Endodontic periodontic lesions / rotary endodontic courses by indian dental academy


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Endodontic periodontic lesions / rotary endodontic courses by indian dental academy

  1. 1. ENDODONTIC –PERIODONTAL PROBLEMS . INDIAN DENTAL ACADEMY Leader in Continuing Dental Education www.indiandentalacademy.com
  2. 2. ENDO-PERIO LESIONSwww.indiandentalacademy.com
  3. 3. INTRODUCTION The tooth,its pulp & supporting structures are inter-related & influence each other during health,function & disease. The tooth vitality depends mainly on the ability of function & not viability of the pulp,Health of the structure is of prime importance. Therefore the tooth and the surrounding periodontium are viewed as a whole Biological unit. The relationship between pulp & periodontium was first described by SIMRING & GOLDBERG in 1964. Since then the term endo-perio lesion has been used to describe lesions of inflammatory products found in varying degrees in both the periodontium & pulpal tissues. www.indiandentalacademy.com
  4. 4. PULPAL-PERIODONTALINTER-RELATIONSHIP. Pulp & Periodontium have a embryonic,anatomic & functional inter-relationship. These structures are ectomesenchymal in origin,which proliferate to form the dental papilla & follicle..the precursors of pulp & periodontium. Embryonic development gives rise to anatomical connections which remain throughout life of the tooth. The apical foramen decreases in size as the proliferation of the sheath of Hetwig continues.This remains patent & serves as the communication on which the pulpal tissue rely for nutrition & nervous innervation. As the root developes the ectomesenchymal channels get incorporated by dentine formation around the blood vessels & brake the continuity of Hetwig sheath,to become acessory or lateral canals. www.indiandentalacademy.com
  5. 5.  Majority of accessory canals are found in the apical part of root & lateral canals in the molar furcation regions. The tubular communication b/w the pulp & periodontium may occur when dentinal tubules become exposed to the periodontium by the absence of overlying cementum. These are the pathways that provide a means by which pathological agents b/w the pulp & periodontium thereby creating the “ENDO-PERIO LESIONS”. www.indiandentalacademy.com
  6. 6. PATHWAYS (to & through)… In normal conditions the pulp gets affected when the carious lesion extends beyond the dentine and into the pulp. Pulpal disease can progress beyond the apical foramen & inflame the PDL, causing it to be replaced by inflammatory tissue. Without proper treatment it can cause resorption of the bone,cementum & dentine. It can also progress through the lateral canals,showing lateral radioluceny on the root. Inflammatory reaponse at the lateral canals may extend crestaly along lateral aspects of the root & involve the furcation or crestal areas along PDL. www.indiandentalacademy.com
  7. 7.  Periodontal Inflammation may exert a direct effect on the pulp..though the clear cut effect is not yet determined. It is known to affect through the same lateral & apical foramen pathways. Gingival wounds on the pulp is shown in irregular dentin formation in the pulp opposite the wound site. www.indiandentalacademy.com
  8. 8. CLASSIFICATION OF ENDO-PERIO LESIONS. Various classifications given for the endo-perio lesions have been stated. OLIET AND GROSSMAN.-Lesions that require endodontic treatment.1.Chronic Periapical abcess,without a sinus tract.2.Chronic periapical abcess with a sinus tract draining through the gingival crevice,passing through a section of the attachment apparatus in its entire length alongside the root.3.Root fractures ,longitudinal and horizontal.4.Root perforations,pathologic & iatrogenic.5.Teeth withwww.indiandentalacademy.comdevelopment. incomplete apical root
  9. 9. 6.Endodntic implants.7.Replants,intentional or traumatic.8.Teeth requiring hemisection or radiosectomy.9.Root submergence.-.Lesions that require periodontal treatment.1.Occlusal trauma causing reversible pulpitis.2.Occlusal taruma plus gingival inflammation resulting in pocket formation.a.Reversible but increased pulpal sensitivity caused by trauma or exposed dentinal tubules.b.Reversible but increased pulpal sensitivity caused by uncovering lateral or acessory canals exiting into the periodontium.3.Suprabony or infrabony pocket formation treated by overzealous curettage & root planing.4.Extensive infrabony pocket,extending beyond root apex. www.indiandentalacademy.com
