Endodontic periodontal relation / dental implant courses

INDIAN DENTAL ACADEMY
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CONTENTSCONTENTS
• INTRODUCTIONINTRODUCTION
• PATHWAYS OF COMMUNICATIONPATHWAYS OF COMMUNICATION
• MICROBIOLOGYMICROBIOLOGY
• CLASSIFICATIONCLASSIFICATION
• ETIOLOGICAL FACTORSETIOLOGICAL FACTORS
• CONTRIBUTING FACTORSCONTRIBUTING FACTORS

• EFFECT OF PULPAL DISEASE ANDEFFECT OF PULPAL DISEASE AND
ENDODONTIC TREATMENT ONENDODONTIC TREATMENT ON
PERIODONTIUMPERIODONTIUM
• EFFECT OF PERIODONTAL DISEASE ANDEFFECT OF PERIODONTAL DISEASE AND
PROCEDURES ON PULPPROCEDURES ON PULP
• CLINICAL DIAGNOSTIC PROCEDURESCLINICAL DIAGNOSTIC PROCEDURES
• THERAPEUTIC MEASURESTHERAPEUTIC MEASURES
• CONCLUSIONCONCLUSION
• REFERENCESREFERENCES

INTRODUCTIONINTRODUCTION
• Pulpal and periodontal tissues have closePulpal and periodontal tissues have close
embryonic,anatomic and functionalembryonic,anatomic and functional
interrelationships. Tissues of dental pulp andinterrelationships. Tissues of dental pulp and
periodontium are derived from a commonperiodontium are derived from a common
mesodermal origin.mesodermal origin.
• Simring and Oldberg in 1964 first described theSimring and Oldberg in 1964 first described the
relationship between the periodontal andrelationship between the periodontal and
endodontic disease.endodontic disease.
• The endo-perio lesion simply means that in anThe endo-perio lesion simply means that in an
involved tooth both the tissues are affected by theinvolved tooth both the tissues are affected by the
disease process.disease process.

Pathways of communicationPathways of communication
• PhysiologicalPhysiological
• DevelopmentalDevelopmental
• Non physiologicalNon physiological
• PathologicPathologic
• IatrogenicIatrogenic

Pathways of developmental originPathways of developmental origin
• Apical foramenApical foramen
• Accessory canals/lateral canalsAccessory canals/lateral canals
• Congenital absence of cementum exposingCongenital absence of cementum exposing
dentinal tubulesdentinal tubules
• Permeability of cementumPermeability of cementum
• Developmental groovesDevelopmental grooves
• Developmental anomaliesDevelopmental anomalies

Pathways of pathological originPathways of pathological origin
• Root fractures following traumaRoot fractures following trauma
• Idiopathic resorption- Internal and externalIdiopathic resorption- Internal and external
• Loss of cementum due to external irritantsLoss of cementum due to external irritants

Pathways of iatrogenic originPathways of iatrogenic origin
• Exposure of dentinal tubules following rootExposure of dentinal tubules following root
planingplaning
• Accidental root perforation duringAccidental root perforation during
endodontic proceduresendodontic procedures
• Root fractures due to endodontic proceduresRoot fractures due to endodontic procedures
• TraumaTrauma
• PostsPosts

Non physiologicalNon physiological
• Perforations produced by powered rotaryPerforations produced by powered rotary
instrumentsinstruments
• Vertical root fracturesVertical root fractures
• Teeth restored with intra canal post areTeeth restored with intra canal post are
more prone to fracturemore prone to fracture
• Extension of post beyond coronal half ofExtension of post beyond coronal half of
root canalsroot canals

MicrobiologyMicrobiology
• A chronic infection in the periodontal pocket or inA chronic infection in the periodontal pocket or in
the root canal may represent a persistent supply ofthe root canal may represent a persistent supply of
bacteria to the blood stream, spreading to nonbacteria to the blood stream, spreading to non
affected parts of the tooth organ as well as otheraffected parts of the tooth organ as well as other
organs of the body.organs of the body.
• Predominance of gram –ve bacteria in root canalPredominance of gram –ve bacteria in root canal
infections, periodontitis – Sundquist(1976)infections, periodontitis – Sundquist(1976)
• Gram –ve anaerobic rods - 74.9% - apical portionGram –ve anaerobic rods - 74.9% - apical portion
of deep periodontal pockets -Slotsof deep periodontal pockets -Slots

