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endo perio relationship in prosthodontic
- 1. ENDO-PERIO INTERACTIONS From Endoto perio From Perio to endo GUIDED BY: DR. RANA K VARGHESE, PROF & HEAD DR. RISHIDEV YADAV , READER DR. SUBHASISH BEHRA , READER DR. MINAL DAGA , SR. LECTURER DR. PRASHANT KHETRAPAL , SR. LECTURER DR. DEEPAK AGRAWAL, SR. LECTURER PRESENTED BY: DR. AASTHA N. SHUKLA
- 2. CONTENTS Introduction Pathwaysconnecting endodontic and periodontal tissues Etiological and contributing factors Definition Classification Diagnosing different endo-perio lesions Treatment Conclusion References
- 3. In 1919 Turnerand Drew first described the effect of periodontal disease on the pulp. The relationship between the periodontium and the pulp was first discovered by Simring and Goldberg in 1964. Since then, the term ‘endo- perio lesion’ has been used to describe lesions due to inflammatory products found in varying degrees in both periodontium and pulpal tissues. Endo perio problems are responsible for more than 50% of tooth ‑ mortality today. The pulp and periodontium have embryonic, anatomic and functional interrelationship.
- 4. PATHWAYS CONNECTING ENDODONTIC& PERIODONTAL TISSUES Anatomical pathways: Apical foramen, accessory canals /lateral canals Congenital absence of cementum exposing dentinal tubules Developmental grooves Non-physiological pathways: Iatrogenic root canal perforations Vertical root fractures caused by trauma, pathway created due to resorption etc.
- 5. ETIOLOGICAL AND CONTRIBUTINGFACTORS IN ENDO PERIO LESIONS ‑
- 7. Moore 1987, Sundqvist1994 Most of the species that have been found in infected root canals can also be present in the periodontal pocket. Rupf et al (2000) studied the profiles of periodontal pathogens in pulpal and periodontal diseases associated with the same tooth and concluded that periodontal pathogens often accompany endodontic infections Didilescu AC et al (2012) - F. nucleatum, P. micra and C. sputigena may play a role in the pathogenesis of endo-periodontal lesions.
- 8. DEFINITION It includes: An isolated,usually narrow, deep probing depth of pulpal or periodontal origin. Lesion with submarginal or intrabony periradicular bone loss of pulpal &/or periodontal origin that communicated with the oral cavity via a probing defect. A localized periodontal probing depth of pulpal or periodontal origin. (K. Gulabivala. Endodontics 2004)
- 9. CLASSIFICATION OF ENDO-PERIO LESIONS I. Based on etiology, diagnosis, treatment and prognosis (by Simon, 1972) Primary endodontic lesions Primary endodontic lesions with secondary periodontal involvement Primary periodontal lesions Primary periodontal lesions with secondary endodontic involvement True combined lesions
- 10. II. Stock (1988)modified Simon’s classification Omitted Class V of the classification. He argued that both Class II and Class IV lesions in advanced stages can become combined lesions and therefore a separate class to describe these lesions was not necessary.
- 11. III. Based onclinical presentation strategies for each (by Weine, 1982) Class 1-Tooth in which symptoms clinically and radiographically simulate periodontal disease but are in fact due to pulpal inflammation and/or necrosis. Class II – Tooth that has both pulpal or periapical disease and periodontal disease Class III –Tooth that has no pulpal problem but requires endodontic therapy plus root amputation to gain periodontal healing. Class IV- Tooth that clinically and radiographically simulates pulpal or periapical diseases but in fact has periodontal disease.