  10. 10. - Lesions that require combined endodontic-periodontic therapy .1.Lesions in Group 1 that results in irreversible reactions in the attachment apparatus and requires perio treAtment.2.Lesion in Group 2 that results in irreversible reactions in pulp and require endodontic therapy.Weinee Classificaton.-CLASS 1:Tooth symptoms clinically & Radiographically stimulate periodontal disease,but are due to pulpal inflammation or necrosis.-CLASS 2:Tooth that has both pulpal & Periodontal disease concomitantly-CLASS 3:Tooth that has no pulpal problem but requires endodontic therapy + Root amputation to gain periodontal healing.-CLASS 4:Clinically & Radiographically stimulates pulpal & periapical disease but infect has periodontal disease. www.indiandentalacademy.com
  11. 11. -COHENS CLASSIFICATION.1.Primary Endodontic Lesion2.Primary endodontic lesion with secondary perio lesion3.Primary periodontal lesion.4.Primary perio lesion with secondary endodontic involvement.5.True combined Endodontic & Periodontic lesion. www.indiandentalacademy.com
  12. 12. ETIOLOGICAL FACTORS-MALALINGMENT OF A TOOTH.Presence of the multirooted tooth in a position usually occupied by a single rooted teeth.Presence of additional canals.Cervical enamel projections into the furca of multirooted teeth.Large lateral canals in coronal & middle sections of the roots.- TRAUMA- MISCELLANEOUS EFRRORS SUCH AS PERFORATIONS www.indiandentalacademy.com
  13. 13. PRIMARYENDODONTIC LESIONS PATHOGENESIS.www.indiandentalacademy.com
  14. 14. PRIMARY ENDODONTIC LESIONS PATHOGENESIS. www.indiandentalacademy.com
  15. 15.  Endodontic lesions are initiated ane sustained by the apical foramena,lateral canal and infrequently dentinal tubules. Abscess formation follows the perio inflammation and spreads through the periodontium. Abcess may drain through a fistula via the periodontal ligament and the adjecent bone. Drainage may tract through PDL into the gingival sulcus or in multirooted teeth into the furcation. This may also perforate the cortical plates. These form pseudo pockets that simulate periodontal disease without permanently damaging the cementum and the fibres. If the acute phase carries on to the chronic phase then the perio pocket with secondary periodontal disease may complicate the lesion. Plaque and calculus can be found in the pocket. www.indiandentalacademy.com
  16. 16.  Simon Glick and Frank divided endodontic lesions into two types.1.Primary Endodontic lesion-when a sinus tract has formed to establish the drainage.2.Primary endodontic lesion with secondary periodontal involvement-when plaque formation occurring in the sinus tract with progression to periodontitis & associated calculus formation. The following classification helps in eliminating the Differential diagnosis to ensure correct choice of treatment for the endodontic lesion. www.indiandentalacademy.com
  17. 17. PRIMARY PERIODONTAL LESIONS PATHOGENESIS. www.indiandentalacademy.com
  18. 18.  Plaque & Calculus = PERIODONTAL LESION Destruction of conecctive tissue,Periodontal ligament and alveolar bone due to inflammatory mediators. Lesion further can progress upto the apex. Healthy pulp tissue is highly polymerised and vascular therefore resistant to infection,this prevents the degeneration of the pulp due to periodontal disease. If the periodontal disease affects the apical foramens the total degeneration of the pulp occurs,due to compromised vascular supply. Contrary to this localised pulp necrosis occurs in the area of the lateral canals exposed to the periodontal lesion. So lateral acessory canals and dentine tubules are potential sources of pulpitis and necrosis. Retrograde pulpitis follows local pulpal inflammation & necrosis & can result in total necrosis of the pulpal tissue. www.indiandentalacademy.com
  19. 19. PATHOGENESIS:TRUE COMBINED LESIONS. www.indiandentalacademy.com
