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ENDO-PERIO LESIONS
This document discusses endo-perio lesions, which involve both the dental pulp and surrounding periodontium. It describes the various types of lesions, including primary endodontic, primary periodontal, endo-secondary perio, and perio-secondary endo lesions. It also discusses diagnostic factors, treatment approaches, and case studies involving endo-perio lesions from 2014 to 2020. The optimal treatment is described as endodontic therapy preceding periodontal treatment to support healing, with regenerative procedures and adjuncts like ozone gas showing promise.
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ENDO-PERIO LESIONS
- 4. PULP PERIODONTIUM Confusion &controversy Pathways of spread of infection Diagnosis, prognosis, treatment EMBRYONIC ANATOMIC FUNCTIONAL
- 5. ENDO- PERIO LESION Lesionsdue to inflammatory products found in varying degrees in both periodontium and pulpal tissues.
- 22. • Tooth withnecrotic pulp reaching apical periodontium • Root perforations • Root fractures • Chronic periapical abscess with sinus tract • Replants • Transplants • Teeth requiring hemisection • Occlusal trauma causing reversible pulpitis • Supra/infra bony pockets caused during periodontal treatment resulting in pulpal inflammation • Occlusal trauma and gingival inflammation resulting in pocket formation • Any lesion of type I which result in irreversible reaction to periodontium requiring periodontal treatment • Any lesion of type II which results in irreversible damage to pulp tissue requiring endodontic
- 23. - Pulpal infectionmay cause a tissue destructive process that proceeds from the apical or furcal region of a tooth towards the gingival margin, as opposed to MARGINAL PERIODONTITIS in which infection spreads from the gingival margin toward the root apex.
- 24. Endo-periodontal lesion withroot damage Root fracture or cracking Root canal or pulp chamber perforation External root resorption Endo-periodontal lesion without root damage Endo-periodontal lesion in periodontitis patients Grade 1- narrow deep periodontal pocket in 1 tooth surface Grade 2- wide deep periodontal pocket in 1 tooth surface Grade 3- deep periodontal pockets in more than 1 tooth surface Endo-periodontal lesion in non-periodontitis patients Grade 1- narrow deep periodontal pocket in 1 tooth surface Grade 2- wide deep periodontal pocket in 1 tooth surface
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- 30. Pulpal inflammation/necrosis Inflammatory responsein PDL Gingival sulcus of involved tooth Gingival sulcus of adjacent tooth Severe – destruction of supporting apparatus viz., PDL, socket, etc. Localized swelling Draining sinus tract Diffuse swelling Attached gingiva Alveolar mucosa
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- 37. Pathogenic bacteria & inflammatoryproducts of periodontal disease Accessory canals/ lateral canals/apical foramen Retrograde pulpitis
- 38. Pulpal response –remaining dentin thickness Negligible response Repair & Healing Pulpal response Necrosis Prophylactic root canal treatment to be completed before periodontal treatment SCALING & ROOT PLANING - REASONS: 1. Dissolved smear layer– - increased hydraulic conductance of involved dentinal tubules - decreased peripheral resistance to fluid flow across dentin 2. Open dentinal tubules– pathway for diffuse transport of bacterial elements in oral cavity to the pulp 3. Peripheral sensitization of pulp nociceptors due to release of inflammatory mediators as seen by A∂ fibers. IN CONCLUSION, unless periodontal disease extends all the way to the tooth apex, the effect of periodontal disease treatment on dental pulp is ineffective
- 40. ENDODONTIC LESION PERIODONTALLESION Pain: Acute, severe, throbbing type, poor localization, postural variation, referred to other sites, not much response to analgesics etc. Chronic onset. Mild to moderate in nature, able to localize pain, no postural variation, responds to mild analgesics etc. Swelling: Mucobuccal fold area, spreads to facial plane, extraoral swelling Attached gingiva, rarely spreads beyond MGJ, rarely facial swellings Mobility: Isolated tooth mobility if acute abscess Usually generalized mobility Periodontal probing: Precipitous drop in probing depth, lesion is narrow coronally than at the apex, no calculus Generalized deep probing, lesion is broader at its point of origin at the apex, calculus on the root Fistulation: Traced to radiographic apex with negative vitality Traced to mid-root Percussion: vertical Horizontal Pulp vitality: Nonvital Vital
- 41. MOBILITY HISTORY PULP VITALITY VISUAL EXAMINATION PALPATIONPERIODONTAL PROBING RADIOGRAPH PERCUSSION SINUS TRACING, CRACKED TOOTH TEST (TRANSILLUMINATION, WEDGING), SELECTIVE ANESTHESIA TEST to localize pain to specific site
