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CONTENTS INTRODUCTION DEFINITION CLASSIFICATION ETIOLOGY CONTROVERSIES REGARDING THE COMBINED LESION PATHWAYS OF SPREAD COMPARISION OF CLINICAL PRESENTATION B/W APICAL & MARGINAL PERIODONTITIS DIFFERENTIAL DIAGNOSIS EFFECT OF PULP & ITS TREATMENT ON PERIODONTIUM EFFECT OF PERIO. DISEASE & TREATMENT ON PULP LESIONS DIAGNOSIS TREATMENT REFERENCES CONCLUSION www.indiandentalacademy.com
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.
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STOCK
COHEN • • • • • • •
Primary endodontic lesion Primary endodontic lesion with secondary periodontal involvement Primary periodontal lesion Primary periodontal lesion with secondary endodontic involvement True combined lesion Concomitant pulpal & periodontal lesion
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WEINE
Type I - Tooth in which symptoms clinically and radiographically simulate periodontal disease but are due to pulpal inflammation Type II - Tooth that has both pulpal and periodontal disease concomitantly Type III - Tooth has no pulpal problem but require endodontic therapy plus root amputation to gain periodontal healing Type IV - Tooth that clinically and radiographically simulate pulpal or periapical disease but infact have periodontal disease
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LESIONS REQUIRING ENDODONTIC TREATMENT ONLY GROUP I 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
GROSSMAN www.indiandentalacademy.com
LESIONS REQUIRING PERIODONTAL TREATMENT ONLY
GROUP II 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
LESIONS REQUIRING COMBINED ENDO – PERIO TREATMENT
GROUP III 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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ATYPICAL ANATOMIC FACTORS Malaligned tooth Multirooted teeth / additional root Additional canal Cervical enamel projection Large lateral / accessory canal TRAUMA
With gingival inflammation Tooth fracture Pulp / perio involvement + sinus tract Cellular changes - resorption
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MISCELLANEOUS Iatrogenic systemic
SINUS TRACT
INFRABONY POCKET
•From canal
•From gingival crevice
•Narrow
•wide
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Causes : ( Stock )
Root fractures – crown / root ( vital / non vital )
Root canal infection
Root resorption
Anatomical anomalies ( palatogingival groove,enamel pearls , root division , fused teeth , invagination )
Root perforation
Orthodontic treatment
Localized periodontal disease Transplantation & replantation www.indiandentalacademy.com
Poorly designed restorations
Multiple endo perio lesion
•Isolated lesion upon gen. periodontitis
•Chronic periodontitis
•Aggressive periodontitis
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CONTROVERSIAL ASPECT CONCERNING THE COMBINED LESION PULPAL PERIODONTAL Chacker Massler Czarnecki & Schilder
PERIODONTAL PULPAL ? Venous blood flow outward
Drawback Lateral / accesory canal - flow bothways Seltzer & bender Stahl
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Physiologic : • Apical foramen • Lateral canals • Dentinal tubules • Periodontal ligament • Alveolar bone • Neural pathways • Vasculolymphatic pathway
Iatrogenic : • Palatogingival grooves • Cementum defect • Vertical root fractures • Perforations www.indiandentalacademy.com
COMPARISION MARGINAL PERIODONTITIS
APICAL PERIODONTITIS
Cervical
Apex
Plaque
Pulpal inflammation
Horizontal / Vertical bone loss - Seldom bone loss – localized generalized & deep Open
Contained
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Attachment loss asso. with Anatomic defect on root Nature of pathogenic flora Necrotic & infected pulp Host defense mechanism defect.