• ‘‘Bacteroides’ is the dominating anaerobic genus ofBacteroides’ is the dominating anaerobic genus of
root canalroot canal
infections.B.intermedium,B.endodontalis,B.denticinfections.B.intermedium,B.endodontalis,B.dentic
ola were frequently foundola were frequently found
• In addition to this fusobacterium,In addition to this fusobacterium,
peptoseptococcus and campylobacter are mostpeptoseptococcus and campylobacter are most
frequently found in the necrotic root canals andfrequently found in the necrotic root canals and
periodontal pocket.periodontal pocket.
• Trope et al found greater % of spirochetes inTrope et al found greater % of spirochetes in
discharge from the draining sinus in lesions ofdischarge from the draining sinus in lesions of
periodontal originperiodontal origin

ClassificationClassification
• Based on etiology by Simon,Glick andBased on etiology by Simon,Glick and
Frank(1972)Frank(1972)
• Type 1-primary endodontic lesionsType 1-primary endodontic lesions
• Type 2-primary endodontic lesions withType 2-primary endodontic lesions with
secondarily periodontal involvementsecondarily periodontal involvement
• Type 3-primarily periodontal lesionsType 3-primarily periodontal lesions
• Type 4-primarily periodontal lesions withType 4-primarily periodontal lesions with
secondary endodontic involvementsecondary endodontic involvement
• Type 5- true combined lesionsType 5- true combined lesions

Primary endodontic lesion

Primary endodontic with
secondary periodontal
involvement

Primary periodontal lesion

Primary periodontal with
secondary endodontic
involvement

True combined lesion

Based on clinical presentationBased on clinical presentation
• By Weine (1982)By Weine (1982)
• Type 1- primary endodontic lesions mimickingType 1- primary endodontic lesions mimicking
periodontal diseaseperiodontal disease
• Type II-endodontic lesion in a periodontallyType II-endodontic lesion in a periodontally
involved toothinvolved tooth
• Type III-primary periodontal lesion requiringType III-primary periodontal lesion requiring
endodontic treatment for healingendodontic treatment for healing
• Type IV-primary periodontal lesion secondarilyType IV-primary periodontal lesion secondarily
involving pulpinvolving pulp

Based on treatment planBased on treatment plan
By GrossmanBy Grossman
• Type I-requiring endodontic treatment onlyType I-requiring endodontic treatment only
• Type I-requiring periodontal treatment onlyType I-requiring periodontal treatment only
• Type III- requiring combined endo-perioType III- requiring combined endo-perio
treatmenttreatment

Etiological factorsEtiological factors
• PathogensPathogens
• BacteriaBacteria
• FungiFungi
• VirusesViruses
• Extrinsic agentsExtrinsic agents
• Foreign bodiesForeign bodies
• AmalgamAmalgam
• Root canal filling materialsRoot canal filling materials
• Cellulose fibres from absorbent pointsCellulose fibres from absorbent points
• Intrinsic agentsIntrinsic agents
• CholestrolCholestrol

Contributing factorsContributing factors
• Poor endodontic treatmentPoor endodontic treatment
• Poor restorationsPoor restorations
• TraumaTrauma
• ResorptionResorption
• PerforationPerforation
• Developmental malformationsDevelopmental malformations
• Cracked tooth syndromeCracked tooth syndrome
• Trauma from occlusionTrauma from occlusion
• Vertical root fractureVertical root fracture

Cracked tooth syndromeCracked tooth syndrome
• Cameron- 1964Cameron- 1964
• Mandibular 2Mandibular 2ndnd
molars,mandibular 1molars,mandibular 1stst
molars,maxillarymolars,maxillary
premolarspremolars
• SymptomsSymptoms
• Pain on biting and ceases after pressure is withdrawnPain on biting and ceases after pressure is withdrawn
• EtiologyEtiology
• Extensive intracoronal restorationExtensive intracoronal restoration
• Repeated occlusal adjustmentsRepeated occlusal adjustments
• High spots on the restorationHigh spots on the restoration
• Excessive removal of tooth structure during cavity preaprationExcessive removal of tooth structure during cavity preapration
• BruxismBruxism