- 42. PRIMARY ENDODONTIC LESION Soft tissue-presence of sinus opening Tooth- presence of decay/large restoration/ # restoration or tooth/ erosions/abrasions/cracks/discolorations/poor RCT PRIMARY PERIODONTAL LESION Inflamed gingiva/gingival recession around multiple teeth Accumulation of plaque and subgingival calculus around multiple teeth Intact teeth Presence of swelling indicating periodontal abscess PRIMARY ENDO- SECONDARY PERIO Plaque forms at the gingival margin of the sinus tract and leads to inflammation of marginal gingiva exudate Root perforation/fracture/misplaced post PRIMARY PERIO- SECONDARY ENDO Presence of plaque, subgingival calculus and swelling around multiple teeth Presence of pus, exudate Presence of localized/generalized gingival recession and exposure of root TRUE COMBINED LESION/ CONCOMITANT PULPAL Plaque, calculus and periodontitis will be present in varying degrees
- 43. PRIMARY ENDODONTIC LESION Sharp Does notindicate whether inflammation is of periodontal/endodontic origin PRIMARY PERIODONTAL LESION Usually dull ache Sharp only in acute condition PRIMARY ENDO- SECONDARY PERIO Usually sharp shooting pain Dull ache in chronic conditions PRIMARY PERIO- SECONDARY ENDO Usually dull ache Sharp only in periodontal abscess TRUE COMBINED LESION/ CONCOMITANT PULPAL AND PERIODONTAL LESIONS Dull ache Severe pain only in acute conditions
- 44. PRIMARY ENDODONTIC LESION Normally tenderon percussion PRIMARY PERIODONTAL LESION The sensitivity of the proprioceptive fibres in an inflamed periodontal ligament will help identify the location of the pain PRIMARY ENDO- SECONDARY PERIO Tender on percussion PRIMARY PERIO- SECONDARY ENDO Tender on percussion TRUE COMBINED LESION/ CONCOMITANT PULPAL AND PERIODONTAL LESIONS Tender on percussion
- 45. PRIMARY ENDODONTIC LESION Fractured rootsand recently traumatized teeth often present high mobility PRIMARY PERIODONTAL LESION Localized to generalized mobility PRIMARY ENDO- SECONDARY PERIO Localized mobility PRIMARY PERIO- SECONDARY ENDO Generalized mobility TRUE COMBINED LESION/ CONCOMITANT PULPAL AND PERIODONTAL LESIONS Generalized mobility with higher grade of mobility related to the involved tooth
- 46. PRIMARY ENDODONTIC LESION A lingeringresponse– irreversible pulpitis No response– necrotic pulp (non-vital) PRIMARY PERIODONTAL LESION The pulp is vital and responsive to testing PRIMARY ENDO- SECONDARY PERIO Pulp vitality tests negative PRIMARY PERIO- SECONDARY ENDO Pulp vitality may be positive in multirooted teeth TRUE COMBINED LESION/ CONCOMITANT PULPAL AND PERIODONTAL LESIONS Usually negative because of non-vital pulp. Vitality tests may give a positive response in multirooted teeth
- 47. PRIMARY ENDODONTIC LESION A deepnarrow solitary pocket in the absence of periodontal disease may indicate the presence of a lesion of endodontic origin or a vertical root fracture PRIMARY PERIODONTAL LESION Multiple wide and deep pockets PRIMARY ENDO- SECONDARY PERIO Presence of solitary wide pocket but if periodontal lesion is due to fracture of root then solitary deep narrow pocket (mainly localized) PRIMARY PERIO- SECONDARY ENDO Presence of multiple wide and deep periodontal pockets TRUE COMBINED LESION/ CONCOMITANT PULPAL AND PERIODONTAL LESIONS Probing reveals the typical conical periodontal type of probing with the exception that at the base of the periodontal lesion, the probe will abruptly drop further down the lateral root surface and may even extend to the apex of the tooth
- 48. PRIMARY ENDODONTIC LESION Presence ofdeep carious lesions/extensive or defective restorations/ previous poor RCT/ possible mishaps/root fracture/root resorption with periapical radiolucency PRIMARY PERIODONTAL LESION Vertical bone loss and more generalized than to lesions of endodontic origin Bone loss wider coronally PRIMARY ENDO- SECONDARY PERIO Presence of deep carious lesions/extensive or defective restorations/previous poor RCT/diminution of the pulp canal space/possible mishaps/root fractures/root resorption with a wide base radiolucency around the apex of the root PRIMARY PERIO- SECONDARY ENDO Angular bone loss in multiple teeth with a wide base coronally and narrow at the apex of the root TRUE COMBINED LESION/ CONCOMITANT PULPAL AND PERIODONTAL LESIONS The radiographic appearance of combined endodontic-periodontal disease may be similar to that of a vertically fractured tooth
- 49. PRIMARY ENDODONTIC LESION A radiographwith gutta percha points to apex or furcation area in molars PRIMARY PERIODONTAL LESION Sinus tract mainly at the lateral aspect of the root PRIMARY ENDO- SECONDARY PERIO Sinus tract mainly at the apex of=r furcation area PRIMARY PERIO- SECONDARY ENDO Sinus tract mainly at the lateral aspect of the root TRUE COMBINED LESION/ CONCOMITANT PULPAL AND PERIODONTAL LESIONS Difficult to trace out the origin of the lesion, if a sinus tract is present, it maybe necessary to raise a flap to determine the etiology of the lesion
- 50. PRIMARY ENDODONTIC LESION Painful responseat the time of chewing, especially on releasing the biting pressure PRIMARY PERIODONTAL LESION No symptoms PRIMARY ENDO- SECONDARY PERIO Painful response at the time of chewing, especially on releasing the biting pressure PRIMARY PERIO- SECONDARY ENDO No symptoms TRUE COMBINED LESION/ CONCOMITANT PULPAL AND PERIODONTAL LESIONS Painful response at the time of chewing, especially on releasing the biting pressure
- 51. Parolia A, GaitTC, Porto IC, Mala K. Endo-perio lesion: A dilemma from 19 th until 21 st century. Journal of Interdisciplinary Dentistry. 2013 Jan Hoyle P, Tank M, Modarres-Simmons S, Storey CA. Assessment and management of endo-periodontal lesions. Dental Update. 2019 Nov 2;46(10):930-41.
