Endo perio interrelation 1 /certified fixed orthodontic courses by Indian dental academy

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Endo perio interrelation 1 /certified fixed orthodontic courses by Indian dental academy

  1. 1. ENDO PERIO RELATION INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  2. 2. Comparison of presentation of apical and marginal periodontitis Causes for attachment loss Pathways of communication between pulp and periodontium * Lateral and accessory canals *Dentinal tubules *Developmental defects *Cementum defects *Iatrogenic perforations and root fracture www.indiandentalacademy.com
  3. 3. Diagnosis of endo perio lesions *history of dentinal pulpal and periapical pain *history of periodontal symptoms *signs and symptoms of pulpal or periapical disease *periodontal charting(probing profile) *radiographic pattern of bone loss Possible causes of endo perio lesions Definition and classification of endo perio lesions Single isolated endo perio lesions Multiple endo perio lesions Management of endo perio lesions *estimation of prognosis *treatment of endo perio cases *root resection *role of regenerative techniques www.indiandentalacademy.com
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  5. 5. Periodontal ligament supporting teeth Junctional epithelium www.indiandentalacademy.com
  6. 6. Loss of marginal attachment www.indiandentalacademy.com
  7. 7. Differential Diagnosis Clinical Pulpal Cause : pulp infection Vitality :non vital Restorative :deep or extensive Plaque /calculus: not related Inflammation :acute Pockets :single and narrow  pH value :acidic Trauma :primary or secondary Microbial :few www.indiandentalacademy.com Periodontal :periodontal :vital :not related :primary cause :chronic :multiple and wide coronally :alkaline :contributing factor :complex
  8. 8. Pulpal Radiographic Pattern :localized Bone loss :wider apically Periapical :radiolucent Vertical bone loss: no periodontal :generalized :wider coronally :not related :yes Histopathology Junctional epithelium :no apical migration :present Granulation tissues : apical (minimal) :coronal (larger) Gingival :normal :recession Treatment Therapy :RCT :Periodontal therapy www.indiandentalacademy.com
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  10. 10. pathways www.indiandentalacademy.com
  11. 11. Case report I: primary endo lesion with secondary perio lesion Abscess irt 23 Radiolucency irt 23 www.indiandentalacademy.com
  12. 12. Flap reflected, curettage done Bone graft placed Post treatment view after augmentation of 23 with composite www.indiandentalacademy.com Post surgical radiograph
  13. 13. Case report II: Primary perio lesion with secondary endo lesion Bone loss up to apex of 44 Pre operative probing www.indiandentalacademy.com Flap reflected, curettage done Bone graft placed
  14. 14. Post operative probing after 9 months Post operative radiograph after 9 months Case report III: True combined periodontal endodontic lesion www.indiandentalacademy.com
  15. 15. Per operative probing Horizontal bone loss and periapical radiolucency www.indiandentalacademy.com Flap reflected, curettage done Bone graft placed
  16. 16. Post operative after 6 months Post operative radiograph after 6 months www.indiandentalacademy.com
  17. 17. Combined lesions: Two separate lesions: “pulpo periapical” and “periodontal with no communication between them Single lesion that involves both endodontic and periapical problem Separate endodontic and periodontal lesion that later communicate “concomitant pulpo periapical lesion” www.indiandentalacademy.com
  18. 18. Early periodontal lesion Advanced periodontal destruct www.indiandentalacademy.com
  19. 19. Horizontal bone loss After 4 yrs Vertical bone loss After 12 yrs www.indiandentalacademy.com
  20. 20. Bone loss encroaching the bone apices Periodontal bone loss involving the mesial root of 36 www.indiandentalacademy.com
  21. 21. Lateral periodontal bone loss of pulpal origin Resolution following RCT www.indiandentalacademy.com
  22. 22. Early periradicular bone loss in 32 Further apical and marginal bone loss over a 10 yr period www.indiandentalacademy.com
  23. 23. Pathways of communication between pulp and periodontium Lateral canals and accessory canals www.indiandentalacademy.com
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  25. 25.  Dentinal tubules Microorganisms within dentinal tubules of infected tooth www.indiandentalacademy.com
  26. 26. Development defects Palatogingival groove in the maxillary central incisor Cementum defects Iatrogenic perforations and root fractures www.indiandentalacademy.com After infilling of bony defect
  27. 27. Effect of pulp disease and its treatment on the periodontium  Periodontal inflammation and bone loss Sub marginal bone loss Horizontal bone loss Furcation involvement  Periodontal wound healing Gingival tissue thickness Alveolar bone level Surgical trauma to flap Effective flap repositioning Root canal treatment www.indiandentalacademy.com
  28. 28. This is why many periodontist’s insist on RCT on teeth with “ doubtful" pulp status when regenerative surgery is planned…….the rationale is to eliminate possible sources of infection to maximize the potential for successful outcome Extrusion of root filling material causing delayed healing www.indiandentalacademy.com
