Endodontic Periodontal Relationships

Endodontic Periodontal LesionsDr shabeel pn

Anatomic ConsiderationsThere 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 ForamenLateral and Accessory CanalsDentinal Tubules

Apical ForamenIt 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

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

Lateral and Accessory CanalsThese 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

Lateral Canals

Dentin TubulesExposed 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)

Dentinal TubulesScanning electron micrograph of open dentinal tubules

Dentin TubulesThe 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

Additional Avenues of communication between the Pulp and the PeriodontiumDevelopmental 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

Additional Avenues of communication between the Pulp and the Periodontium

Endodontic Disease and the PeriodontiumWhen 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 periodontiumSeltzer and Bender 1967

Periodontal Disease and the PulpThe 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)

Differential Diagnosis of Endo/Perio LesionsThe following classification system was developed by Simon, Glick and Frank in 1972:Primary Endodontic DiseasePrimary Periodontal DiseasePrimary Endo w/ Secondary Perio Primary Perio w/ Secondary EndoTrue Combined Lesions

Differential Diagnosis of Endo/Perio Lesions

Primary Endodontic DiseaseTypically, 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

Primary Endodontic DiseaseWhen 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

Primary Endodontic DiseaseFor 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

Primary Endodontic DiseasePrimary 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

Primary Endodontic DiseasePre-op #30 Post-op 2 yr follow-up

Primary Endodontic DiseasePre-op #19: periapical and furcal RL + a deep narrow perio defect

Primary Endodontic Disease1 yr follow-up: complete healing of RL and buccal defect

Primary Periodontal DiseaseCaused 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

Primary Periodontal DiseaseFrequently 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

Primary Periodontal DiseasePre-op: alveolar bone loss + a periapical lesion, a deep narrow pocket was traced on the mesial aspect of the root, the tooth tested vital

Primary Periodontal DiseaseThe tooth was extracted. Note the deep mesial radicular developmental groove

Primary Periodontal Disease#31 was referred for RCT. The tooth tested vital to cold

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

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

Primary Endo with Secondary PerioThis 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

Primary Endo with Secondary PerioThe pathway of inflammation into the periodontium is through the apical foramen, accessory and lateral canals

Primary Endo with Secondary PerioThe 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

Primary Endo with Secondary PerioWith 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

Primary Endo with Secondary Perio Pre-op: interradicular defect extends to the apex Post-op

Primary Endo with Secondary Perio1 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

Primary Perio with Secondary EndoIn 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

Primary Perio with Secondary EndoThe progression of periodontitis by way of lateral canal and apex to induce a secondary endodontic lesion

Primary Perio with Secondary EndoIn 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

Primary Perio with Secondary EndoEven 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

Primary Perio with Secondary EndoAt 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.

True Combined DiseaseTrue 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.

True Combined DiseaseConcomitant 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

True Combined DiseaseRadiograph shows separate progression of endodontic disease and periodontal disease. The tooth remained untreated and consequently the two lesions joined together

True Combined DiseaseRadiograph 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

True Combined Disease

DiagnosisA thorough clinical and radiographic examination is imperative for developing a diagnosis

Data Collected must include: periapical radiographspulp vitality testing: cold, EPT, cavity testpercussionpalpation pocket probingsinus tract trackingcracked tooth testing: transillumination, tooth-slooth, staining

Treatment Decision-Making and PrognosisTreatment 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

Treatment Decision-Making and PrognosisDiagnosis 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

Treatment Decision-Making and PrognosisThe 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

Treatment Decision-Making and PrognosisCombined 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

Fractures are an abnormal connection *It is a two way pathway From the pulp to the PDL, and from the PDL to the pulp *They are not centered on the apex because there are lateral canals

*The apical third has most of them It is very difficult to instrument and obturate these canals so we count on the sealers to fill these canals otherwise the bacteria will continue to leak

*the periodentuim is usually attached with the malformation which is great, but the problem starts if there is perio disease then the bacteria can reach all the way down the palatogingical groove or malformation down to the apex and will cause de-vitalization or loss of the tooth due to perio disease *Resorption will cause a poor prognosis *You would see a lesion on the radiograph but it will not contain any bacteria only by-products that cause inflammation and loss of bone. *We do know that pulpal disease can cause periodontal inflammation and can loss of bone of bone in the periapical region. A lot of studies show that perio disease doesnt affect the pulp at least until it reaches the apex *This is a simplification If you have pulpal disease it can spread through the canals into the periodontal area and even through the apex, also furcation canalsYou will see endo teeth with furcation involvement that is not due to perio. Primary perio lesion you will have a vital pulp but the perio involvement is all the way to the apex and you will have a J-shaped lesion similar to the one you see in a vertical root fracture True endo perio lesion, you have both conditions and the lesion meet in the middleEndo lesion that has progressed for so long and worked its way up to the top *Check if the tooth is vital or notIf it is vital then it is not an endo lesion

*Use an 02 40 cone Take two x-rays straight on and distal to localize the tract *Vitality means perio Another way to differentiate primary and endo from perio is that when you treat a primary perio with RCT the disease will not resolve. *Tooth endo involved, lesion in apical and furcation area, the endo treatment was done and the areas healed *PA and furcation involvement also *The furcation healed and the probe doesnt go in so much **The first thing you want to check for this tooth vitality and it turned out to be vital It also had a sinus tract The lesion could be a little buccal to the apex**Vital tooth Referring dentist insisted on endo treatment *Did not heal after endo because it is not endo in origin *Untreated endo lesions that leads to perio problems Calculus will build up in that area *Periodontal break down and calculus formation from the apex upward *More complicated The prognosis is different The tooth will need both endo and perio treatment If the perio involvement is only in the coronal third then there will be a better prognosis

*Now it needs perio treatment *Not always will become necrotic but it may become *With the multirooted you can still save the remaining roots *Prognosis is guarded specially in single rooted teeth *Endo treatment followed by surgical perio tx

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