- 12. IV. Based ontreatment plan (Grossman classification,1991) Type 1 – Requiring endodontic treatment only. Type II – Requiring periodontal treatment only. Type III – Requiring combined endo-perio treatment
- 13. V. Classification asrecommended by the World Workshop for Classification of Periodontal Diseases (1999) Endodontic-periodontal lesion Periodontal-endodontic lesion Combined lesion
- 14. DIAGNOSTIC PROCEDURES USEDTO IDENTIFY THE ENDO-PERIO LESION Examination/ tests 1º endodontic lesion 1º periodontal lesion 1º endodontic 2º periodontal 1º periodontal 2º endodontic True combined lesion Visual Soft tissue - sinus opening Tooth ‑ decay/ large restoration/ fractured restoration or tooth/ erosions/abrasi ons/cracks/ discolorations/ poor RCT Inflamed gingiva/ recession (multiple teeth) Plaque & subgingival calculus (multiple teeth) swelling indicating periodontal abscess Plaque forms at the gingival margin of the sinus tract leads to inflammation of marginal gingiva Exudate Root perforation/ fracture Plaque, subgingival calculus & swelling (multiple teeth) Pus, exudate Localized/ generalised recession & exposure of root Plaque, calculus & periodontitis will be present in varying degrees Swelling around single or multiple teeth Pus, exudate
- 15. Examination/ tests 1º endodontic lesion 1º periodontal lesion 1ºendodontic 2º periodontal 1º periodontal 2º endodontic True combined lesion Pain Sharp Usually dull ache Sharp only in acute condition Usually sharp shooting Dull ache in chronic conditions Usually dull ache Sharp only in acute periodontal abscess Dull ache usually Only in acute conditions it is severe Palpation Does not indicate whether the inflammatory process is of endodontic or periodontal origin Pain on palpation Pain on palpation Pain on palpation Pain on palpation Percussion Normally tender on percussion Tender on percussion Tender on percussion Tender on percussion Tender on percussion
- 16. Examination/ tests 1º endodontic lesion 1º periodontal lesion 1ºendodontic 2º periodontal 1º periodontal 2º endodontic True combined lesion Mobility Fractured roots and recently traumatized teeth often present high mobility Localized to generalized mobility of teeth Localized mobility Generalized mobility Generalized mobility with higher grade of mobility related to the involved tooth Pulp vitality test, A lingering response‑ irreversible pulpitis No response ‑ Necrotic pulp (non vital) ‑ pulp is vital and responsive to testing Pulp vitality tests negative Pulp vitality may be positive in multirooted teeth Usually negative because of non vital ‑ pulp. Pocket probing A deep narrow solitary pocket* Multiple wide and deep pockets Presence of solitary wide pocket Presence of multiple wide and deep periodontal pockets Probing reveals typical conical periodontal type of probing
- 17. 15/27 Examination/ tests 1º endodontic lesion 1º periodontal lesion 1ºendodontic 2º periodontal 1º periodontal 2º endodontic True combined lesion Sinus tracing A radiograph with gutta percha points to apex or furcation area in molars Sinus tract mainly at the lateral aspect of the root Sinus tract mainly at the apex/ furcation area Sinus tract mainly at the lateral aspect of the root Difficult to trace out the origin of the lesion Radiographs Cracked tooth testing Painful response on chewing No symptoms Painful response on chewing No symptoms Painful response on chewing
- 18. CLINICAL PULPAL PERIODONTAL CAUSE PULPINFECTION PERIODONTAL INFECTION VITALITY NONVITAL VITAL RESTORATIVE DEEP OR EXTENSIVE NOT RELATED PLAQUE/CALCULUS NOT RELATED PRIMARY CAUSE INFLAMMATION ACUTE CHRONIC POCKETS SINGLE,NARROW MULTIPLE, WIDE CORONALLY pH VALUE OFTEN ACID USUALLY ALKALINE TRAUMA PRIMARY OR SECONDARY CONTRIBUTING FACTOR MICROBIAL FEW COMPLEX
- 19. RADIOGRAPHIC PULPAL PERIODOLNTAL PATTERN LOCALISEDGENERALIZED BONE LOSS WIDER APICALLY WIDER CORONALLY PERIAPICAL RADIOLUCENT NOT OFTEN RELATED VERTICAL BONE LOSS NO YES HISTOPATHOLOGY JUNCTIONAL EPITHELIUM NO APICAL MIGRATION APICAL MIGRATION GRANULATION TISUES APICAL (MINIMAL) CORONAL (LARGER) GINGIVAL NORMAL SOME RECESSION THERAPY TREATMENT ROOT CANAL THERAPHY PERIODONTAL TREATMENT
- 20. DIFFERENCES BETWEEN PERIODONTALAND PERIAPICAL ABSCESS PERIODONTAL ABSCESS PERIAPICAL ABSCESS Periodontal pocket is present Caries/ fracture is present May occur after periodontal treatment May occur after endodontic or restorative treatment. Tooth is vital Tooth is non - vital Pain is usually dull and localized Pain is severe and difficult to localize Swelling is present on the lateral surface of root usually without fistulous track as abscess usually drains from pocket opening. Swelling is present at the apical portion of tooth which drains by formation of a fistulous track. Tender on lateral percussion Tender on vertical percussion Usually not visible on radiographs Appears as a periapical radiolucency
- 21. ENDO – PERIO– CONTROVERSY • Two basic questions have been raised and continue to be a matter of dispute : 1) Is periodontal disease a cause of pulp necrosis? 2) Can a pulpless tooth be the cause of periodontal disease?
