periodontitis associated with endodontic lesions


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  • The surgical support necessary to alter the dento-gingival complex has been oversimplified. The request from the restorative dentist to merely crown lengthen # 6-11 is inadequate communication. This review will focus on the clinical techniques necessary to establish predictable combined periodontal and restorative results.
  • Pulpal disease shares an identical etiology with periodontal disease. Both entities have Microbiologic and Immunologic/ Histopathologic features in common.
  • Microbiota in necrotic pulps is not as complex (1 or 2 species may predominate)
  • Pack AR; Chandler NP. A combined endodontic-periodontic lesion of developmental origin: a case report. NZ Dent J 92: 46-48, 1996. Kerekes K, Olsen I. Similarities in the microfloras of root canals and deep periodontal pockets. Endod Dent Traumatol 6: 1-5, 1990. Jansson L, Ehnevid H, Lindskog S, Blomlöf L. Relationship between periapical and periodontal status. A clinical retrospective study. J Clin Periodontol 22: 598-602, 1995
  • Pack AR; Chandler NP. A combined endodontic-periodontic lesion of developmental origin: a case report. NZ Dent J 92: 46-48, 1996. Kerekes K, Olsen I. Similarities in the microfloras of root canals and deep periodontal pockets. Endod Dent Traumatol 6: 1-5, 1990. Jansson L, Ehnevid H, Lindskog S, Blomlöf L. Relationship between periapical and periodontal status. A clinical retrospective study. J Clin Periodontol 22: 598-602, 1995
  • periodontitis associated with endodontic lesions

    1. 1. Periodontitis Associated with Endodontic Lesions
    2. 2. <ul><li>Tooth and periodontium form a biologic unit, an organ; disease in one affects the other. </li></ul><ul><li>Periodontic-Endodontic lesions are found simultaneously in both the peri- and endodontic spaces. </li></ul>Periodontic-Endodontic Lesions
    3. 3. <ul><li>Lesions of the periodontal ligament and adjacent alveolar bone may originate from infections of the periodontium (Periodontitis) or tissues of the dental pulp. </li></ul>Periodontic-Endodontic Lesions
    4. 4. Anatomical Pathways Connecting Endodontic & Periodontal Tissues <ul><li>Apical Foramina </li></ul><ul><li>Accessory Canal </li></ul><ul><li>Exposure of Dentinal tubules </li></ul><ul><ul><li>Enamel-cementum disjunction, periodontal diseases, SRP </li></ul></ul>
    5. 5. 8.8 % 1.6 % 17 % Frequency of Accessory Canals <ul><li>Accessory canals were found in approximately 27% with the highest prevalence on the apical third. </li></ul><ul><li>28.4% of the teeth exhibited patent accessory canals in the “furcation region” (29.4% mand / 27.4% max). </li></ul>De Deus, 1975
    6. 6. Accessory Canals <ul><li>The inflammatory process is not always circumscribed at the apex. It may appear along the lateral aspect of the root or furcal area. </li></ul><ul><li>This process is induced and maintained by </li></ul>bacterial byproducts that could reach the periodontium through accessory canals.