• DiagnosisDiagnosis
• Vitality test +veVitality test +ve
• Non tender on percussionNon tender on percussion
• TransilluminationTransillumination
• Dye testDye test
• Bite testBite test

TreatmentTreatment
• Small peripheral crack-restore it withSmall peripheral crack-restore it with
compositecomposite
• Large central crackLarge central crack
• No pulpal involvement-occlusal adjustmentNo pulpal involvement-occlusal adjustment
• Pulpal involvement-endodontic treatmentPulpal involvement-endodontic treatment
• Hopeless prognosis-extractionHopeless prognosis-extraction

Trauma from occlusionTrauma from occlusion
• Increased mobilityIncreased mobility
• Inflamed periodontium-further spread ofInflamed periodontium-further spread of
inflammation apicallyinflammation apically
• Bone resorptionBone resorption
primary secondary acute chronic

Effect of pulpal disease on theEffect of pulpal disease on the
periodontiumperiodontium
• Bacterial and toxic irritants in pulpBacterial and toxic irritants in pulp
• Increased intrapulpal pressureIncreased intrapulpal pressure
• Retrograde periodontitisRetrograde periodontitis
• Unresolved endodontic lesionUnresolved endodontic lesion
• Inflammation begins apically and extends coronallyInflammation begins apically and extends coronally
• Furcal bone thinner than periapical boneFurcal bone thinner than periapical bone
• First indication- thickening of PDL at the apical endFirst indication- thickening of PDL at the apical end

• Nature and extent of periodontal destruction isNature and extent of periodontal destruction is
dependant on several factorsdependant on several factors
• Virulence of irritating stimulation in root canalVirulence of irritating stimulation in root canal
• Duration of diseaseDuration of disease
• Host defense mechanismHost defense mechanism
• In acute casesIn acute cases
• Extrusion of tooth in its socketExtrusion of tooth in its socket
• Severe tenderness to percussionSevere tenderness to percussion
• Mobility of toothMobility of tooth

Effect of periodontitis on dental pulpEffect of periodontitis on dental pulp
• Atrophic changesAtrophic changes
• Interference of blood supply toInterference of blood supply to
lateral/accessory canalslateral/accessory canals
• Reduction in pulp cellsReduction in pulp cells
• Dystrophic calcificationDystrophic calcification
• FibrosisFibrosis
• ResorptionResorption

Primary endodontic lesionsPrimary endodontic lesions
• CausesCauses
• Deep carious lesionDeep carious lesion
• Large restoration approximating pulpLarge restoration approximating pulp
• History of pulpotomy, pulp cappingHistory of pulpotomy, pulp capping
• Poor root canal treatmentPoor root canal treatment
• MobilityMobility
• Localized bone lossLocalized bone loss
• Tenderness to percussionTenderness to percussion
• Sinus tractSinus tract
• SwellingSwelling

• RadiographsRadiographs
• Pulpal vitality testPulpal vitality test
• Tracing of sinus tractTracing of sinus tract
• Periodontal probingPeriodontal probing
• TreatmentTreatment
• Conventional endodontic therapyConventional endodontic therapy

Differential diagnosisDifferential diagnosis
• Presence of large carious lesion or previousPresence of large carious lesion or previous
restoration close to the pulprestoration close to the pulp
• Patient may not have any periodontalPatient may not have any periodontal
disease in other areas of the mouthdisease in other areas of the mouth
• Tooth is nonvitalTooth is nonvital
• Narrow deep pocketNarrow deep pocket
• Upon endodontic treatment,the lesions healUpon endodontic treatment,the lesions heal
rapidlyrapidly

Primary endodontic lesions withPrimary endodontic lesions with
secondarily periodontal involvementsecondarily periodontal involvement
• CharacteristicsCharacteristics
• Long standing pulpal pathosisLong standing pulpal pathosis
• Accumulation of plaque and calculus leads furtherAccumulation of plaque and calculus leads further
apical migration of attachmentapical migration of attachment
• Generalized periodontal diseaseGeneralized periodontal disease
• Pulp vitality testPulp vitality test
• Periodontal probingPeriodontal probing

• Endodontic treatmentEndodontic treatment
• Periodontal treatmentPeriodontal treatment