- 22. EFFECT OF PULPALDISEASE ON THE PERIODONTIUM Early inflammatory changes in the pulp very little effect on the periodontium. Necrotic pulp produces inflammatory response transverse into periodontal tissues. Nature and extent of periodontal destruction depends on: 1. Virulence of pathogens in the canal system 2. Duration of the disease 3. Defense mechanism of the host. CARRANZA 12TH EDITION, 2016
- 23. CONTRADICTING STUDY Sanderset al. (1983) reported that after the use of freeze dried bone allograft, 65% of the teeth that did not have root canal treatment showed complete or greater than 50% bone-fill in periodontal osseous defects; while only 33% of the teeth which had root canal treatment prior to the periodontal surgical procedure had complete or greater than 50% bone-fill. Diem et al (2002) reported that all tissues of the periodontium had a potential for regeneration regardless of the status of the pulp. With proper endodontic treatment, periodontal disease of pulpal origin should heal. Jansson et al (1998) Potential effect of tooth with a necrotic pulp has been described as a risk factor in the initiation and progression of periodontal disease, and the resolution of periodontal pockets.
- 24. INFLUENCE OF ENDODONTICPROCEDURES ON PERIODONTIUM Aggressive removal of periodontal ligament and underlying cementum during interim endodontic therapy adversely affects periodontal healing. Precautions to be taken when periodontal therapy to follow endodontic treatment Induce less mechanical trauma Use more biocompatible sealers
- 25. EFFECT OF PERIODONTITISON THE PULP Result in atrophic and other degenerative changes like Reduction in the number of pulp cells Dystrophic mineralization/ calcification Fibrosis Reparative dentin formation Inflammation and Resorption CAUSE: Disruption of blood flow through the lateral canals localized areas of coagulation necrosis in the pulp. CARRANZA 12TH EDITION, 2016
- 26. Seltzer et al(1978) found inflammatory alterations and localized pulp necrosis adjacent to lateral canals in roots exposed by periodontal disease. Cohen, 2002 have suggested that periodontal disease causes pulpal necrosis. Periodontal disease is a direct cause of pulpal atrophy and necrosis. Rathod et al 2014, severe chronic periodontitis can affect dental pulp
- 27. CONTRADICTING STUDIES Kirkham (1975)studied 100 periodontally involved teeth & found 2% had lateral canals in the periodontal pocket. Tagger & Smukler (1979) removed roots from molars, extensively involved with periodontal disease in which root amputation was necessary. Pulps of these showed no inflammatory changes. Mazur and Massler (2009) found no relationship of periodontal disease as a causative factor in pulpal disease.
- 28. EFFECT OF PERIODONTALPROCEDURES ON PULP Scaling and root planing: removes the bacterial plaque and calculus. However, improper root planing procedures can also remove cementum and the superficial parts of dentin, thereby exposing the dentinal tubules to the oral environment. Acid etching: citric acid removes the smear layer, an important pulp protector. Application of citric acid may have a detrimental effect on the dental pulp.
