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ENDODONTIC PERIODONTAL INTER-RELATIONSHIPS

ENDODONTIC PERIODONTAL INTER-RELATIONSHIPS. CONTENTS. INTRODUCTION DEFINITION DEVELOPMENTAL RELATIONSHIP PATHWAYS OF COMMUNICATIONS PULPAL PERIODONTAL INTER-RELATIONSHIP PERIODONTAL PULPAL INTER-RELATIONSHIP ETIOLOGICAL FACTORS CLASSIFICATION OF ENDO PERIO LESIONS

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ENDODONTIC PERIODONTAL INTER-RELATIONSHIPS

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  1. ENDODONTIC PERIODONTAL INTER-RELATIONSHIPS

  2. CONTENTS • INTRODUCTION • DEFINITION • DEVELOPMENTAL RELATIONSHIP • PATHWAYS OF COMMUNICATIONS • PULPAL PERIODONTAL INTER-RELATIONSHIP • PERIODONTAL PULPAL INTER-RELATIONSHIP • ETIOLOGICAL FACTORS • CLASSIFICATION OF ENDO PERIO LESIONS • DIFFERENTIAL DIAGNOSIS • DIAGNOSIS • TREATMENT • PROGNOSIS • CONCLUSION • REFERENCES

  3. INTRODUCTION • The tooth, its pulp and its surrounding supporting structures - biologic unit • Interrelationship among these structures influence each other during health, function and disease • vitality of tooth depends on its ability to function and not on the viability of the pulp….

  4. > 50%- tooth mortality… • Diagnosis is challenging…

  5. DEFINITION A true endo-perio lesion is defined based on the following criteria (HARRINGTON-1979) 1. The teeth involved must be pulpless 2. There must be destruction of periodontal apparatus from gingival sulcus to either the apex of tooth or the area of an involved lateral/accessory canal. 3. Both the endodontic and periodontal therapy must be required in order to resolve the lesion.

  6. DEVELOPMENTAL RELATIONSHIP • Pulp and periodontium are structurally and functionally diff from each other – are seperated by dentine , cementum with major communication between them – apical foramen • However from developmental part of view both have close relationship and disease affecting one of them can influence the other

  7. Dental papilla and dental sac are seperated initially by HERS which progresses apically from CEJ. • Common vascular supply for both. • It is postulated that during this apical progress blood vessels penetrate the root sheath to reach pulp. • Absence of cementum and dentin deposition and forms canal….

  8. PINEDA ET AL- maximum lateral canals – middle 1/3rd of root – maxillary C I. • COHEN AND BURNS-stated accessory canals anywhere along root can act as an endodontic periodontal route

  9. PATHWAYS OF COMMUNICATIONS • Developmental origin; 1. Apical foramen 2. Accessory / lateral canals 3. Dentinal tubules exposure / congenital absence of cementum… 4. Developmental groove / lingual groove 5. Permeability of cementum 6. Enamel projection and enamel pearls

  10. Pathologic origin; 1. Caries 2. Empty space created by destroyed sharpey’s fibre 3. Vertical root fracture caused by trauma 4. Idiopathic resorption- Internal/External 5. Loss of cementum due to external irritants • Iatrogenic origin; 1. Exposure of dentinal tubules following root planing 2. Accidental lateral perforation during endodontic therapy 3. Root fractures due to endodontic procedures

  11. Developmental origin • Apical foramen - Main pathway - Irritants from pulp – foramen – periapical pathosis - Irritants from deep pdl pocket- foramen- pulp - Local inflammatory response – bone and root resorption - Elimination of these irritants leads to healing

  12. Accessory / lateral canals - These canals are formed early during tooth development when HERS breaks down before completion of root formation… - 30-40% - apical 1/3rd of root - 23-76% - furcation area Seltzes et al suggested that pulpal inflammation or necrosis may cause inflammatory reaction in interradicular periodontal tissues . Thus patent accessory canals are a potential pathway…

  13. Dentinal tubules exposure…. - disease process - surgical procedures involving root surfaces… - congenital absence of cementum NOYES[1938] – cementum and enamel fail to meet at cervical region – 5-10% teeth congenital absence of cementum at CEJ – Leads to 15,000 dentinal tubules/mm2 to be open CEJ characteristic may vary covered on one side and absent on other

  14. Developmental groove/ lingual grooves….. Incidence – 1.9 – 8 % Extension- central fossa – cingulum- go apically sometimes to apex Pdl tissues are in close proximity to pulp…

  15. Permeability of cementum- - cellular and acellular cementum highly permeable… CELLULAR – APICAL 1/3rd OF ROOT ACELLULAR – CORONAL 2/3rd OF ROOT - CARRANZA found in some areas of cellular cementum the canaliculi are contiguous with dentinal tubules…

  16. Enamel projection and enamel pearls…. - Enamel projection extending into furcation often exhibit localized severe periodontal pocket - Pearls encourage plaque formation and lead to pocket extending apically…..