Primary periodontal lesionsPrimary periodontal lesions
• Teeth vitalTeeth vital
• Generalised bone lossGeneralised bone loss
• Calculus/plaqueCalculus/plaque
• Soft tissue inflammationSoft tissue inflammation
• Broad based pocketsBroad based pockets
• Periodontal abscess during acute phasePeriodontal abscess during acute phase

DiagnosisDiagnosis
• Visual examinationVisual examination
• ProbingProbing
• Pulp testingPulp testing

TreatmentTreatment
• Periodontal therapyPeriodontal therapy
• Root amputationRoot amputation
• Guided tissue regenerationGuided tissue regeneration

Primary periodontal lesion withPrimary periodontal lesion with
secondary endodontic involvementsecondary endodontic involvement
• Deep periodontal pocketsDeep periodontal pockets
• History of extensive periodontal proceduresHistory of extensive periodontal procedures
• Irreversible pulpal pathosisIrreversible pulpal pathosis
• Sensitivity to temperatureSensitivity to temperature
• Tenderness to percussionTenderness to percussion
• SwellingSwelling

• History of disease progressionHistory of disease progression
• ProbingProbing
• Pulp testingPulp testing
• Radiographic changesRadiographic changes
• Differential diagnosisDifferential diagnosis
• Presence of generalised periodontal diseasePresence of generalised periodontal disease
• Failure of GP point to reach the apexFailure of GP point to reach the apex
• Presence of pulp vitalityPresence of pulp vitality

• Endodontic treatmentEndodontic treatment
• Periodontal therapyPeriodontal therapy
• Root amputationRoot amputation

True combined lesionsTrue combined lesions
• Once the pulpal and periodontal lesionsOnce the pulpal and periodontal lesions
coalesce, they may be clinicallycoalesce, they may be clinically
indistinguishable.indistinguishable.
• Necrotic pulp/failed endodontic treatment,Necrotic pulp/failed endodontic treatment,
plaque,calculus and periodontitis will beplaque,calculus and periodontitis will be
present in varying degreespresent in varying degrees

• ProbingProbing
• Pulpal testingPulpal testing

Therapeutic measuresTherapeutic measures
• Initial considerationInitial consideration
• Extraction should always be considered an alternativeExtraction should always be considered an alternative
• Prognosis should be assessed carefullyPrognosis should be assessed carefully
• Functional need of the tooth?Functional need of the tooth?
• Provide an adequate root filling?Provide an adequate root filling?
• Tooth is restorable after lesion has been treated?Tooth is restorable after lesion has been treated?
• Periodontal prognosis??Periodontal prognosis??
• High patient motivation.High patient motivation.

Treatment – endodontic lesionTreatment – endodontic lesion
• Conventional endodontic treatmentConventional endodontic treatment
• Review 4-6 months post operatively-Review 4-6 months post operatively-
healinghealing
Treatment-periodontal lesionTreatment-periodontal lesion
• Phase 1 therapyPhase 1 therapy
• Periodontal surgeryPeriodontal surgery

Theraupeutic measuresTheraupeutic measures
• Alternative treatment- resection orAlternative treatment- resection or
regeneration proceduresregeneration procedures
• Resective measures- eliminating theResective measures- eliminating the
diseases structurediseases structure
• Regenerative measures- restore lost biologicRegenerative measures- restore lost biologic
structuresstructures

Root AmputationRoot Amputation
• Refers to the removal of one or more rootsRefers to the removal of one or more roots
of a multirooted tooth while others areof a multirooted tooth while others are
retained.retained.
• Grossman referred to as ‘Grossman referred to as ‘half loaf is betterhalf loaf is better
than none’than none’

Factors to be consideredFactors to be considered
• Length of the root trunkLength of the root trunk
• Divergence between the root conesDivergence between the root cones
• Length and shape of the root conesLength and shape of the root cones
• Fusion between root conesFusion between root cones
• Amount of remaining support around individualAmount of remaining support around individual
rootsroots
• Stability of individual rootsStability of individual roots
• Access for oral hygiene devicesAccess for oral hygiene devices
• Angulation and position of the tooth in the archAngulation and position of the tooth in the arch
• Feasability of endodontic and restorativeFeasability of endodontic and restorative
treatmentstreatments www.indiandentalacademy.com