- 29. Primary Endodontic Lesion Causes: Deep caries Large restorations Traumatic injuries History of pulp capping or pulpotomy Poor root canal treatment Characteristics Clinical Features: Tooth mobility Narrow pocket Swelling in mucobuccal fold Sore to bite/percussion
- 30. Characteristics clinical features: Sinus tract Localized bone loss Test: Pulpal test: -ve Rapid onset Sinus tract Treatment & Prognosis: Conventional root canal therapy Excellent prognosis
- 32. Primary Endodontic Lesionwith Secondary Periodontal Lesion Characteristics clinical features: Long standing pulpal pathoses. Superimposition of plaque/calculus. Generalized periodontal disease. Test: Pulpal test: -ve. Significant periodontal inflammation. Radiographic evidence of angular defects. Treatment: Conventional root canal therapy. Periodontal treatment.
- 34. Primary Periodontal Lesion Characteristicsclinical features: Teeth vital Generalized bone loss Calculus/plaque Soft-tissue inflammation Broad-based pocket Possible occlusal trauma Test: Pulpal test: +ve Radiographs Periodontal probing
- 35. Treatment & Prognosis: Periodontal treatment. Unfavorable prognosis.
- 37. Primary Periodontal Lesionwith Secondary Pulpal Lesion Characteristics clinical features: Deep Periodontal pockets>6-8 mm History of extensive Periodontal procedures Irreversible pulpal pathosis Pain accentuation Teeth has large restoration Test: H/o disease progression Periodontal probing Pain
- 38. Treatment &Prognosis: Endodontic treatment (Periodontal treatment). Dependent on periodontal therapy.
- 39. True Combined Lesion Characteristicsclinical features: Etiological factors present for both conditions. Generalized periodontal destruction that connects to periapical lesion. Differential diagnosis: Vertical root fracture Perforation Resorption
- 40. Test: Vitality: -ve Periodontal probing at numerous sites Treatment & Prognosis: Endodontic treatment Periodontal involvement
- 41.
- 42. Concomitant Pulpal &Periodontal Lesion Characteristic Clinical Features: Both disease states exist with no evidence that either has influenced the other. Treatment & Prognosis: Both entities must be treated concomitantly with prognosis dependent on removal of individual causes.
- 43.
- 46. CONCLUSION A perioendo lesion can have a varied pathogenesis which ranges from quite ‑ simple to relatively complex one. To make a correct diagnosis the clinician should have a thorough understanding and scientific knowledge of these lesions. Despite the segmentation of dentistry into the various areas of specialization, a clinician needs to perform restorative, endodontic or periodontal therapy, either singly or in combination. Therefore, to achieve the best outcome for these lesions, a multi disciplinary ‑ approach should be involved.
- 47. REFERENCES Textbook ofEndodontics 6th edition – Ingle Pathways of pulp 10th edition– Cohen Text book of endodontics 12th edition – Grossman Textbook of Periodontics 10th edition - Carranza The pathogenesis and treatment of endo-perio lesions.Mhairi R Walker.CPD Dentistry 2001; 2(3):91-95. Endodontic-periodontic Bifurcation Lesions: A Novel Treatment Option. The Journal of Contemporary Dental Practice, Volume 9, No. 4, May 1, 2008. The endo-perio lesion: a critical appraisal of the disease condition. ILAN ROTSTEIN & JAMES H. SIMON, Endodontic Topics 2006. Diagnosis, prognosis and decision-making in the treatment of combined periodontal endodontic lesions Ilan Rotstein & James H. S. Simon Periodontology 2000, Vol. 34, 2004, 165–203
- 48. THANK YOU
Editor's Notes
- #3 Ectomesenchymal cells proliferate to form dental papilla and follicle which are the precursors of periodontium and pulp resp. this embryonic development gives rise to anatomical connections which remain throughout life. Mortality: death, especially on a large scale.