  29. 29.  Effect of iatrogenic problem Perforations Reparative dentine defending the pulp space www.indiandentalacademy.com
  30. 30. Effect of periodontal disease and its treatment on the pulp  Effect of periodontal disease on the pulp Pulpal and periodontal involvement of maxillary premolar Progression of the two separate lesion to give a combined www.indiandentalacademy.com
  31. 31. Effect of periodontal disease and its treatment on the pulp  Effect of periodontal treatment on the pulp Scaling and root planning may sometimes result in removal of excessive cementum and exposure of the dentinal tubules, leading to pulp inflammation --Micro flora --Host defense Pulpal inflammation adjacent to open dentinal tubules www.indiandentalacademy.com
  32. 32. Endo perio lesions Definition An isolated, usually narrow, deep probing depth of pulpal or periodontal origin Lesion with sub marginal or intrabony periradicular bone loss of pulpal and/or periodontal origin that communicates with the oral cavity via probing defect A localized periodontal probing depth of pulpal or periodontal origin www.indiandentalacademy.com
  33. 33. Classification According to SIMON GLICK FRANk (cohen) Primary endodontic lesion Primary endodontic lesion with secondary periodontal involve Primary periodontal lesion Primary periodontal lesion with secondary endodontic involve rue combined lesion According to WEINE I. Tooth in which symptoms clinically and radiographically simulate periodontal disease but are due to pulpal inflammation II. Tooth that has both pulpal and periodontal disease concomitantly III.Tooth has no pulpal problem but require endodontic therapy plus root amputation to gain periodontal healing www.indiandentalacademy.com
  34. 34. According to OLIET, POLLOCK (Grossman Lesions that require endodontic procedures onl necrotic pulp and apical granulomatous tissue replacing periodontium with or without sinous tract Chronic periapical abscess with sinus tract Longitudinal and horizontal root fractures Pathologic and iatrogenic root perforations Teeth with incomplete apical root development Endodontic implants Teeth that require hemisection Root submergence www.indiandentalacademy.com
  35. 35. II.Lesions that require periodontal procedures only Occlusal trauma causing reversible pulpitis Occlusal trauma plus gingival inflammation resulting in pocket formation and reversible pulpitis Suprabony or infrabony pocket formation treated with overzealous root planning and curettage leading to pulpal sensitivity Extensive infrabony pocket formation extending beyond the root apex and sometimes coupled with lateral or apical resorption yet with pulp that responds with in normal limits to clinical testing www.indiandentalacademy.com
  36. 36. III. lesions that require combined endodontic and periodontic treatment Any lesion in Group I That results in irreversible reactions in the attachment apparatus and requires periodontal treatment Any lesion in Group II that results in irreversible reactions to the pulp tissue and also requires endodontic treatment www.indiandentalacademy.com
  37. 37. Diagnosis of endo perio lesions History of dentinal / pulpal pain History of periodontal symptoms (bleeding, mobility) Signs and symptoms of pulpal / periapical disease (vitality) Periodontal charting (probing profile) Radiographic pattern of marginal and periradicular bone loss www.indiandentalacademy.com
  38. 38. Diagnosis of endo perio lesions Distopalatal Midpalatal Mesio palatal Three point probing depths www.indiandentalacademy.com
  39. 39. Periodontal probing Continuous probing around maxillary molar showing sudden changes in probing depths www.indiandentalacademy.com
  40. 40. Charting continuous probing profile of a single tooth www.indiandentalacademy.com
  41. 41. Long narrow pockets: endodontic origin “Blow out” lesion www.indiandentalacademy.com Lateral endodontic abscess: wide and deep pocket
  42. 42. Radiographic patterns ( angularity and presence of marginal bone) Bone loss and absence of periodontal ligament space www.indiandentalacademy.com
  43. 43. Possible causes of endo perio lesions  Single isolated endo perio lesions Bone loss on one side because of lateral canal Resolution after re treatment www.indiandentalacademy.com
  44. 44. GP points used to trace localized deep probing defects www.indiandentalacademy.com
  45. 45. Fractures in teeth with vital pulp  Definitive treatment is placement of cusp covered cast restoration Suspected cuspal fracture www.indiandentalacademy.com Tooth preparation with occlusal reduction
  46. 46. Root Fractures Bucco palatal fracture Mesio distal fracture Following removal of fractured root www.indiandentalacademy.com
  47. 47. Fracture of mesial root of vital molar Bone loss related to fracture of mesial root of vital molar www.indiandentalacademy.com
  48. 48. Fracture at middle third www.indiandentalacademy.com RCT of whole incisor
  49. 49. Horizontal fracture at middle third RCT till fracture line www.indiandentalacademy.com
  50. 50. Root perforations Perforation with furcal and periapical bone loss www.indiandentalacademy.com
  51. 51. Coronal third perforation Crown lengthening with RCT and new post retained restoration www.indiandentalacademy.com
