Endo perio interrelation /certified fixed orthodontic courses by Indian dental academy

INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com


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

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.


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


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


LESIONS REQUIRING ENDODONTIC TREATMENT ONLY
GROUP I
 necrotic pulp and apical granulomatous tissue replacing periodontium with
or without sinus 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 / replants / transplants
 Teeth that require hemisection
 Root submergence

GROSSMAN

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


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


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


MISCELLANEOUS
Iatrogenic
systemic

SINUS TRACT

INFRABONY POCKET

•From canal

•From gingival crevice

•Narrow

•wide


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

Poorly designed restorations

Multiple endo perio lesion

•Isolated lesion upon gen. periodontitis

•Chronic periodontitis

•Aggressive periodontitis


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


Physiologic :
• Apical foramen
• Lateral canals
• Dentinal tubules
• Periodontal ligament
• Alveolar bone
• Neural pathways
• Vasculolymphatic pathway
• Palatogingival grooves
• Cementum defect
Iatrogenic :
•
•

Vertical root fractures
Perforations


COMPARISION
MARGINAL
PERIODONTITIS

APICAL
PERIODONTITIS

Cervical

Apex

Plaque

Pulpal inflammation

Horizontal / Vertical bone loss - Seldom bone loss – localized
generalized
& deep
Open

Contained


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


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


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


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

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

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


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


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


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


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


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


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.


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


BIOLOGIC DEPTH
PROBING DEPTH
FORCE : 0.75N
POCKET DEPTH
LEVEL OF ATTACHMENT
GINGIVAL RECESSION
6 POINT CHARTING

DISTOPALATAL

MID PALATAL

MESIOPALATAL

CONTINUOUS PROBING PROFILE


LONG NARROW POCKETS: ENDODONTIC ORIGIN

LATERAL ENDODONTIC ABSCESS
WIDE AND DEEP POCKET
“BLOW OUT” LESION


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


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?

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

www.indiandentalacademy.com Extract
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

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.”

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.”


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


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


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


Contraidications
Root fusion making separation impossible
Angulation or position of tooth in the arch
Root morphology
Improperly shaped occlusal contact


 Poor prognosis
 Retained roots

SURGICAL CONSIDERATIONS
 Buccal + Palatal flaps
 Releiving incision
 Intracrevicular incision
 Full thickness flap
 Undersurface of crown - bevelled
.


Envelop Type Flaps
Little Or No Attached Gingiva
Flap Edges - Sutured
Full Flap - Periodontal Disease - Scaling, Curettage Or Osseous
Contouring Procedures


REGENERATIVE TECHNIQUES
GTR – Differential tissue development
Barrier

Resorbable

Collagen
Synthetic

Non resorbable

Enamel matrix derived protein
Barrier – principle - stiff


ANTIBIOTICS FOR ENDO PERIO LESION

 Tetracycline

250 mg (qid)

 Doxycycline

100 mg ( bd / od )

 Metronidazole

250 mg ( tid for 7 days)

 Chlorhexidine


REFERENCES

 The use of guided tissue regeneration principles in endodontic surgery for
induced chronic periodontic-endodontic lesions: a clinical, radiographic,
and histologic evaluation
J Periodontol. 2005 Mar;76(3):450-60.
 Pathologic interactions in pulpal and periodontal tissues.
J Clin Periodontol. 2002 Aug;29(8):663-71.

 The influence of endodontic treatment upon periodontal wound healing.
J Clin Periodontol. 1997 Jul;24(7):449-56.


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