Perio endo lesions

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  • 1. Dr. Akinmoladun Abiodun .S
  • 2. Outline  Introduction  Pathways of Communication  Influence of pulpal disease on the periodontium  Influence of periodontal disease on the pulp  Classification of Perio- Endo Lesions  Diagnosis of Perio-Endo Lesions  Treatment of Perio-Endo Lesions  Conclusion
  • 3. Introduction  There are interrelationships between pulpal and periodontal disease  Primarily due to intimate anatomic and vascular connections between the pulp and periodontium  This could make diagnosis a challenge because these diseases have been studied as separate entities  Each primary disease could mimic clinical characteristics of the other
  • 4.  The relationship between periodontal and pulpal disease was 1st described by Simring and Goldberg in 1964  Since then the term “Perio- Endo Lesion” has been used to describe lesions due to inflammatory products found in varying degrees in both the periodontium and the pulpal tissues.
  • 5.  The Periodontium and pulp have embryonic, anatomic and functional Interrelationships  Embryonically, the pulp originates from the dental papilla and the periodontal ligament from the dental follicle  These are separated by Hertwig’s epithelial root sheath
  • 6.  As the tooth matures and the root is formed  Ectomesenchymal channels get incorporated either due to dentin formation around existing blood vessels or breaks in the continuity of the sheath of Hertwig, giving rise to accessory or lateral canals.
  • 7. Pathways of Communication  The possible pathways for ingress of bacteria and their products into these tissues can broadly be divided into: Anatomical Pathways  Apical foramen  Lateral and accessory canals  Dentinal tubules
  • 8. Non-physiological Pathways  Root canal perforation  Vertical root fracture Other Pathways:  Palatogingival grooves
  • 9. Apical Foramen  This is the principal and most direct route of communication between the periodontium and the pulp.  Although periodontal disease has been shown to have cumulative damaging effect on the pulp  Total disintegration of the pulp is only certain if bacterial plaque involves the main apical foramen, compromising the vascular supply
  • 10.  Also, following necrosis of the pulp, various bacterial products like enzymes, metabolites, antigens e.t.c reach the periodontium through the apical foramen initiating inflammation  This results in destruction of periodontal tissue fibers and resorption of adjacent alveolar bone
  • 11. Lateral and accessory canals  The majority of accessory canals are found in the apical part of the root and lateral canals in the molar furcation region  They contain connective tissue and vessels connecting both pulp and periodontium  Bender et al stated that “perio-endo” problems are much more frequent in molars than in the anterior teeth  Due to the greater number of accessory canals present in the molars
  • 12. Dentinal tubules  Dentinal tubules contain odontoblastic processes that extend from the odontoblasts at the pulp dentin border to the dentino - enamel junction (DEJ)/cemento - dentinal junction(CDJ)
  • 13.  Exposed dentinal tubules in areas devoid of cementum serve as communication pathways between the pulp and the periodontium  This can occur due to periodontal disease, surgical procedures or developmentally when the cementum and enamel don’t meet at the CEJ
  • 14. Root canal perforation  Perforation of the root creates a communication between the root canal system and periodontal ligament  Due to over instrumentation during endodontic procedures, internal or external root resorption or caries invading through the floor of the pulp chamber
  • 15.  Prognosis is determined by the location of the perforation, time left unsealed, ability to seal perforation, the chance of building new attachments and accessibility of the remaining canals.  Perforations in middle/apical 3rd of root have the greatest chance of healing
  • 16.  The closer the perforation to the gingival sulcus particularly the coronal 3rd of root or furcation region  The greater the likelihood of apical migration of gingival epithelium and initiation of a periodontal lesion
  • 17. Vertical root fracture  Caused by trauma  Incidence is higher in Teeth that have been filled with lateral condensation technique Teeth restored with intracanal posts
  • 18.  This over time can cause deep periodontal pocketting and localized destruction of alveolar bone  The fracture site also provides a portal of entry for irritants from the root canal system to the surrounding periodontal ligament
  • 19. Palatogingival grooves  Developmental anomalies of the maxillary incisor teeth  Lateral incisors more frequently affected than central incisors  Generally, incidence range from 1.9% - 8.5%  These usually begin in the central fossa, cross the cingulum and extend apically with varying distances  Extension to the root apex contributes to endodontic pathology.