  52. 52. Lateral perforation www.indiandentalacademy.com
  53. 53. Management of perforations www.indiandentalacademy.com
  54. 54. Radiograph following sealing www.indiandentalacademy.com 3 yrs later
  55. 55. Root resorption Internal resorption Required resection www.indiandentalacademy.com
  56. 56. Anatomical anomalies Probing developmental groove www.indiandentalacademy.com
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  58. 58. Max : lateral incisor with two roots and a palato gingival groove www.indiandentalacademy.com
  59. 59. Orthodontic Treatment Loss of periodontal attachment on the distal side of a maxillary canine following orthodontic treatment www.indiandentalacademy.com
  60. 60. Tooth transplantation and replantation poorly designed restorations Localized periodontal breakdown related to a poorly placed restoration www.indiandentalacademy.com
  61. 61. Management Of Endo Perio Lesions Estimation of prognosis Treatment of endo perio cases www.indiandentalacademy.com
  62. 62. Endo perio lesion : usually isolated, narrow localized pocket Check endodontic status Causes: o Endo o Perio o Fracture o Resorption o Anatomy Root treated Not root treated Evaluate adequacy Vitality tests Preparation: Obturation: oUnder prepared oOver prepared oPerforation oZipping oledges oUnder filled oOverfilled oPoor adaptation Is root canal re-treatment feasible? www.indiandentalacademy.com
  63. 63. Feasible re-treatment? No Yes Try OHI + debridement OHI Resolution? Resolution? No Yes No Yes oDo first stage endo oClean and shape canals Extract oDress with calcium hydroxide Resolution? No Yes www.indiandentalacademy.com Extract
  64. 64. Vitality tests Negative Positive Root canal treatment Resolution? No Yes Check Check vitality again: OHI and perio If in doubt- do RCT Still no resolution: look for other causes Perio treatment Resolution? No Yes Extract, resect , hemisect www.indiandentalacademy.com
  65. 65. Tooth resections: Classification of degree of Furcation involvement I. Horizontal loss of periodontal support< one third of tooth width II.Horizontal loss of periodontal support> one third but not encompassing the total width of the tooth III.Horizontal through and through destruction of the periodontal tissue in the furcal area www.indiandentalacademy.com
  66. 66. Root Amputation : Removal of one or more roots of a multi rooted tooth while the others are retained Hemisection : Removal or separation of root with its accompanying crown portion of mandibular molars Radisection : Newer terminology for removal of roots of maxillary molars Bisection / Bicuspidization : Separation of mesial and distal roots of mandibular molar along with its crown portion, where both segments are then retained individually www.indiandentalacademy.com
  67. 67. Indications for Resections Periodontal indications Severe vertical bone loss involving only one root of a multi rooted tooth Through and through furcation destruction Unfavorable proximity of roots of adjacent teeth, preventing adequate hygiene maintenance in proximal areas Severe root exposure due to dehiscence www.indiandentalacademy.com
  68. 68. Restorative and endodontic indications: Prosthetic failure of abutments within a splint Endodontic failure: perforations, over extension , obstructed canals, separated instrument , root resorption Vertical fracture of one root Restorative reasons: sub gingival caries, erosion of large part of crown and root, traumatic injury Combination of these www.indiandentalacademy.com
  69. 69. Contraindications Root fusion making separation impossible Angulation or position of tooth in the arch: if the tooth is buccally or lingually, mesially or distally cannot be resected Root morphology: short conical roots are difficult to resect Improperly shaped occlusal contact may convert occlusal forces in to destructive forces and cause failure of hemisection www.indiandentalacademy.com
  70. 70. Surgical exposure of Furcation prior to sectioning of disto buccal root Initial cut with a diamond instrument www.indiandentalacademy.com Widened cut to allow instrumentation
  71. 71. Appearance of tooth following the removal of disto buccal root Elevation of disto buccal root www.indiandentalacademy.com Surgical closure
  72. 72. Vertical bone loss around distal root Retained mesial root Vertical cut towards the bifurcation Full coverage cast restoration of hemisected molar www.indiandentalacademy.com
  73. 73. Role of regenerative techniques in treatment of endo perio lesions Histological section showing new attachment formation using a barrier www.indiandentalacademy.com
  74. 74. References o Management of periodontitis associated with endodontically involved teeth: The journal of dental practice, volume 6, No2 2005 oWeine FS: endodontic therapy oStepten Cohen : Pathways of pulp oJan Lindhe : clinical implantology oGlickman : periodontology : periodontology oStock : endodontics www.indiandentalacademy.com
  75. 75. Conclusion A concise knowledge of both pulpal and periodontal disease is necessary for proper identification of the lesion.  Thus with adequate tender love and care we can nourish it for a peaceful coexistance……. Between the tooth and gums www.indiandentalacademy.com
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