- 52. Identify occlusaltrauma and eliminate– reduce risk of exacerbating inflamed periodontium C/F: fremitus test +ve on lateral/protrusive movements Splinting– indicated when not possible to eliminate such forces absolutely - Also indicated for accurate occlusal adjustment (mobility) Primary endodontic disease– necrotic pulp– clinically seen with drainage from sulcus/sinus + swelling in buccal attached gingiva Patient may be ASYMPTOMATIC In absence of adequate healing– further periodontal treatment is indicated.
- 54. Herrera D, Retamal‐ValdesB, Alonso B, Feres M. Acute periodontal lesions (periodontal abscesses and necrotizing periodontal diseases) and endo‐periodontal lesions. J Clin Periodontol 2018
- 55. Combination treatment Endodontic therapy BEFORE periodontal therapy
- 56. TREATMENT Endodontic treatment only-root canal therapy Bakland LK, Andreasen FM, Andreasen JO. Management of traumatized teeth. In: Walton RE, Torabinejad T, editors. Principles and Practice of Endodontics. 3rd ed. Philadelphia, PA: WB
- 57. Bakland LK, AndreasenFM, Andreasen JO. Management of traumatized teeth. In: Walton RE, Torabinejad T, editors. Principles and Practice of Endodontics. 3rd ed. Philadelphia, PA: WB TREATMENT 1. Periodontal treatment only 2. SRP 3. Removal of poorly contoured restorations and developmental grooves
- 58. Bakland LK, AndreasenFM, Andreasen JO. Management of traumatized teeth. In: Walton RE, Torabinejad T, editors. Principles and Practice of Endodontics. 3rd ed. Philadelphia, PA: WB TREATMENT 1) Endodontic treatment, evaluate 2) Periodontal treatment– initially a close procedure 3) Revaluation at 4-6 wks. post-treatmen
- 59. Bakland LK, AndreasenFM, Andreasen JO. Management of traumatized teeth. In: Walton RE, Torabinejad T, editors. Principles and Practice of Endodontics. 3rd ed. Philadelphia, PA: WB
- 60. Bakland LK, AndreasenFM, Andreasen JO. Management of traumatized teeth. In: Walton RE, Torabinejad T, editors. Principles and Practice of Endodontics. 3rd ed. Philadelphia, PA: WB
- 61. Bakland LK, AndreasenFM, Andreasen JO. Management of traumatized teeth. In: Walton RE, Torabinejad T, editors. Principles and Practice of Endodontics. 3rd ed. Philadelphia, PA: WB
- 63. 2014 Periodontal considerations: - Severevertical bone loss involving 1 root - Through-and-through furcation destruction - Proximity of adjacent roots-prevent oral hygiene maintenance - Root exposure- dehiscence - GOOD PROGNOSIS observed with proper occlusion, absence of mobility, and healthy periodontal condition with regular follow-up. HEMISECTIONING
- 64. 2016 Advocated the roleof endotherapy preceding periodontal treatment Periodontal regenerative therapy of furcation-involved teeth is MORE COST EFFECTIVE than extraction/implant. Use of enamel matrix derivative>> more effective in class 1 and 2 furca involved ACCESS FLAP+ EMD
- 65. 2019 Periodontal regenerative procedures Endodontic treatmentbefore definitive periodontal regenerative procedures SUPPORTS PERIODONTAL HEALING in case of apical involvement Strict SPT program DBBM+ 10% COLLAGEN
- 66. 2020 Newer modality– fewstudies Ozone– antimicrobial activity Useful adjunct to conventional sequence of endotherapy followed by periodontal treatment OZONE GAS
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