  • 20. Influence of pulpal disease on the periodontium  Degeneration of the pulp results in release of necrotic debris, bacterial byproducts and other toxic substances  This can move to the apical foramen causing periodontal tissue destruction apically  Subsequently migrate toward the gingival margin  Termed as “retrograde periodontitis”  To differentiate it from marginal periodontitis in which the disease moves from the gingival margin to the apex
  • 21.  The inflammatory process leads to destruction of periodontal ligament, cementum ,dentin, resorption of alveolar bone and pocket formation  Also, high concentrations root canal medicaments(e.g CaOH) and irrigants can irritate the periodontium
  • 22. Influence of periodontal disease on the pulp  Infection can spread from a periodontal pocket to the pulp through accessory canals at the furcation , the apex and exposed dentinal tubules  Pulpal reaction can also occur due to periodontal treatment e.g scaling and root planing especially when the cementum is denuded and dentin is exposed  Some studies have suggested that periodontal disease has no effect on the pulp except when the apex is involved
  • 23.  While some other studies have suggested that the effect of periodontal disease is degenerative in nature with increase in calcification and fibrosis of the pulp  And canals associated with periodontally involved teeth were reportedly narrower than canals of teeth which were not periodontally involved
  • 24.  Generally, if the blood supply through the apical foramen remains intact the pulp is usually capable of withstanding physiologic insults produced by periodontal disease
  • 25. Classification of Perio-Endo Lesions  Simon, Glick and Frank in 1972 :  Primary Endodontic Lesions  Primary Periodontal Lesions  Primary Endodontic Lesions with secondary periodontal involvement  Primary Periodontal Lesions with secondary endodontic involvement  True combined lesions Concomitant pulp and periodontal lesions
  • 26. Primary Endodontic Lesions  An acute exacerbation of a chronic apical lesion of a tooth with a necrotic pulp  May drain coronally through the periodontal ligament into the gingival sulcus  This can clinically mimic a periodontal abscess  But in reality it’s a sinus tract of pulpal origin that opens through the periodontal ligament area
  • 27.  For diagnosis, the clinician should insert a gutta- percha cone into the sinus tract and take radiographs to determine the origin of the lesion  Usually on probing ,the pocket is narrow without width  This can also occur when drainage from the apex of a molar tooth extends coronally into the furcation area  Also drainge of lateral canals extending from necrotic pulp to furcation area
  • 28.  Usually heal following root canal treatment  The sinus tract usually disappears once the affected pulp has been removed and root canals cleaned, shaped and obturated.
  • 29. Primary periodontal lesions  In this, chronic marginal periodontitis progresses apically along the root surface  Pulp test usually indicate a clinically normal pulp  There is usually accumulation of plaque and claculus with wider periodontal pockets  Prognosis depends on the stage of periodontal disease and efficacy of periodontal treatment
  • 30. Primary endodontic lesions with secondary periodontal involvement  Occcurs when a suppurating primary endodontic disease remains untreated and become secondarily involved with marginal periodontal breakdown  Plaque forms at the gingival margin of the sinus tract and leads to plaque-induced periodontitis in the area
  • 31.  The pathway of inflammation into the periodontium is through the apical foramen, accessory and lateral canals
  • 32.  The treatment and prognosis are now different than those of teeth simply having only primarily endodontic or periodontal disease  The tooth now requires both endodontic and periodontal treatments  Once endodontic treatment is adequate, the prognosis then depends on the severity of the plaque-induced periodontitis and the efficacy of periodontal treatment
  • 33.  With endodontic treatment alone, only part of the lesion will heal to the level of the secondary periodontal lesion  Root fractures and perforations may also present as primary endodontic lesion with secondary periodontal involvement
  • 34. Primary periodontal lesions with secondary endodontic involvement  There’s periodontal pocket formation and progression of periodontitis  Involving the lateral canal and apex and inducing a secondary endodontic lesion  Making the pulp necrotic
  • 35.  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.  Periodontal treatment can also lead to secondary endodontic involvement  When lateral canals and dentinal tubules are opened to the oral environment by curettage, scaling and surgical flap procedures and microbes pushed into them.
  • 36. True combined lesions  True combined perio-endo disease occurs less frequently than other perio-endo 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 making prognosis poor, particularly for single-rooted teeth.
  • 37. Concomitant pulpal and periodontal lesions  This is commonly seen clinically and show the presence of two separate and distinct entities  Both disease states exists but with different causative factors and with no clinical evidence that either disease state has influenced the other  Both disease processes must be treated independently and prognosis is dependent on the removal of individual causative factors.
  • 38. Diagnosis of perio-endo lesions  Accurate diagnosis can be achieved by careful history taking, examination and use of special tests  Diagnosis of primary endodontic disease and primary periodontal disease usually present no clinical difficulty  In primary periodontal disease, the pulp is vital and responsive to testing  While in primary endodontic disease, the pulp is infected and non – vital  However, combined lesions are clinically and radiographically very similar
  • 39.  The following aids are useful in making appropriate diagnosis:  periapical radiographs  pulp vitality testing: Thermal , EPT  Percussion  palpation  pocket probing  sinus tract tracking  cracked tooth testing: transillumination,
  • 40. Treatment and prognosis of perio- endo lesions  The prognosis and treatment of each endo/perio disease type varies  Primary endodontic lesions should only be treated by endodontic therapy and has a good prognosis  Primary periodontal lesions should only be treated by periodontal treatment. The prognosis depends on severity of the periodontal disease and patient response to treatment
  • 41.  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 treatment.  Prognosis depends on the periodontal involvement and treatment
  • 42. Conclusion  Perio - endo lesions result from the close inter- relationship of pulp tissue and periodontium  The major pathways of communication being the apical foramen, lateral and accessory canals and dentinal tubules.  Differential diagnosis of perio-endo lesions is not always straight forward and lesions with combined causes require both endodontic and periodontal therapy.