IndicationsIndications
• Sufficient support available for the segmentSufficient support available for the segment
to be restoredto be restored
• Proper restoration of retained segmentProper restoration of retained segment
Periodontal Endodontic and restorative

Periodontal indications for rootPeriodontal indications for root
amputationsamputations
• Severe vertical bone loss involving only one rootSevere vertical bone loss involving only one root
of a multirooted toothof a multirooted tooth
• Through an through furcation destruction that mayThrough an through furcation destruction that may
not be corrected by GTR or a similar periodontalnot be corrected by GTR or a similar periodontal
surgerysurgery
• Unfavorable proximity of roots of adjacent teeth,Unfavorable proximity of roots of adjacent teeth,
preventing adequate hygiene maintenance ofpreventing adequate hygiene maintenance of
proximal areasproximal areas
• Severe root exposure due to dehiscenceSevere root exposure due to dehiscence

Endodontic and restorativeEndodontic and restorative
indicationsindications
• Prosthetic failure of pier/abutment within aProsthetic failure of pier/abutment within a
splintsplint
• Endodontic failureEndodontic failure
• Vertical root fracture of one rootVertical root fracture of one root
• Severe destructive processSevere destructive process

ContraindicationsContraindications
• Strong adjacent teeth available for bridgeStrong adjacent teeth available for bridge
abutments as alternatives to rootabutments as alternatives to root
amputation.amputation.
• Inoperable canals in root or roots to beInoperable canals in root or roots to be
retainedretained
• Root fusionRoot fusion

Root resectionRoot resection::
removal of a root without the removal of anyremoval of a root without the removal of any
portion of the crown.portion of the crown.
Hemisection:Hemisection:
When one root and its corresponding crown portionWhen one root and its corresponding crown portion
are cut and removed the procedure is calledare cut and removed the procedure is called
hemisection.hemisection.
Bisection/bicuspidizationBisection/bicuspidization::
One tooth is cut into two different parts withoutOne tooth is cut into two different parts without
the removal of any part of the root or crown.the removal of any part of the root or crown.

Non vital root resectionNon vital root resection::
When the endodontic therapy isWhen the endodontic therapy is
accomplished first,in which case theaccomplished first,in which case the
procedure is called non-vital root resection.procedure is called non-vital root resection.
Vital root resection:Vital root resection:
Root resection without prior endodonticRoot resection without prior endodontic
therapy.therapy.

• Periodontal diseasesPeriodontal diseases
• Chemotherapeutic agentsChemotherapeutic agents
• Regenerative approachesRegenerative approaches
• Tricalcium phosphate graftTricalcium phosphate graft
• Platelet rich plasmaPlatelet rich plasma

ConclusionConclusion
• Interelationship between pulpal andInterelationship between pulpal and
periodontal diseases have been confirmedperiodontal diseases have been confirmed
since ages.An in depth understanding of thesince ages.An in depth understanding of the
mechanisms by which these diagnosticmechanisms by which these diagnostic
processes interact together with a thoroughprocesses interact together with a thorough
diagnostic examination usually will helpdiagnostic examination usually will help
direct the proper course of treatment.direct the proper course of treatment.

ReferencesReferences
• The endodontic periodontal lesion-a rational approach to treatment-The endodontic periodontal lesion-a rational approach to treatment-
JADA 1995 apr 473-479JADA 1995 apr 473-479
• The endodontic periodontal continum revisited-The endodontic periodontal continum revisited- JADA 1997 novJADA 1997 nov
1541-15481541-1548
• Pulpal periodontal disease-Pulpal periodontal disease- JP 1977 sep 598-609JP 1977 sep 598-609
• Pathologic interactions in pulpal and periodontal tissues-Pathologic interactions in pulpal and periodontal tissues-
JCP 2002;29;663-671JCP 2002;29;663-671
• The influence of endodontic treatment upon periodontal woundThe influence of endodontic treatment upon periodontal wound
healing-healing- JCP 1997;24;449-456JCP 1997;24;449-456
• Combining endodontic,priodontic,restorative treatments-Combining endodontic,priodontic,restorative treatments-
JADA 1991 jan 102-104JADA 1991 jan 102-104
• Clinical periodontology-Carranza-10Clinical periodontology-Carranza-10thth
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