Endodontic periodontic lesions / rotary endodontic courses by indian dental academy

ENDODONTIC –
PERIODONTAL PROBLEMS

.

INDIAN DENTAL ACADEMY
Leader in Continuing Dental Education

www.indiandentalacademy.com

ENDO-PERIO
LESIONS


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.


PULPAL-PERIODONTAL
INTER-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.


 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”.


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.

 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.


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

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.

- 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.


-COHENS CLASSIFICATION.
1.Primary Endodontic Lesion
2.Primary endodontic lesion with secondary perio lesion
3.Primary periodontal lesion.
4.Primary perio lesion with secondary endodontic involvement.
5.True combined Endodontic & Periodontic lesion.


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


PRIMARY
ENDODONTIC
LESIONS
PATHOGENESIS.


PRIMARY ENDODONTIC LESIONS
 PATHOGENESIS.


 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.


 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.


PRIMARY PERIODONTAL
LESIONS

PATHOGENESIS.


 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.

PATHOGENESIS:
TRUE COMBINED LESIONS.


 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.


IATROGENIC LESIONS :
PATHOGENESIS.


 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.


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.


TREATMENT…initial
considerations.
 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.


TREATMENT-Endodontic
lesions
 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.


 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.


 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.


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.


 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.



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.


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.


 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.


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.


 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.


CASE
1:Periodontal
lesion with
secondary
endodontic
involvement.


CASE 2:Pre operative radiograph of the second molar with a
pocket to the apex long distal root & communicating with a
apical lesion.Treated endodontically & no pero therapy
required.


CASE 3:Endodontic treatment and no periodontal treatment.


Three months after treatment..healed periapical lesion and
lateral incisor remains without mobility.


CASE 4:Very long term follow up on treatment of Class 1
Endodontic -Periodontal Problems.


CASE 5: Exposure via lateral canals.


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


REFRENCES.
 Pathways of pulp-Cohen
 Endodontic therapy-Weine.

 Endodontic Practice-Grossman.

 NET SEARCHES-

Google search
Endo journal articles.
USC Endodntics Department Website.
NYU Dentistry.


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