- #4 Cleidocranial dysplasia …autosomal dominant disorder presents with significant dental problems such as retention of multiple deciduous teeth, impaction or delay in eruption of permanent teeth and often, the presence of supernumerary teeth along with skeletal dysplasia Inflammation frm pulp may extends into the periodontium causing destruction of periodontal tissues such a periodontal lesion is kas retrograde periodontitis. Retrograde pulpitis occurs as a result of extension of inflammation from periodontal tissues into the pulp.
- #5 etiological factors: risk factors contributing to the cause of a disease like underweight, high bp, tobacco , alcohol etc. Contributing factors: something that is partly responsible for a development or phenomenon ⇒ Stress, Predisposing factors: any conditioning factor that influences both the type and the amount of resources that the individual can elicit to cope with stress. Include herediatery factors and lifestyle factors. Risk factors: A risk factor is any attribute, characteristic or exposure of an individual that increases the likelihood of developing a disease or injury. Some examples of the more important risk factors are underweight, high blood pressure, tobacco and alcohol consumption, and unsafe water, sanitation and hygiene
- #6 etiological factors: risk factors contributing to the cause of a disease like underweight, high bp, tobacco , alcohol etc. Contributing factors: something that is partly responsible for a development or phenomenon ⇒ Stress, Predisposing factors: any conditioning factor that influences both the type and the amount of resources that the individual can elicit to cope with stress. Include herediatery factors and lifestyle factors. Risk factors: A risk factor is any attribute, characteristic or exposure of an individual that increases the likelihood of developing a disease or injury. Some examples of the more important risk factors are underweight, high blood pressure, tobacco and alcohol consumption, and unsafe water, sanitation and hygiene
- #7 A. actinomycetemcomitans Capnocytophaga sp. F. nucleatum P. gingivalis P. intermedia T. forsythia T. denticola
- #12 most accepted classification
- #14 Abrasion describes the wearing away of a substance or structure through mechanical processes, such as grinding, rubbing or scraping. EROSION describes the process of gradual destruction of the surface of TEETH usually BY chemical processes. ABFRACTION a special form of wedge-shaped defect at the cementoenamel junction (CEJ) of a tooth
- #15 Acute conditions: anug, acute periodontal abscess, acute herpetic gingivostomatits Palpation is performed by applying firm digital pressure to mucosa covering the roots and apices. With the index finger the mucosa is presses against the underlying cortical bone. This will detect the presence of periradicular abnormalities that produce painful response to digital pressure. A positive response to palpation may indicate active periradicular inflammatory process. However this test doesnot indicate whether the inflammatory process is of endodontic or periodontal origin. Percussion is performed by tapping on the incisal or occlusal surfaces of the teeth with the back of mirror handle the tooth is tapped vertically and horizontally. Positive Vertical percussion indicates the periapical pathology.. Positive Horizontal percussion indicates periodontium ass problems..
- #16 *in the absence of periodontal disease may indicate the presence of a lesion of endodontic origin or a vertical root fracture Mobility testing can be performed using 2 mirror handles on each side of the crown. Pressure is applied in facial- lingual as well as in a vertical direction and tooth mobility is scored. Pocket probing: a tooth with this type of lesion will show normal sulcus depth all the way around the tooth until the area of the swelling is probed. At this point, the probe drops suddenly, to a level near the apex. The pulp is non vital
- #17 1radiograph showing periapical and interradicular radiolucencies. 2. ) Radiograph showing alveolar bone loss and a periapical lesion.3. root resorption with a wide base radiolucency around the apex of the Root and in the furcation area 4 . Angular bone loss in multiple teeth 5. Radiograph showing separate progression of endodontic disease and periodontal disease. if a sinus tract is present, it may be necessary to raise a flap to determine the etiology of the lesion Use a rubber wheel, wood stick or other instrument to focus biting pressures on specific cusps to reproduce the patient’s complaint
- #20 pre-existing gum disease (periodontitis)………bacterial infection from a deep periodontal pocket…………..trauma to the gum eg. from food or debris embedded in the gum Periapical….bacteria from plaque invading the pulp of the tooth. Bacteria enter the pulp through progression of a cavity (decay) or tooth fracture eg. trauma or through the gums and supporting tissues. The pulpal infection spreads and reaches the bone surrounding the root tip, forming an abscess.