  17. Pathologic origin • Caries - On root surface - Extending via pulp chamber… • Empty space created by destroyed sharpey’s fibre…. • Vertical root fracture caused by trauma – is fracture of root that is longitudinal oriented at more or less an oblique angle towards the long axis of the tooth

  18. Idiopathic resorption- Internal/External • Loss of cementum due to external irritants – Cementum can form in areas of hypocalcification and fissures in cellular cementum…

  19. Pathways of iatrogenic origin • Exposure of dentinal tubules following root planing - Deep scaling and excessive root planing….. • Accidental lateral perforation during endodontic therapy - Overinstrumentation…… • Root fractures due to endodontic procedures - Pin and post placement - Obturation

  20. PULPAL PERIODONTAL INTER-RELATIONSHIP • When pulp is infected it elicits inflammatory response of pdl ligament at apical foramen or lateral canals • Procedures during RCT…can also cause inflammatory response but are transient. • Procedural mishaps in RCT… • VRF caused by excessive pressure during obturation…

  21. PERIODONTAL PULPAL INTER-RELATIONSHIP • Procedural errors during periodontal therapy that is if accessory canals are severed or opened to oral environment during - scaling, - currettage or - periodontal surgery.

  22. ETIOLOGICAL FACTORS • Microbial factors: Bacteria Fungi Virus • Non microbial endodontic diseases • Contributing factors: Inadequate endodontic therapy Coronal leakage Traumatic injuries Root perforation Developmental malformation • Systemic factors: Diabetes mellitus

  23. Microbial factors • Microbes play an important role… • Studies have shown great similarities in microflora of advanced periodontitis and pulpal lesions • Majority of microbes grow in biofilms – 15% cells by volume embedded in 85% matrix material…

  24. Bacteria- - Plays a critical role in both diseases - Studies have shown that perio and endo pathogens are similar and endo perio inter relationships are a critical pathway for both diseases. - Spirochetes but found more in subgingival plaque, in root canal T.denticola and T.maltophilium. - WOLLINELLA gram –ve rod commonly found…

  25. Fungi- - Presence and prevalence of fungi in endo infections are well documented. - Colonize canal walls and penetrate tubules - Gain access to canals due to poor asepsis…. - 20% adult periodontitis patients harbor subgingival yeasts - C. albican common others such as

  26. Viruses- - Also plays a critical role in both diseases - Periodontal diseases – Herpes simplex virus found in gingival fluid and biopsies. But in periapical lesions not found - Common virus found Human cytomegalo virus and Epstein barr virus

  27. Non microbial endodontic diseases • Non living pathogens is also known to effect health of endo and perio tissues. • Extrinsic agents- Foriegn bodies- dentin and cementum chips, amalgam, cellulose fibers from paper points, gingival retraction cord. Intrinsic agents- Epithelial rests of malassez Cholesterol crystals Russell bodies Rushton hyaline bodies Charcot leyden crystals

  28. Contributing factors • Inadequate endodontic therapy- - Poor endodontic treatment leads to treatment failure. - Failure can be treated by orthograde retreatment or by endodontic surgery by good success rate.

  29. Coronal leakage - Leads to treatment failure. - Delay in placement of coronal seal, or fracture of coronal restoration or tooth leads to contamination by microbes.

  30. Traumatic injuries – - When trauma occurs there can be involvement of both pulp and surrounding periodontal attachment apparatus - Treatment and prognosis depends on the type of injury.

  31. Root perforation - - Causes clinical complication that lead to periodontal lesions. • Extensive caries lesion, resorption, operator error during instrumentation or post space preparation. • Success depends on degree of periodontal damage and immediate sealing of perforation and infection control.