    7. 7. Dentinal Tubules <ul><li>The ability of the pulp and periodontium to communicate via dentinal tubules is possible, specially where cementum was denuded (after repeated S&RP). </li></ul><ul><li>Many authors have suggested that an interrelationship does exists once the integrity of the dentinal tubules is violated. </li></ul>
    8. 8. Dentinal Tubules Vs. Accessory Canals Dentinal Tubules Accessory Canal
    9. 9. Furcation Foramina
    10. 10. <ul><li>Simon provided a classification for periodontic-endodontic lesions based on possible etiology, diagnosis, and prognosis. </li></ul><ul><li>Theoretically delineates five types of lesion formation that are interrelated. </li></ul>Simon et al (1972) Classification
    11. 11. Simon et al (1972) Endodontic lesions with secondary periodontic involvement COMBINED LESIONS (“True” combined lesions) ENDODONTIC LESIONS PERIODONTIC LESIONS Periodontic lesions with secondary endodontic involvement
    12. 12. Primary Endodontic Lesion <ul><li>Characterized by: </li></ul><ul><li>Necrotic pulp </li></ul><ul><li>Localized osseous destruction. </li></ul><ul><ul><li>Pulp necrosis and secondary periradicular disease may produce destruction of periodontal tissues with formation of a sinus-like tract through the periodontium. </li></ul></ul><ul><ul><li>Fistulation through the apex or a lateral canal may cause furcation involvement. </li></ul></ul><ul><li>Excellent prognosis for re-attachment. </li></ul>
    13. 14. Drainage of endodontic abscess into the sulcus follows one or two routes: Extraosseous fistulation Periodontal ligament fistulation
    14. 16. Effect of Pulpal Disease on the Periodontium <ul><li>Pulp disease can cause periradicular pathosis (inflammation) </li></ul><ul><li>Bone loss and/or drainage through sulcus can mimic periodontal disease </li></ul>
    15. 17. Periodontal ligament Fistulation
    16. 18. Primary Endodontic Lesion w/Secondary Periodontal Involvement <ul><li>Existing endodontic lesion with secondary periodontal involvement due to plaque and calculus accumulation beginning at the cervical area. </li></ul>
    17. 19. Calculus If this lesion was considered for endodontic treatment – it is necessary to complete “closed” root planing if there is to be any osseous regeneration
    18. 20. Retrograde Periodontitis <ul><li>Pulpal infection may cause a tissue destructive process that proceeds from the apical or furcal region of a tooth toward the gingival margin, as opposed to marginal periodontitis in which infection spreads from the gingival margin toward the root apex. </li></ul>
    19. 21. Primary Periodontal Lesion <ul><li>Lesion caused by periodontal disease. Periodontitis gradually progresses until the apical region is reached. </li></ul><ul><li>Characterized by: </li></ul><ul><ul><li>Vital pulp </li></ul></ul><ul><ul><li>Generalized bone loss </li></ul></ul><ul><li>Local factors present: </li></ul><ul><ul><li>Plaque, calculus </li></ul></ul><ul><ul><li>Developmental defects (palato-gingival groove) </li></ul></ul><ul><li>Prognosis for re-attachment more questionable </li></ul>
    20. 22. Primary Periodontic Lesion w/Secondary Endodontic Involvement <ul><li>Primary periodontal lesion leading to exposure of a lateral canal to the oral environment with the resulting pulpal infection and necrosis. </li></ul><ul><li>Could be the result of periodontal procedures in very deep lesions where the vasculature (apical or lateral) is severed by an instrument. </li></ul>
    21. 23. Primary Perio Lesion W/ Secondary Pulpal Disease
    22. 24. “ True” Combined Lesions <ul><li>This lesions occur where an endodontically induced periapical lesion exists on a tooth that is also periodontally involved. </li></ul><ul><li>Radiographically the two entities meet and merge somewhere along the root surface. </li></ul><ul><li>Very difficult to diagnose. </li></ul>
    23. 25. TRUE COMBINED
    24. 26. Pathogenesis Pulpal disease Periodontal disease SHARED ETIOLOGY Microbiologic Immunologic
    25. 27. Microbiology <ul><li>Similar to periodontal disease, potential pathogens most often associated with endodontic infections are found in the anaerobic segment of the flora. The microorganisms most commonly involved in the causation of both periodontal and pulp lesions are: </li></ul>SPIROCHETES Fusobacterium Prevotella Porphyromonas Peptostreptococcus Eubacterium Capnocytophaga Lactobacillus