- #22 Even a pulp that is significantly inflamed may have little or no effect on periodontium. It is thought that this initial pulpal inflammatory response is an attempt by the body to prevent the spread of inf to the apical tissues. Narrow pocket with non vital pulpal response suggest problem is of endodontic origin. Unresolved endodontic lesion causes bone loss, pocket formation and impair wound healing. Virulence is a harmful quality possessed by microorganisms that can cause disease. Factors: lps. Vesicles .enzymes fatty acids capsules nd pilli enterococcus faecalis: ..
- #23 Clinical message is root canal treatment should be completed before periodontal therapy. Autograft.. a graft of tissue from one point to another of the same individual's body. Allograft ..a tissue graft from a donor of the same species as the recipient but not genetically identical. Xenograft .. a tissue graft or organ transplant from a donor of a different species from the recipient. Fdba- osteoconductive scaffold and elicits resorption .. Dfdba- osteoconductive and also osteoinductive
- #24 Mechanical preparation, sealers, surgical trauma hinder new bone, cementum and connective tissue repair. Biocompatibility refers to the ability of a material to perform with an appropriate host response in a specific situation Sealapex Obtuseal root canal sealer
- #25 The effect of periodontal disease on pulp apperars to be more contaversial. Pathological changes occurs in pulp as a result of advanced periodontiis but the pulp doenot show degeneratve changes as long as the main canal has not been involved. It seems therefore that both influence each other but periodontal disease seems to have less influence on pulp compared to effect of pulp on periodontium ac to carranza 12th ed Fibrosis is the formation of excess fibrous connective tissue in an organ or tissue in a reparative or reactive process. Dystrophic calcification (DC) is the calcification occurring in degenerated or necrotic tissue, …………..reaparative dentin: Morphologically irregular dentin formed in response to an irritant, such as caries, disease, or drilling to prepare a cavity for filling. Also called irregular dentin, reparative dentin.
- #27 Root amputation is a specialized dental procedure, whereby one root is removed from a multi-root tooth. hemi-section refers to the sectioning of a molar tooth with the removal of an unrestorable root which maybe affected by periodontal, endodontic,……. Bicuspidization is a surgical procedure carried out exclusively on the mandibular molars, where the mesial and distal roots are separated with their respective crown portions;
- #28 During periodontal regenerative therapy, root conditioning using citric acid helps to remove bacterial endotoxin and anerobic bacteria and to expose collagen bundles to serve as a matrix for new connective tissue attachment to cementum. Though beneficial in the treatment of periodontal disease, Precautions taken during periodontal therapy: 1.Avoidance of the use of irrigating chemicals on the root surface 2. minimization of the use of ultrasonic scalers when there is less than 2mm of remaining dentin 3. Subsidence of minor pulpal irritations before completion of additional procedures.
- #43 Intracanal .. Calcium hydroxide ..Eight principle antibiotic groups have been extensively evaluated for treatment of the periodontal diseases; tetracycline, minocycline, doxycycline, erythromycin, clindamycin, ampicillin, amoxicillin and metronidazole. The biological principle of using cell-occlusive barriers was described by Melcher on the repair potential of periodontal tissues. (GTR) could be driven by excluding or restricting the re-population of periodontal defects by epithelial and gingival connective cells. Thus, providing space and favorable niche to maximize PDL cells, cementoblasts, and osteoblasts to migrate selectively, proliferate and differentiate within the periodontal defects help in promoting the reconstruction of the supporting tissue and attachment…. Mineral trioxide aggregate…retrofilling material…Super EBA is a reinforced zinc oxide cement
- #46 Prognosis Good Prognosis Depends upon periodontal treatment and patient’s response Prognosis Depends upon endodontic and periodontal treatment and patient’s response Prognosis Depends upon severity of the periodontal disease and periodontal tissue response to treatment combined.. More guarded prognosis Ofloxacin ..........200 mg Ornidazole,IP …..... 500 mg.. Amoxy clav clav 125mg.. Augumentin,,, E. faecalis are gram positive cocci and facultative anaerobes.