  32. CLASSIFICATION OF ENDO PERIO LESIONS 1. SIMON ( Based on etiology, diagnosis, prognosis and treatment ) Simon J.H.S., Glick, D.H., and Frank, A.L.,J Periodontol 1972;43:202 Class 1 Class 2 Class 3 Class 4 Class 5 Class 6

  33. 2. WEINE 1982 ( Based on etiology of disease which determines type of therapy required and probable prognosis ) - Class 1 - Class 11 - Class 111 - Class 1V

  34. 3. GROSSMAN 1991 - Lesions that require endodontic treatment only - Lesions that require periodontal treatment only - Lesions that require combined endodontic periodontal treatment

  35. 4. STOCK AND GULABIVALA - Primary endo lesion [ with potential for true secondary perio involvement] - Primary periodontal lesion [ with potential for true secondary pulpal involvement] - True combined lesion of dual origin

  36. 5. Glickman classified endo-perio as Type 1- Pulpal infection progressing to periapical area, moving coronally and causing gingival inflammation Type 2 – Marginal periodontitis transversing the apical foramen or the lateral canal to infect the pulp. Type 3 – Two separate lesions coalescing to form a combined lesion

  37. DIFFERENTIAL DIAGNOSIS

  38. Pulpal inflammation Caries Restoration Trauma Clinical signs Acute pain Swelling May/not be present Primary Endo Sinus tract Gingival Sulcus Crestal bone level normal Pulp vitality: EPT; negative

  39. Destruction of periodontal ligament, Break down of supporting hard and soft tissues Endodontic involvement Failure of host defense Virulence of Microorganisms Primary Endo Secondary Perio Drainage Thru the gingival sulcus Pulp vitality: EPT; negative Angular bone loss Periradicular bone loss Presence of Bacteria and plaque in the sulcus Apical migration of Junctional epithelium

  40. Inflammation in the Sulcular region Plaque and Calculus accumulation in Sulcus Destruction of hard and soft tissues, Primary Perio Abcess formation + drainage Bone loss in the lateral aspect and in furcation areas Pulp vitality: EPT; positive

  41. Inflammation in the Sulcular region Exposure of Lateral Canals /dentinal tubules Plaque and Calculus accumulation in Sulcus Primary Perio Secondary Endo Endodontic Involvement Extensive periodontal involvement Deep pockets History of past perio treatment Symptoms of Pulpitis ie acute pain Pulp vitality: EPT; negative

  42. Endodontic involvement of teeth Periodontal disease in other areas Pulp vitality: EPT; negative indicating necrosis As disease progress Combines Periodontal probing reveals deep pockets Combined Endo Perio

  43. Concomitant lesion • Two independent lesion co exist on the same tooth without showing any signs that one influences the other • These lesions do not join and should be treated separately but at same time.

  44. DIAGNOSIS • First proper history…scleroderma, metastatic carcinoma, osteosarcoma • Signs and symptoms: PAIN Endo origin- Acute in onset, severe, occurs spontaneously and is localized….. Perio origin- Chronic, mild to moderate in nature, dull….. Combined lesion- minimum pain as there will be drainage through gingival sulcus.

  45. Intra oral examination - Colour, contour, texture, architecture of gingiva should be noted. - Any abberration on the teeth, caries, fractures, discolourations and extensive restoration - Pulpal pathology…. - Absence of any above abberration along with presence of plaque and calculus – periodontal pathology

  46. Swelling endo origin- mucobuccal fold – spreads to facial planes- extra oral swelling. perio origin- attached gingiva – rarely spreads and no swelling. • Mobility endo origin- one tooth and grade 1 perio origin- generalized • Suppuration endo origin- acute or chronic alveolar abcess with draining sinus perio origin- acute periodontal abcess, phoenix abcess

  47. Periodontal probing…. • Presence of local factors – plaque and calculus….caries or large fractured restoration….

  48. Percussion and palpation- endo origin- on palpation, sensitive in periosteum immediately over the apex of the root. pain on vertical percussion…. perio origin- on palpation , no pain.... pain on lateral percussion when source of inflammation from lateral canals, apical foramen or marginal periodontium.

  49. CLINICAL TESTS: Pulp vitality tests: - Most important in differentiating a combined lesion 1. Heat / Cold test – immediate pain disappear on removal of stimulus – healthy pulp No response or pain lingers – necrotic/ irreversible state • EPT………. 3. Test cavity preparation….

  50. Topaz test • Chair-side test for the detection of bacterial toxins, bacterial proteins and human inflammatory proteins in gingival crevicular fluid.  • More simply put, the Topaz system allows for a determination of toxicity potential of a tooth by measuring the fluid in the periodontal pocket of a tooth. • This test has a high degree of accuracy in making its determination about the toxicity potential of a questionable tooth

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