    26. 28. Microbiology <ul><li>The microorganisms associated with periodontal lesions also may be capable of producing necrosis of pulp cells through the action of their metabolic products , destructive enzymes , or other mechanisms . </li></ul><ul><li>Porphyromonas and Prevotella species induce the activation of macrophages which subsequently produce interleukin-1 . This mediator may enhance bone resorption and perpetuation of the combined pulp-periodontal lesion. </li></ul>
    27. 29. <ul><li>The following entities or pathways have also been mentioned in the literature as possible causes of endo-perio lesions </li></ul><ul><li>Palato-gingival grooves </li></ul><ul><li>Periodontal Therapy (S/RP) </li></ul><ul><li>Root anomalies (microcracks) </li></ul><ul><li>Trauma induced root resorption </li></ul><ul><li>Fractures </li></ul><ul><li>Perforations </li></ul><ul><li>Over-instrumentations, </li></ul><ul><li>Debris extrusion </li></ul>Predisposing Factors that Contribute to Endo- Perio Lesions
    28. 30. Palato-Gingival Grooves <ul><li>Low incidence in </li></ul><ul><li>maxillary centrals and </li></ul><ul><li>laterals. </li></ul><ul><ul><li>43% of the grooves </li></ul></ul><ul><ul><li>extended less than 5mm </li></ul></ul><ul><ul><li>47% extended 6-10 mm </li></ul></ul><ul><ul><li>10% over 10mm </li></ul></ul>Kogan,1986
    29. 31. Trauma-Induced Root Resorption <ul><li>Trauma </li></ul><ul><li>Necrotic pulp </li></ul><ul><li>Injury to cementum and periodontium </li></ul><ul><li>Rapid root resorption </li></ul>
    30. 33. Cracked Tooth <ul><li>Fracture resulting from external (occlusal) load </li></ul><ul><li>Direction of fracture usually M-D </li></ul>
    31. 34. Vertical Root Fracture <ul><li>Fracture resulting from internal load </li></ul><ul><li>Direction of fracture usually B-L </li></ul>
    32. 35. Vertical Root Fracture
    33. 38. Root Perforations <ul><li>During RCT and preparation for the insertion of posts, instrumentation can accidentally cause perforation of the root and wound the PDL. </li></ul><ul><li>-  Mobility </li></ul><ul><li> Probing depth </li></ul><ul><li>- Loss of fibrous attachment </li></ul><ul><li>- Suppuration </li></ul><ul><li>If undetected or unsuccessfully treated the periodontal signs of root perforation are: </li></ul>
    34. 40. Endodontic Therapy <ul><li>Endodontic etiology should be taken into account when breakdown of periodontal tissue, specially if associated with poor quality RCT. </li></ul><ul><li>Periodontal pockets can be non-responsive to periodontal therapy, showing retarded or impaired healing due to periapical pathology or failing endodontic therapy. </li></ul>
    35. 41. Effects of Periodontal Disease on the Pulp <ul><li>Perio disease may irritate the pulp </li></ul><ul><ul><li>Increased secondary dentin, pulp stones, dystrophic calcification, fibrosis and collagen resorption . </li></ul></ul><ul><ul><li>All may be age related, or more related to the tooth's past Hx such as caries and resultant operative procedures. </li></ul></ul><ul><li>Perio disease is inflammatory, but does not appear to have a direct inflammatory effect on the pulp. </li></ul><ul><ul><li>Except when perio disease is severe enough to compromise the root apex, then pulp necrosis and inflammation can ensue. </li></ul></ul>
    36. 42. Effect of Perio Tx on the Pulp <ul><li>Unless root planing is invasive (either significantly deep layers of dentin removed, or severance of apical vessels), it is doubtful perio Tx results in significant pathologic changes in the pulp. * </li></ul><ul><li>Most studies have found no pulpal changes in presence of perio disease.** </li></ul>*Bergenholtz and Lindhe,1978 **Mazur and Massler, 1964 Czarnecki and Schilder, 1979 Torabinejad and Kiger,1985
    37. 43. Effect of Endo Tx on the Periodontium <ul><li>Iatrogenic alterations of the periodontium </li></ul><ul><ul><li>Perforations, Over-instrumentations, Debris extrusion </li></ul></ul><ul><ul><li>Vertical root fracture </li></ul></ul><ul><ul><ul><li>Cause is excessive internal force either during obturation or post placement </li></ul></ul></ul><ul><ul><ul><li>Results in narrow probing defect </li></ul></ul></ul><ul><li>RC contents may delay healing in perio Tx </li></ul>
    38. 44. Diagnosis
    39. 46. Diagnostic Considerations <ul><li>Is the tooth vital? </li></ul><ul><li>Is the lesion localized or generalized? </li></ul><ul><ul><li>Periodontitis usually more generalized. </li></ul></ul><ul><ul><li>Endodontic lesion and/or endo-perio lesions more localized. </li></ul></ul><ul><li>Is there a periodontal pocket? </li></ul><ul><ul><li>Probe prior to endo therapy to rule out vertical fracture or developmental anomalies. </li></ul></ul><ul><ul><li>Isolated deep pocket surrounded by a normal sulcus is indicative of a vertical fracture. </li></ul></ul>
