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

ENDO PERIO RELATION

INDIAN DENTAL ACADEMY
Leader in continuing dental education

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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

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

Periodontal ligament
supporting teeth

Junctional
epithelium


Loss of marginal attachment

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

Periodontal

:periodontal
:vital
:not related
:primary cause
:chronic
:multiple and wide
coronally
:alkaline
:contributing factor
:complex

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

pathways

Case report I: primary endo lesion with
secondary perio
lesion

Abscess irt 23
Radiolucency irt 23


Flap reflected, curettage done

Bone graft placed

Post treatment view after
augmentation of 23 with composite


Post surgical radiograph

Case report II: Primary perio lesion with
secondary endo lesion

Bone loss up to apex of 44

Pre operative probing



Bone graft placed

Post operative probing
after 9 months

Post operative radiograph
after 9 months

Case report III: True combined periodontal
endodontic lesion

Per operative probing

Horizontal bone loss and
periapical radiolucency



Bone graft placed

Post operative after 6
months
Post operative radiograph
after 6 months


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”

Early periodontal lesion

Advanced periodontal destruct


Horizontal bone loss

After 4 yrs

Vertical bone loss

After 12 yrs


Bone loss encroaching the bone apices

Periodontal bone loss involving the
mesial root of 36


Lateral periodontal bone loss of
pulpal origin

Resolution following RCT


Early periradicular
bone loss in 32

Further apical and marginal
bone loss over a 10 yr period


Pathways of communication
between pulp and
periodontium
Lateral canals and accessory canals




Dentinal tubules

Microorganisms within dentinal
tubules of infected tooth

Development defects

Palatogingival
groove in the
maxillary central
incisor
Cementum defects
Iatrogenic perforations and

root fractures

After infilling of bony defect

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


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

 Effect of iatrogenic problem

Perforations

Reparative dentine
defending the pulp space


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


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

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

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

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

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

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


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

Diagnosis of endo perio lesions

Distopalatal

Midpalatal

Mesio palatal

Three point probing depths

Periodontal probing

Continuous probing around maxillary molar
showing sudden changes in probing depths

Charting continuous probing profile of a
single tooth


Long narrow pockets: endodontic origin

“Blow out” lesion

Lateral endodontic abscess: wide and deep pocket

Radiographic patterns

( angularity and presence of marginal bone)
Bone loss and absence of periodontal ligament space

Possible causes of endo perio
lesions
 Single isolated endo perio lesions

Bone loss on one side because of lateral canal
Resolution after re treatment

GP points used to trace localized deep probing defects

Fractures in teeth with vital pulp
 Definitive treatment is placement of cusp

covered cast restoration

Suspected cuspal fracture


Tooth preparation with
occlusal reduction

Root Fractures

Bucco palatal fracture
Mesio distal fracture

Following removal of fractured root


Fracture of mesial root
of vital molar

Bone loss related to
fracture of mesial root of
vital molar


Fracture at middle third


RCT of whole incisor

Horizontal fracture at
middle third
RCT till fracture line


Root perforations

Perforation with furcal and
periapical bone loss

Coronal third perforation
Crown lengthening with RCT
and new post retained
restoration


Lateral perforation

Management of perforations


Radiograph following sealing

3 yrs later

Root resorption

Internal resorption

Required resection

Anatomical anomalies

Probing developmental groove


Max : lateral incisor with two roots
and a palato gingival groove


Orthodontic Treatment

Loss of periodontal attachment on the
distal side of a maxillary canine following
orthodontic treatment

Tooth transplantation and replantation
poorly designed restorations

Localized periodontal
breakdown related to a
poorly placed restoration


Management Of Endo Perio
Lesions

Estimation of prognosis

Treatment of endo perio cases


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?

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


Extract

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

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

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

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

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

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

Surgical exposure of
Furcation prior to
sectioning of disto
buccal root

Initial cut with a
diamond instrument


Widened cut to allow
instrumentation

Appearance of tooth
following the removal
of disto buccal root

Elevation of disto buccal root


Surgical closure

Vertical bone loss
around distal root

Retained mesial root

Vertical cut towards
the bifurcation

Full coverage cast restoration
of hemisected molar


Role of regenerative techniques in treatment
of endo perio lesions

Histological section showing
new attachment formation
using a barrier

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

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


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

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