  20. 20.  The pathogenesis of a true-combined lesion is identical to the primary perio and endo lesions. The individual lesions-Periapical lesion originating from the necrotic pulp & periodontal lesion progressing apically… eventually merge. These lesions are indistinguishable from an advanced primary endodontic lesion with secondary periodontal involvement & or a primary periodontal lesion with secondary endodontic involvement. www.indiandentalacademy.com
  21. 21. IATROGENIC LESIONS :PATHOGENESIS. www.indiandentalacademy.com
  22. 22.  Root perforations, overfilling of root canals.intra-canal medicaments & vertical fractures. Root perforations-during instrumentation,causing a communication b/w the pulp and periodontium. At the site of perforation an inflammatory reaction occurs causing degeneration of the surrounding tissues. Over filling of Root Canals also cause the similar effect Vertical Root fractures-caused when the root is weakened. Strong antiseptic drugs used for the root canal disinfection & pulp devitalization can cause severe damage if they leak into the periodontal tissues. www.indiandentalacademy.com
  23. 23. DIAGNOSIS. The critical factor of the Endo-Perio lesions is a correct diagnosis. This is achieved by taking a correct history,examination and use of special tests. Past history of disease trauma and pain should be considered . Vitality tests should be carried out on the relevant teeth In case of fracture surgical exposure may be necessary for its conformation. Advanced and true combined lesions may be difficult to differentiate if doubt exists they should be considered as endodontic lesions. www.indiandentalacademy.com
  24. 24. TREATMENT…initialconsiderations. The prognosis of the tooth should be considered carefully,before the commencement of any kind of advanced restorative treatment. Other important considerations are whether the tooth is restorable after the lesion has been treated,and patient suitability for lengthy,costly,invasive treatment with a need for high patient motivation. If any of these factors are deemed negative,extraction is then the choice of treatment. Extraction of tooth should be considered only as an alternative. www.indiandentalacademy.com
  25. 25. TREATMENT-Endodonticlesions Primary endodontic lesions require conventional therapy. Post operative review after 4-6 months shows healing of the periodontal pockets. Even in the presence of a large periradicular radiolucency & periodontal abscesses endodontic surgery proves to be unnessary. Invasive periodontal procedures should be avoided. If lesion persist..diagnosis should be questioned,as the lesion may have underlying secondary periodontal lesion,or could be a true combined lesion. www.indiandentalacademy.com
  26. 26.  Primary endodontic lesion with secondary periodontal involvement. These may not resolve with endodontic therapy alone. Root canal treatment is instituted immediately & the cleaned & shaped root canal is filled with Calcium Hydroxide Paste. This favours the repair and inhibits the resorption. The treatment removes the contaminants via the patent channels connecting the pulp & periodontium. Canals are filled with a conventional obturation Hygeine phase therapy is initiated immediately although deep scaling & periodontal surgery will resolve the part of the lesion. A conventional root filler is placed to prevent the delay in healing. www.indiandentalacademy.com
  27. 27.  Prognosis of the primary Endodontic lesion is good but worsens in the advanced stages of secondary periodontal involvement. Prognosis depends upon the effective periodontal treatment and with advancement can be comparable to the true- combined lesions. www.indiandentalacademy.com
  28. 28. TREATMENT..Periodontal lesions. Primary periodontal lesions are treated by hygine phase therapy in the first instance. Poor restorations and developmental grooves are removed as these areas are difficult to treat. After this phase periodontal surgery is performed, if deemed nessary. www.indiandentalacademy.com
