Endodontic Periodontal Lesions

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Endodontic Periodontal Lesions

• Dr shabeel pn

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Anatomic Considerations

• There is an intimate relationship between the
  periodontium and pulpal tissues
• As the tooth develops and the root is formed, 3
  main avenues for communication are created
• Apical Foramen
• Lateral and Accessory Canals
• Dentinal Tubules

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Apical Foramen

• It is the principal and the most direct route of
  communication between the pulp and periodontium
• Bacterial and inflammatory byproducts may exit
  readily through the apical foramen to cause
  periapical pathosis
• The apex may also serve as a portal of entry of
  inflammatory byproducts from deep periodontal
  pockets to the pulp

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Apical Foramen

• SEM of the apical third of a root. Note the
  opening of an accessory canal at ninety degrees
  from the main canal

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Lateral and Accessory Canals

• These may be present anywhere along the root
• Patent accessory and lateral canals may serve as
  a potential pathway for the spread of bacterial
  byproducts
• 30-40 of all teeth have lateral or accessory
  canals and the majority of them are found in the
  apical third of the root

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Lateral Canals
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Dentin Tubules

• Exposed dentinal tubules in areas of denuded
  cementum may serve as communication pathways
  between the pulp and PDL
• In the root, dentinal tubules extend from the
  pulp to the dentinocemental junction. They range
  in size from 1 to 3 microns in diameter (bacteria
  and their toxins are smaller in size)

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Dentinal Tubules

• Scanning electron micrograph of open dentinal
  tubules

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Dentin Tubules

• The tubules may be denuded of their cementum
  coverage as a result of perio disease, surgical
  procedures or developmentally when the cementum
  and enamel do not meet at the CEJ thus leaving
  areas of exposed dentin
• Patients experiencing cervical dentin
  hypersensitivity are examples of such a
  phenomenon

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Additional Avenues of communication between the
Pulp and the Periodontium

• Developmental malformations such as
  palatogingival grooves of maxillary incisors.
  These usually begin in the central fossa, cross
  the cingulum, and extend apically with varying
  distances
• Perforations these may result from extensive
  carious lesions, resorption, or from operator
  error
• Vertical root fractures these can produce deep
  periodontal pocketing and localized destruction
  of alveolar bone. The fracture site provides a
  portal of entry for irritants from the root canal
  to the PDL

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Additional Avenues of communication between the
Pulp and the Periodontium
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Endodontic Disease and the Periodontium

• When the pulp becomes inflamed or necrotic,
  inflammatory byproducts may leach out through the
  apex, lateral and accessory canals as well as the
  dentinal tubules to trigger an inflammatory
  vascular response in the periodontium
• Seltzer and Bender 1967

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Periodontal Disease and the Pulp

• The effect of periodontal inflammation on the
  pulp is controversial and conflicting studies
  exist
• It has been suggested that periodontal disease
  has no effect on the pulp, at least until it
  involves the apex (Czarnecki Schilder, 79)
• On the other hand, some studies suggest that the
  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)
• It has been reported that pulpal changes
  resulting from periodontal disease are more
  likely to occur when the apical foramen is
  involved (Langland et al 74)

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Differential Diagnosis of Endo/Perio Lesions

• The following classification system was developed
  by Simon, Glick and Frank in 1972
• Primary Endodontic Disease
• Primary Periodontal Disease
• Primary Endo w/ Secondary Perio
• Primary Perio w/ Secondary Endo
• True Combined Lesions

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Differential Diagnosis of Endo/Perio Lesions
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Primary Endodontic Disease

• Typically, endodontic lesions resorb bone
  apically and laterally and destroy the attachment
  apparatus adjacent to a nonvital tooth
• It is possible for an acute exacerbation of a
  chronic periapical lesion on a tooth with a
  necrotic pulp to drain through the PDL into the
  gingival sulcus. This clinical presentation
  mimics the presence of a periodontal abscess, or
  a deep periodontal pocket

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Primary Endodontic Disease

• When endodontic infection drains through the PDL,
  the pocket is very narrow and deep. In reality,
  it is a sinus tract of pulpal origin that opens
  through the PDL, and not breakdown due to
  periodontal disease
• A similar situation can occur where drainage
  from the apex of a molar tooth extends coronally
  into the furcation area. These cases resemble a
  through-and-through furcation defect (Grade
  III) of periodontal disease

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Primary Endodontic Disease

• For diagnostic purposes, it is imperative to
  trace the sinus tract by inserting a gutta-percha
  cone and exposing one or more radiographs to
  determine the origin of the lesion
• The sinus tract of endodontic origin is readily
  probed down to the tooth apex, where no increased
  probing depth would otherwise exist around the
  tooth

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Primary Endodontic Disease

• Primary endodontic disease will heal following
  root canal treatment
• The sinus tract extending into the gingival
  sulcus or the furcation area disappears at an
  early stage once the necrotic pulp has been
  removed and the root canals are well sealed

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Primary Endodontic Disease

• Pre-op 30 Post-op
  2 yr follow-up

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Primary Endodontic Disease

• Pre-op 19 periapical and furcal RL a deep
  narrow perio defect

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Primary Endodontic Disease

• 1 yr follow-up complete healing of RL and buccal
  defect

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Primary Periodontal Disease

• Caused by periodontal pathogens
• It is the result of progression of chronic
  periodontitis apically along the root surface
• Pulp tests yield a clinically normal pulpal
  reaction

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Primary Periodontal Disease

• Frequently accumulation of plaque and calculus
  are seen throughout the dentition
• Periodontal pockets are wider, and are
  generalized
• The prognosis depends on the stage of periodontal
  disease and the efficacy of periodontal treatment

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Primary Periodontal Disease

• Pre-op alveolar bone loss a periapical lesion,
  a deep narrow pocket was traced on the mesial
  aspect of the root, the tooth tested vital

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Primary Periodontal Disease

• The tooth was extracted. Note the deep mesial
  radicular developmental groove

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Primary Periodontal Disease

• 31 was referred for RCT. The tooth tested vital
  to cold

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Primary Periodontal Disease

• Referring dentist insisted that endo be done.
  However, since the etiology was periodontal
  disease, no bony healing took place

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• A periapical lesion of endodontic origin will not
  occur in the presence of a normal vital pulp!!!

