Endo perio lesion an interdisciplinary approach to solve the dilemma of which came first the chicken or the egg
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Endo perio lesion an interdisciplinary approach to solve the dilemma of which came first the chicken or the egg

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Endo perio lesion an interdisciplinary approach to solve the dilemma of which came first the chicken or the egg Endo perio lesion an interdisciplinary approach to solve the dilemma of which came first the chicken or the egg Document Transcript

  • ( • INDIAN DENTAL ASSOCIATION WEST DELHI Endo-Perio Lesion: An Interdisciplinary Approach To Solve The Dilemma Of Which Came First -The Chicken Or The Egg? Dr. Harpreet Singh Grover, Dr. Shailly Luthra, Dr. ShrutiMaroo • ABSTRACT The interrelation ship bet w een periodonta l and endodontic disease has aroused confusion, queries and con troversy. The actual re lati onshi p between periodontal and pu lpal disease was first described by Simring and Goldberg in 1964. Since then, the term "perio·endo" lesion has been used to describe lesions attri butable to inf lam matory product s found in va rying degrees in both the periodontium and the pulpal tissues. Th e pulp and period o ntium have embryon ic, anatomic and function al inter·relationsh ips. The simu ltaneou s existence of pul pal problems and infl ammatory periodonta l disease can obscure diagnosis and treatment planning. A perio' endo lesion can have a diverse pathogenesis which ranges from qu ite simple to somewhat complex. Knowledge of th ese disease processes is essentia l in coming to the correct diagnosis. This is achievable by ca reful histo ry taking, exam ination and the use of radiographs. Th e prognosis and treat'l1ent of each endodontic· periodontal disease type vari es. Prim ary periodontal disease w ith secondary endodontic involvement and tru e combined endodontic'periodont al diseases requ ire both en dodontic and periodonta l therapies. The prognosis of the se cases equally depends on the severity of periodontal disease and the response to pe riodonta l treatmen t . Thi s "-20Ies the operator to const r uct a suitable t reat ment plan w here unnecessary, prolonged or even detrimental :",£=:.~ .... : 's avoided. lCeyword5: ;; ~d "erio Lesions, Periodontal, Pu Ipal, Diagnosis, Treatment ,,- :;oc -'c 0eriodontallesion t reatment is a ch allenge to the cl inician and treatment often requ ires a combined therapeutic effort. The cl assification of periodontal disorders by the American Academy of Periodontology, 1999', co ntain s 'periodontitis in connection with endodontallesions' (commonly referred to as perio-end a lesion s) as one ofthe total of eight disorder groups. This is comprehended to mean pathological disorders that can be determ ined, cl inically or through the use of radiographs, to be common t o both t he periodontium and the endodontium of a tooth. JIDA West Delhi· Dec. 2012
  • The relationship between periodontal and pulpal disease was fi rst 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. The dental pulp and periodontal t issues are closely related . The pu lp originates from the dental papilla while the periodontal ligament from the denta l fo ll icle and is sepa rated by Hertwig's epithelial root sheet As the toot h matu res and the root is formed, thre e main apertures for exchange of infectious elements and other irrita nts bet ween the t wo compartments are created by (1) Dentinal tubules, (2) l ateral and accessory canals, and (3) The apica l foramen. When the pulp becomes inflamed/infected, it elicits an inflammatory response of the pe riodonta l ligament at the apical foramen and/or adjacent to openings of accessory canals.'Noxious ele ments of pulpal origin, includ ing inflammatory mediators and bacterial byproducts, may leach out through the apex, lateral and accessory canals, as well as the dentinal tubules, triggering an inflammatory response in the periodontium including a n early expression of antige n presentation.' Periodontal and endodontal bacterial disorders are anaerobic mixed infections . In general as well as in particular cases, this has been evident by, f ind ing extensive bacterial colonisation of periodonta l pocket s and infected root canals time and again. s" . Perio-endo lesions are often init ially not clinica lly visible or are accompanied by non-specific discomfort, such as sensitivity when biting. Sometimes this may lead to fistula formation or an abscess. The diagnosis of perio-endo lesions often results from coincidenta l findings, e.g. due to conspicuous ra diograph results and in particular du e to significantly increased exploratory depths at one particular aspect of a tooth .• The most commonly used classification was given by Simon, Glick and Frank in 1972" According to this classification, perio-endo lesions can be classified into: 1. Primary endodontic lesion 2. Primary periodontal lesion 3. Pri mary endodontic lesion with secondary periodontal involvement 4. Primary periodontal lesion with secondary endodontic involvement 5. True combin ed lesion An acute exacerbation of a chronic apical lesion in a tooth with a necrotic pulp may drain coronally through th e periodontal ligament into the gingiva l sulcus. This condition may clinically mimic a peri odonta l a bscess. Primary endodontic lesions usua lly hea l follow ing root canal treatment. The sin us tract extending into the gingival sulcus orfurcation area disappears at an early stage once the affected pulp has been removed and the root canals have been well cleaned, sh aped and obturated. If, after a period of time, a suppurating primary endodontic disease remains untreated, it may then become secondarily involved with marginal periodontal breakdown . Plaque forms at the gingival margin of the si nus tract and leads to marginal periodontitis. The t ooth subseq uent ly requires both endodontic and periodonta l treatment. Primary endodontic lesions with secondary periodonta l involvement should first be treated w ith endodontic therapy followed by periodontal therapy. "'This reduces the JIDA West Delhi- Dec. 2012