  29. 29.  Primary Periodontal lesions with secondary Endodontic involvement. Early stage of involvement is limited to the pulpal hypersensitivity that is reversible,which can be treated by pure Periodontal therapy. The periodontal treatment removes the noxious stimuli & secondary mineralization of the dentinal tubules allow the resolution of the hypersensitivity. If the pulpal inflammation is irreversible the root treatment along wit periodontal therapy is carried out. In some cases surgical intervention is required. www.indiandentalacademy.com
  30. 30.  The prognosis of the periodontal lesion is poorer than endodontic lesions & is dependent on the apicl extension of the lesion. As the lesion advances the prognosis approaches the of the true- combined lesions. www.indiandentalacademy.com
  31. 31. TREATMENT-True Combined Lesions These lesions are initially treated as for the primary endodontic lesions with secondary periodontic lesions Periodontal surgery is not always called for in these cases. Root amputation,Hemisection or seperation may allow the root configuration to be changed, for the part of the root structure to be saved. Prior to surgery, palliative periodontal therapy should be completed & root canal treatment carried out on the roots to be saved. The advanced treatment plans are based on responses to conventional periodontal & endodontic treatment over an extended period of time. www.indiandentalacademy.com
  32. 32.  Prognosis of these true & combined lesions is often poor or even hopeless,mainly when periodontal lesions are chronic with extensive loss of attachment. Prognosis of the affected tooth can also be improved by increasing the bony support..achieved by bone grafting & guided tissue regeneration. The most critical determinant of prognosis being the loss of periodontal support. www.indiandentalacademy.com
  33. 33. TREATMENT-Iatrogenic Lesions. These lesions are treated the same way as the primary endodontic lesions. The first priority of the treatment is to close the iatrogenic communication and to establish a seal. Root perforations are treated in accordance to the etiology. Perforations during the root canal instrumentation,post hole preperation often need a surgical approach. Sealing includes direct sealing, facilitated through the access cavity, with a zinc oxide eugenol, glass ionomer or mineral trioxide aggregate.(MTA) filling material. A perforated canal can be measured,cleaned,shaped & filled using the same technique as the conventional root canal. www.indiandentalacademy.com
  34. 34.  Palatal perforations are difficult to manage,even surgically and leads to extractions often. Over-filling of root canals & intra-canal medicaments can usually be resolved by periradicular surgery…or accompanied by retrograde root canal filling. Teeth with lesions caused by vertical root fractures have a hopeless prognosis and should be extracted. Successful treatment depends upon the early detection and sealing. Prognosis is deemed poor,though a successful outcome can be achieved. www.indiandentalacademy.com
  35. 35. CASE1:Periodontallesion withsecondaryendodonticinvolvement. www.indiandentalacademy.com
  36. 36. CASE 2:Pre operative radiograph of the second molar with apocket to the apex long distal root & communicating with aapical lesion.Treated endodontically & no pero therapyrequired. www.indiandentalacademy.com
  37. 37. CASE 3:Endodontic treatment and no periodontal treatment. www.indiandentalacademy.com
  38. 38. Three months after treatment..healed periapical lesion andlateral incisor remains without mobility. www.indiandentalacademy.com
  39. 39. CASE 4:Very long term follow up on treatment of Class 1Endodontic -Periodontal Problems. www.indiandentalacademy.com
  40. 40. CASE 5: Exposure via lateral canals. www.indiandentalacademy.com
  41. 41. CONCLUSION A perio-endo lesion can have a varied pathogenesis which ranges from quite simple to relatively complex. A knowledge of these disease processes is essential in coming to the correct diagnosis. This enables the construction of a suitable treatment plan where unnecessary, prolonged or even detrimental treatment is avoided www.indiandentalacademy.com
  42. 42. REFRENCES. Pathways of pulp-Cohen Endodontic therapy-Weine. Endodontic Practice-Grossman. NET SEARCHES-Google searchEndo journal articles.USC Endodntics Department Website.NYU Dentistry. www.indiandentalacademy.com
  43. 43. www.indiandentalacademy.com