Aggresiveness asso with Lateral & apical foramen Nature of flora Apical host defense
Periodontal probing & radiographic examination
Radiographic examination
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DIFFERENTIAL DIAGNOSIS PULPAL
PERIODONTAL
CLINICAL Cause
pulp infection
periodontal
Vitality
non vital
vital
Restorative
deep or extensive
not related
Plaque /calculus
not related
primary cause
Inflammation
acute
chronic
Pockets
single and narrow
multiple and wide
pH value
acidic
alkaline
Trauma
primary or secondary
contributing factor
Microbial
few
coronally
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complex
RADIOGRAPHIC Pattern Bone loss Periapical Vertical bone loss
localized wider apically radiolucent no
generalized wider coronally not related yes
HISTOPATHOLOGY Junctional epithelium Granulation tissues Gingival
no apical migration apical (minimal) normal
present coronal (larger) recession
TREATMENT Therapy
RCT
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Periodontal therapy
Problems in diagnosis : Vertical root fracture: varied radiographic picture Different angulations Surgical exposure lateral condensation excessive Post placement Cause Extensive restorations Older patients Gingival sulcus & pocket area Single rooted teeth multirooted teeth Developmental grooves In doubt ? – Biopsy / Histological analysis Systemic diseases mimic lesion on radiograph : Scleroderma Metastatic carcinoma Osteosarcoma www.indiandentalacademy.com
EFFECT OF PULP AND ITS TREATMENT ON PERIODONTIUM Periodontal inflammation & bone loss Sub marginal bone loss Horizontal bone loss Vertical intrabony pockets Furcation involvement Periodontal wound healing Traumatized necrotic pulp RC infection – compromised healing Gingival tissue thickness Alveolar bone level Surgical trauma to flap Effective flap repositioning Root canal treatment Doubtful pulpal status Iatrogenic problems www.indiandentalacademy.com
EFFECT OF PERIODONTAL DISEASE & ITS TREATMENT ON PULP Periodontal disease & pulp •Limited •Channels closed + dystrophic calcification- chronic •Sufficient viurlence – pulpal disease •Poor prognosis •Extraction / Root resection Periodontal treatment & pulp
•Scaling & root planing – excessive cementum removal •Compromised pulp
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PRIMARY ENDODONTIC LESION Caries / trauma / restorative procedure Pulp
Inflammation
Apical / lateral / Furcation / Attachment apparatus Pain , swelling , tenderness , marginal gingiva swelling Suppurative process – Sinus tract Pdl / Patent channels Multirooted Teeth Gr. III thru & Thru Furcation defect Diagnosis : Necrotic / Vitality test Treatment : RCT
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Ging. Sulcus ( GP / Probe to apex)
PRIMARY ENDODONTIC WITH SECONDARY PERIODONTAL Unchecked endo lesion Periapical alveolar bone destruction Interradicular area Drainage
Hard / soft tissue
Plaque / Calculus
Apical attachment migration ( perio disease) Diagnosis : Necrosis / Calculus accumulation Treatment : Both
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PRIMARY PERIODONTAL LESION Sulcus
Plaque / Calculus Inflammation
Apex Alv. Bone / Pdl Clinical attachment loss acute Abscess
Lateral root / Furcation / TFO ( isolated lesion ) Diagnosis : Tooth mobility positive pulp test Broad based pocket / Plaque & calculus Generalized Treatment : Periodontal therapy
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osseous defects
PRIMARY PERIODONTAL & SECONDARY ENDODONTIC Periodontium
Pulp
Dentinal tubules Lateral canals Diagnosis : Deep pocket H/O extensive periodontal disease Past treatment Treatment : Both
TRUE COMBINED LESIONS
CONCOMITANT LESIONS
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Oral cavity
DIAGNOSIS OF ENDO PERIO LESIONS History of dentinal / pulpal pain History of periodontal symptoms (bleeding, recur. Infection , mobility) - nature / duration - risk factors Signs and symptoms of pulpal / periapical disease (vitality) Periodontal charting (probing profile) - Recession - Mobility - Furcation involvement - Attachment loss
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Clinical signs of pocket formation : Bluish red marginal gingiva / vertical zone extending from marginal to attached gingiva. “Rolled” edge separating gingival margin form tooth surface. Enlarged edematous gingiva. Bleeding, suppuration, loose extruded teeth.