  • potential risk of introducing bacteria and their by-products duri ng the initial healing phase." If the endodontic . treatment is adequate, the prognosis depends on the severity of the marginal periodontal damage and the efficacy of the periodontal treatment. Wi t h endodontic treatment alone, only part of the lesion wil l heal to the level ofthe secondary periodontal lesion. While scaling and root planing remain the initial t reatment modalities in periodontal therapy, subgingival curettage can be used as an adjunct along with routine endodontic treatment for treatment of this malady. CASE REPORT A 34-year-old female patient reported to the outpatient Department of SGT Dental College, Hospital and Research Institute, Gurgaon with the chief complaint of pain for the last f ifteen days and a swelling since two days in the lower right back region of the jaw. Patient did not give any releva nt medical history and there were no underlying systemic conditions . On intraoral examination, revealed grossly carious 45 along with an intraoral swelling present in relation with 45. A radiograph was taken. 10PA also showed widening of periodontal ligament space in relation wi th the mesial root and radiolucency in the furcation area. (Fig 1) (Fig 1) (Fig 2) The horizontal probing depth (HPD) with Naber's probe and vertical probing depth (VPD) with the UNC-15 probe were measured which were found to be 6 mm and 7 mm, respectively. Endodontic treatment was taken up first under Local Anesthesia using Xylocaine with Adrenaline 1:200,000. Access cavities were prepared.Cleaning and shaping of the canals was done w ith 5.25% sodium hypochlorite irrigation and a single sitting Root Canal Treatment was completed and a temporary dressing was placed (Fig 2). (Fig 3) (Fig 4) (FigS) This was followed by Subgingival scafing along with subgingival curettage being performed in the same sitting. (Fig 3) The patient was prescribed Ofloxacilin+ Ornidazole SOOmg B.D. for S days along with Ibuprofen 400 mg B.D for 5 days .she was advised proper plaque control, using 0.2% chlorhexidine mouthwash twice daily for t wo weeks. One week post operatively there was complete resolution of the abscess and a reduced probing de pt h or JIDA West Delhi- Dec. 2012 •
  • 3mm. (Fi g:4) A post- operative 10PA X-ray revea led decreased radio lucency and bone fill in the furcation area in j ust one week afte r the combined perio-endo treatment.(Fig: 5) DISCUSSION : Endo-perio lesions can persist if not treated properly. To obtain excellent results patient's case history with al l possibl e ro utes, an accurate diagnosis and correct treatment pla n are necessa ry:Based on treatment plan, Grossman (1988) classified endo -perio lesion s into 3 types: Type 1- Requ iri ng endodontic treatment o nly; • Type 2 - Requiring periodontal treatment only and; Typ e 3 - Requiring combin ed endo-perio treatm ent. " As a consequence of the sha red root and anatomica lly predetermined connect ion paths between the periodontium and the endodontium, a bacterial infection originating in one of these tis sues may tra nsfer to the other. Endo-Perio lesion always poses a cha llenge to the cl inician for correct diagnosis and treatment planning. The long-term prognosis after t reatment of perio-endo lesions is determined by correct prima ry diagnosis and careful endodontic treatment, followed by periodontal treatment. It is imperative that both endodontic lesion and periodonta Ilesion be addressed in dividually and se quentially. CONCLUSION In this case performing endodontic- pe rio dontal treatment of the tooth sequentially the lesion reduced and subsided com pletely. Hence this case report demonstrates th e nature of periodontal lesion as a seconda ry involvement to an origina Ily endodontic lesion involving the tooth. In th is case both endodontic and periodonta l trea t ment s were carried out seq uentially in the same appointment resulting in shorter chair side time, eliminating the need for a second separate appointment for periodontal surgica l procedures. Thus, t his li ne of • treatment may hold better prospect s of treating endodontic periodontal lesions in a shorter time. BIBLIOGRAPHY 1. American Academy of Periodontology. International workshop for a classification of periodontal diseases and co nd itions. Ann PeriodontoI1999;4:1-112 . 2. Th e pulpal pocket approach: Retrograde Periodontitis . Simring M, Goldberg M ..J PeriodontoI1964:35:2248 3. The density and branchi ng of dentinal t ubu les in hu ma n teeth. Mjor lA, Nordahl !. Arch Ora l Bioi 1996:41: 401- 412. 4. Shetty A, Ramachandra BK, Shubhashini NS, Anjali K, Niharika J. Diode Las er Assisted Management of Endo-perio Lesion in Maxilla ry incisor using LANAP: A Case Report. International Dentistry SA 2010;12: 3843. 5. Kip ioti A, Nakou M, Legakis N, Mitsis F. M icrobiologica l fi nd ings of infected root cana ls and adjacent JIDA West Delhi- Dec. 2012 ,