later
Root resorption
Internal resorption
Required resection www.indiandentalacademy.com
Anatomical anomalies
Probing developmental groove
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Max : lateral incisor with two roots and a palato gingival groove
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Orthodontic Treatment
Loss of periodontal attachment on the distal side of a maxillary canine following orthodontic treatment www.indiandentalacademy.com
Tooth transplantation and replantation poorly designed restorations
Localized periodontal breakdown related to a poorly placed restoration
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Management Of Endo Perio Lesions
ď Ź Estimation of prognosis
ď Ź Treatment of endo perio cases
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Endo perio lesion : usually isolated, narrow localized pocket Check endodontic status
Causes:
o Endo o Perio o Fracture o Resorption o Anatomy
Root treated Not root treated Evaluate adequacy Vitality tests Preparation: Obturation: oUnder prepared oOver prepared oPerforation oZipping oledges
oUnder filled oOverfilled oPoor adaptation
Is root canal re-treatment feasible? www.indiandentalacademy.com
Feasible re-treatment? No Yes Try OHI + debridement OHI Resolution? Resolution? No Yes No Yes oDo first stage endo oClean and shape canals Extract oDress with calcium hydroxide Resolution? No Yes
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Extract
Vitality tests Negative
Positive
Root canal treatment Resolution? No Yes Check Check vitality again: OHI and perio If in doubt- do RCT Still no resolution: look for other causes
Perio treatment Resolution? No Yes
Extract, resect , hemisect www.indiandentalacademy.com
Tooth resections: ď Ź Classification of degree of Furcation
involvement I. Horizontal loss of periodontal support< one third of tooth width II.Horizontal loss of periodontal support> one third but not encompassing the total width of the tooth III.Horizontal through and through destruction of the periodontal tissue in the furcal area www.indiandentalacademy.com
Root Amputation : Removal of one or more roots of a multi rooted tooth while the others are retained Hemisection : Removal or separation of root with its accompanying crown portion of mandibular molars Radisection : Newer terminology for removal of roots of maxillary molars Bisection / Bicuspidization : Separation of mesial and distal roots of mandibular molar along with its crown portion, where both segments are then retained individually www.indiandentalacademy.com
Indications for Resections Periodontal indications
Severe vertical bone loss involving only one root of a multi rooted tooth Through and through furcation destruction Unfavorable proximity of roots of adjacent teeth, preventing adequate hygiene maintenance in proximal areas Severe root exposure due to dehiscence www.indiandentalacademy.com
Restorative and endodontic indications: Prosthetic failure of abutments within a splint Endodontic failure: perforations, over extension , obstructed canals, separated instrument , root resorption Vertical fracture of one root Restorative reasons: sub gingival caries, erosion of large part of crown and root, traumatic injury Combination of these www.indiandentalacademy.com
Contraindications Root fusion making separation impossible Angulation or position of tooth in the arch: if the tooth is buccally or lingually, mesially or distally cannot be resected Root morphology: short conical roots are difficult to resect Improperly shaped occlusal contact may convert occlusal forces in to destructive forces and cause failure of hemisection www.indiandentalacademy.com
Surgical exposure of Furcation prior to sectioning of disto buccal root
Initial cut with a diamond instrument
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Widened cut to allow instrumentation
Appearance of tooth following the removal of disto buccal root
Elevation of disto buccal root
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Surgical closure
Vertical bone loss around distal root
Retained mesial root
Vertical cut towards the bifurcation
Full coverage cast restoration of hemisected molar
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Role of regenerative techniques in treatment of endo perio lesions
Histological section showing new attachment formation using a barrier www.indiandentalacademy.com
References o Management of periodontitis associated with endodontically involved teeth: The journal of dental practice, volume 6, No2 2005 oWeine FS: endodontic therapy
oStepten Cohen : Pathways of pulp oJan Lindhe : clinical implantology
oGlickman : periodontology : periodontology oStock : endodontics www.indiandentalacademy.com
Conclusion A concise knowledge of both pulpal and periodontal disease is necessary for proper identification of the lesion. Thus with adequate tender love and care we can nourish it for a peaceful coexistance……. Between the tooth and gums
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