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Symptoms of pocket formation Usually painless Localized or radiating pain or sensation of pressure after eating which gradually diminishes. Foul taste in localized areas. Sensitivity hot and cold Tooth ache in absence of caries are present
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BIOLOGIC DEPTH PROBING DEPTH FORCE : 0.75N POCKET DEPTH LEVEL OF ATTACHMENT GINGIVAL RECESSION 6 POINT CHARTING
DISTOPALATAL
MID PALATAL www.indiandentalacademy.com
MESIOPALATAL
CONTINUOUS PROBING PROFILE
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LONG NARROW POCKETS: ENDODONTIC ORIGIN
LATERAL ENDODONTIC ABSCESS WIDE AND DEEP POCKET “BLOW OUT” LESION
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RADIOGRAPHIC PATTERN OF BONE LOSS •Apical extent of bone loss •Definite Pdl space absent •Shape of bone defect ( angularity / marginal bone ) Bone defect contributed by pulp infection : - Periodontal intrabony defect – 2/3 root length - Horizontal bone loss - 2/3 root length - periodontal bone loss involving root end
Acute pain generally absent in endo perio – open nature 30 – 60 % spirochaetes 0 – 10 % spirochaetes
- perio origin - endo origin
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Causes: o Endo o Perio o Fracture o Resorption o Anatomy
Endo perio lesion usually isolated, narrow localized pocket
Check endodontic status
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
MANAGEMENT
Feasible re-treatment? No
Yes
Try OHI + debridement OHI Resolution?
Resolution? No
Yes
No
Yes
oDo first stage endo oClean and shape canals oDress with calcium hydroxide Extract
Resolution? Yes
Extract www.indiandentalacademy.com No
Vitality tests
Negative
Positive
Root canal treatment
Perio treatment
Resolution?
Resolution? Yes
No
No
Yes
Check OHI and perio
Check vitality again: If in doubt- do RCT Still no resolution: look for other causes
Extract, resect , hemisect www.indiandentalacademy.com
TREATMENT ALTERNATIVES ROOT RESECTION
REGENERATIVE TECHNIQUES ROOT RESECTION : “ Sectioning & removal of one or two roots of a multirooted teeth with accompanying odontoplasty.” 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.” www.indiandentalacademy.com
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.”
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ROOT RESECTION Furcation involvement.
( Maxillary / Mandibular - 3 point / Nabers probe )
Classification of degree of Furcation involvement Class I - Horizontal loss of periodontal support< one third of tooth width Class II - Horizontal loss of periodontal support> one third but not encompassing the total width of the tooth Class III - Horizontal through and through destruction of the periodontal tissue in the furcal area
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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 Severe root exposure due to dehiscence
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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
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Contraidications 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
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Factors Tooth related : - tooth restorability - strategic value - endo feasibility - post treatment stability - shape , size , posn. Of adj. tooth Root related : - length of the root trunk - divergence b/w the roots - curvature Bone related factors : - residual bone - localised deep attachment loss Final restoration : - resection nature - amt. of remaining tooth structure - perio. Status - pt. occlusion www.indiandentalacademy.com
Poor prognosis Retained roots
SURGICAL CONSIDERATIONS Buccal + Palatal flaps Releiving incision Intracrevicular incision Full thickness flap Undersurface of crown - bevelled .
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Envelop Type Flaps Little Or No Attached Gingiva Flap Edges - Sutured Full Flap - Periodontal Disease - Scaling, Curettage Or Osseous Contouring Procedures Endodontic Implants Root Amputation – Max. Molars
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REGENERATIVE TECHNIQUES GTR – Differential tissue development Barrier
Resorbable
Collagen Synthetic
Non resorbable
Enamel matrix derived protein Barrier – principle - stiff Combined lesion – poor prognosis
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ANTIBIOTICS FOR ENDO PERIO LESION
Tetracycline
250 mg (4 times a day)
Doxycycline
100 mg (2 times on first day and once thereafter)
Metronidazole
250 mg (3 times a day for 7 days)
Chlorhexidine
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REFERENCES
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