    40. 47. Diagnostic Considerations <ul><li>Radiographic presence of severe pulpal calcifications ? </li></ul><ul><ul><li>Pulpal pathology may be secondary to perio pathology </li></ul></ul><ul><li>Is there apical resorption or condensing osteitis in the radiograph? </li></ul><ul><ul><li>Suggestive of pulpal pathology </li></ul></ul><ul><li>What are the pain symptoms </li></ul><ul><ul><li>Endo: Acute, sharp </li></ul></ul><ul><ul><li>Perio: Chronic, dull, tolerable </li></ul></ul>
    41. 48. Treatment <ul><li>Therapy is directed toward the removal of the etiologic factors responsible for the tissue destruction. </li></ul><ul><li>Essential in the prognosis is the origin of the pathosis </li></ul>
    42. 49. <ul><li>Treatment of perio-endo lesions is a combination of conventional treatment for each separate lesion: </li></ul><ul><ul><li>Root Canal Treatment </li></ul></ul><ul><ul><li>Scaling and Root Planing </li></ul></ul><ul><ul><li>Regenerative Procedures </li></ul></ul><ul><li>Treatment involves always completing the endodontic therapy before the periodontal treatment. </li></ul>Treatment
    43. 50. Endodontic Lesion <ul><li>Clinical Findings </li></ul><ul><li>Periapical bone loss </li></ul><ul><li>Drainage through the sulcus </li></ul><ul><li>Pulp test negative </li></ul><ul><li>Rapid onset </li></ul><ul><li>Inadequate root canal </li></ul><ul><li>Periodontal probing yields narrow, isolated pocket </li></ul><ul><li>Treatment </li></ul><ul><li>Endodontic Treatment only </li></ul>
    44. 51. Endodontic Lesion with secondary Periodontal disease <ul><li>Clinical Findings </li></ul><ul><li>Necrotic Pulp </li></ul><ul><li>Periodontitis with plaque and calculus </li></ul><ul><li>Pulp test negative </li></ul><ul><li>Increase in pocket depth and attachment loss </li></ul><ul><li>Rx evidence of pulp and periodontal disease </li></ul><ul><li>Treatment </li></ul><ul><li>First: Endodontic treatment, evaluate. </li></ul><ul><li>Then: Periodontal treatment </li></ul><ul><ul><li>Initially a closed procedure </li></ul></ul><ul><ul><ul><li>Revaluation 4-6 weeks post treatment </li></ul></ul></ul>
    45. 53. Periodontal lesion <ul><li>Clinical Findings </li></ul><ul><li>History of disease progression/therapy </li></ul><ul><li>Deep pockets </li></ul><ul><li>Attachment loss </li></ul><ul><li>No evidence of pulpal disease </li></ul><ul><li>Pulp test positive </li></ul><ul><li>Treatment </li></ul><ul><li>Periodontal treatment only </li></ul>
    46. 54. Periodontal Lesion with secondary Endodontic disease <ul><li>Clinical findings </li></ul><ul><li>Deep pockets </li></ul><ul><li>Extensive attachment loss </li></ul><ul><li>Pulp disease: increase pain, pulp test negative </li></ul><ul><li>Rx evidence </li></ul><ul><li>Treatment </li></ul><ul><li>First: Endodontic treatment, evaluate. </li></ul><ul><li>Then: Periodontal treatment </li></ul><ul><ul><li>Not very common unless the disease involves the main pulpal blood supply </li></ul></ul>
    47. 55. Combined Lesion <ul><li>Clinical findings </li></ul><ul><li>Etiologic factors present for both conditions </li></ul><ul><li>Generalized periodontal destruction that connects to periapical lesion </li></ul><ul><li>Pulp test negative </li></ul><ul><li>Root Fracture </li></ul><ul><li>Treatment </li></ul><ul><li>Root Canal therapy </li></ul><ul><li>Periodontal therapy </li></ul><ul><li>Extraction? </li></ul>
    48. 56. <ul><li>The major determinant of successful treatment of periodontic-endodontic lesions is the chronicity of the periodontal component. </li></ul><ul><li>Typically, bone loss of endodontic origin has a better prognosis than periodontal origin, because. </li></ul><ul><ul><li>Endodontic Lesions are generally acute. </li></ul></ul><ul><ul><li>Periodontic lesions are generally chronic. </li></ul></ul><ul><ul><li>Intact periodontium (JE and CT attachment) is the best barrier. </li></ul></ul>Treatment
    49. 57. <ul><li>The character of the clinical symptoms may occasionally be confusing and cause misinterpretation of their etiology. </li></ul><ul><li>The clinician should, therefore be well acquainted with the pathogenesis as well as with available diagnostic measures aimed at identifying disease conditions of these tissues. </li></ul>Periodontic-Endodontic Lesions