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Primary Endo with Secondary Perio

• This happens with time as suppurating primary
  endodontic disease remains untreated, it may
  become secondarily involved with periodontal
  breakdown
• Plaque forms at the gingival margin of the sinus
  tract and leads to plaque-induced periodontitis
  in the area

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Primary Endo with Secondary Perio

• The pathway of inflammation into the periodontium
  is through the apical foramen, accessory and
  lateral canals

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Primary Endo with Secondary Perio

• The treatment and prognosis are now different
  than those of teeth simply having endo or perio
  disease
• The tooth now requires both endodontic and
  periodontal treatments
• If the endo Tx is adequate, the prognosis depends
  on the severity of the plaque-induced
  periodontitis and the efficacy of perio Tx

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Primary Endo with Secondary Perio

• With endo Tx alone, only part of the lesion will
  heal to the level of the secondary periodontal
  lesion
• Root fractures and perforations may also peresent
  as primary endo with secondary periodontal
  involvement

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Primary Endo with Secondary Perio

• Pre-op interradicular
• defect extends to the apex
  Post-op

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Primary Endo with Secondary Perio

• 1 yr follow-up resolution of most of the
  periradicular lesion, however, a bony defect at
  the furcal area remained. Perio Tx is necessary
  for further healing

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Primary Perio with Secondary Endo

• In this case, 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

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Primary Perio with Secondary Endo

• The progression of periodontitis by way of
  lateral canal and apex to induce a secondary
  endodontic lesion

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Primary Perio with Secondary Endo

• In single-rooted teeth the prognosis is usually
  poor, as the periodontal breakdown is very
  severe, necessitating extraction
• In molar teeth the prognosis may be better, since
  not all the roots may suffer the same loss of
  supporting periodontium. Root resection may be
  considered as a treatment alternative

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Primary Perio with Secondary Endo

• Even though unusual, the treatment of periodontal
  disease can also lead to secondary endodontic
  involvement. Lateral canals and dentinal tubules
  may be opened to the oral environment by scaling
  and root planing or surgical flap procedures

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Primary Perio with Secondary Endo

• At initial presentation 13 shows evidence of
  horizontal bone loss as well as a periapical
  radiolucency. The crown was intact, but vitality
  tests were negative. The post-op radiograph shows
  that a lateral canal was exposed to the oral
  environment due to bone loss. That lateral canal
  could serve as a potential pathway for bacteria.

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True Combined Disease

• True combined endo/perio disease occurs less
  frequently than other endo/perio problems
• It is formed when an endodontic disease
  progressing coronally joins with an infected
  periodontal pocket progressing apically
• The degree of attachment loss in this type of
  lesion is large and the prognosis is thus
  guarded, particularly for single-rooted teeth.

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True Combined Disease

• Concomitant endo-perio lesion is an additional
  classification that has been proposed to describe
  the presence of endo and perio disease as two
  separate and distinct entities

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True Combined Disease

• Radiograph shows separate progression of
  endodontic disease and periodontal disease. The
  tooth remained untreated and consequently the two
  lesions joined together

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True Combined Disease

• Radiograph shows bone loss in 2/3 of the root
  with calculus present and a separate periapical
  radiolucency. Clinical exam revealed coronal
  color change and pus exuding from the gingival
  crevice. Pulp vitality tests were negative

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True Combined Disease
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Diagnosis

• A thorough clinical and radiographic examination
  is imperative for developing a diagnosis
• Data Collected must include
• periapical radiographs
• pulp vitality testing cold, EPT, cavity test
• percussion
• palpation
• pocket probing
• sinus tract tracking
• cracked tooth testing transillumination,
  tooth-slooth, staining

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Treatment Decision-Making and Prognosis

• Treatment decision-making and prognosis depend
  primarily on the diagnosis of the specific
  endodontic and/or periodontal disease
• The main factors to consider are pulp vitality
  and type and extent of the periodontal defect

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Treatment Decision-Making and Prognosis

• Diagnosis of Primary endo and Primary perio
  disease usually present no clinical difficulty.
  In primary endo the pulp is nonvital. In primary
  perio the pulp is vital
• However, the diagnosis of the combined endo/perio
  lesions could present a challege as they present
  clinically and radiographically very similar.
  The diagnosis is often tentative with a
  definitive diagnosis formulated following
  treatment

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Treatment Decision-Making and Prognosis

• The prognosis and treatment of each endo/perio
  disease type varies
• Primary endo should only be treated by endodontic
  therapy and has a good prognosis
• Primary perio should only be treated by
  periodontal treatment. The prognosis depends on
  severity of the perio disease and patient
  response to treatment

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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. This
  sequence allows for sufficient time for initial
  tissue healing and better assessment of the
  periodontal condition to determine if the tooth
  needs SC/RP or surgical treatmen. Prognosis
  depends on the periodontal involvement and
  treatment
• Cases of True Combined disease usually have a
  more guarded prognosis