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INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com

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CONTENTS INTRODUCTION DEFINITION CLASSIFICATION ETIOLOGY CONTROVERSIES REGARDING THE COMBINED LESION PATHWAYS OF SPREAD COMPARISION OF CLINICAL PRESENTATION B/W APICAL & MARGINAL PERIODONTITIS DIFFERENTIAL DIAGNOSIS EFFECT OF PULP & ITS TREATMENT ON PERIODONTIUM EFFECT OF PERIO. DISEASE & TREATMENT ON PULP LESIONS DIAGNOSIS TREATMENT REFERENCES CONCLUSION www.indiandentalacademy.com


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.

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STOCK


COHEN • • • • • • •

Primary endodontic lesion Primary endodontic lesion with secondary periodontal involvement Primary periodontal lesion Primary periodontal lesion with secondary endodontic involvement True combined lesion Concomitant pulpal & periodontal lesion

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WEINE

Type I - Tooth in which symptoms clinically and radiographically simulate periodontal disease but are due to pulpal inflammation Type II - Tooth that has both pulpal and periodontal disease concomitantly Type III - Tooth has no pulpal problem but require endodontic therapy plus root amputation to gain periodontal healing Type IV - Tooth that clinically and radiographically simulate pulpal or periapical disease but infact have periodontal disease

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LESIONS REQUIRING ENDODONTIC TREATMENT ONLY GROUP I  necrotic pulp and apical granulomatous tissue replacing periodontium with or without sinus 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 / replants / transplants  Teeth that require hemisection  Root submergence

GROSSMAN www.indiandentalacademy.com


LESIONS REQUIRING PERIODONTAL TREATMENT ONLY

GROUP II  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

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LESIONS REQUIRING COMBINED ENDO – PERIO TREATMENT

GROUP III  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

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ATYPICAL ANATOMIC FACTORS Malaligned tooth Multirooted teeth / additional root Additional canal Cervical enamel projection Large lateral / accessory canal TRAUMA

With gingival inflammation Tooth fracture Pulp / perio involvement + sinus tract Cellular changes - resorption

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MISCELLANEOUS Iatrogenic systemic

SINUS TRACT

INFRABONY POCKET

•From canal

•From gingival crevice

•Narrow

•wide

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Causes : ( Stock )

Root fractures – crown / root ( vital / non vital )

Root canal infection

Root resorption

Anatomical anomalies ( palatogingival groove,enamel pearls , root division , fused teeth , invagination )

Root perforation

Orthodontic treatment

Localized periodontal disease Transplantation & replantation www.indiandentalacademy.com

Poorly designed restorations


Multiple endo perio lesion

•Isolated lesion upon gen. periodontitis

•Chronic periodontitis

•Aggressive periodontitis

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CONTROVERSIAL ASPECT CONCERNING THE COMBINED LESION  PULPAL  PERIODONTAL Chacker Massler Czarnecki & Schilder

PERIODONTAL PULPAL ? Venous blood flow outward

Drawback Lateral / accesory canal - flow bothways Seltzer & bender Stahl

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Physiologic : • Apical foramen • Lateral canals • Dentinal tubules • Periodontal ligament • Alveolar bone • Neural pathways • Vasculolymphatic pathway • Palatogingival grooves • Cementum defect Iatrogenic : • •

Vertical root fractures Perforations

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COMPARISION MARGINAL PERIODONTITIS

APICAL PERIODONTITIS

Cervical

Apex

Plaque

Pulpal inflammation

Horizontal / Vertical bone loss - Seldom bone loss – localized generalized & deep Open

Contained

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Attachment loss asso. with  Anatomic defect on root  Nature of pathogenic flora  Necrotic & infected pulp  Host defense mechanism defect.

Aggresiveness asso with  Lateral & apical foramen  Nature of flora  Apical host defense

Periodontal probing & radiographic examination

Radiographic examination

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DIFFERENTIAL DIAGNOSIS PULPAL

PERIODONTAL

CLINICAL Cause

pulp infection

periodontal

Vitality

non vital

vital

Restorative

deep or extensive

not related

Plaque /calculus

not related

primary cause

Inflammation

acute

chronic

Pockets

single and narrow

multiple and wide

pH value

acidic

alkaline

Trauma

primary or secondary

contributing factor

Microbial

few

coronally

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complex


RADIOGRAPHIC Pattern Bone loss Periapical Vertical bone loss

localized wider apically radiolucent no

generalized wider coronally not related yes

HISTOPATHOLOGY Junctional epithelium Granulation tissues Gingival

no apical migration apical (minimal) normal

present coronal (larger) recession

TREATMENT Therapy

RCT

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Periodontal therapy


Problems in diagnosis : Vertical root fracture: varied radiographic picture Different angulations Surgical exposure lateral condensation excessive Post placement Cause Extensive restorations Older patients Gingival sulcus & pocket area Single rooted teeth multirooted teeth Developmental grooves In doubt ? – Biopsy / Histological analysis Systemic diseases mimic lesion on radiograph : Scleroderma Metastatic carcinoma Osteosarcoma www.indiandentalacademy.com


EFFECT OF PULP AND ITS TREATMENT ON PERIODONTIUM Periodontal inflammation & bone loss Sub marginal bone loss Horizontal bone loss Vertical intrabony pockets Furcation involvement Periodontal wound healing Traumatized necrotic pulp RC infection – compromised healing Gingival tissue thickness Alveolar bone level Surgical trauma to flap Effective flap repositioning Root canal treatment Doubtful pulpal status Iatrogenic problems www.indiandentalacademy.com


EFFECT OF PERIODONTAL DISEASE & ITS TREATMENT ON PULP Periodontal disease & pulp •Limited •Channels closed + dystrophic calcification- chronic •Sufficient viurlence – pulpal disease •Poor prognosis •Extraction / Root resection Periodontal treatment & pulp

•Scaling & root planing – excessive cementum removal •Compromised pulp

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PRIMARY ENDODONTIC LESION Caries / trauma / restorative procedure Pulp

Inflammation

Apical / lateral / Furcation / Attachment apparatus Pain , swelling , tenderness , marginal gingiva swelling Suppurative process – Sinus tract Pdl / Patent channels Multirooted Teeth Gr. III thru & Thru Furcation defect Diagnosis : Necrotic / Vitality test Treatment : RCT

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Ging. Sulcus ( GP / Probe to apex)


PRIMARY ENDODONTIC WITH SECONDARY PERIODONTAL Unchecked endo lesion Periapical alveolar bone destruction Interradicular area Drainage

Hard / soft tissue

Plaque / Calculus

Apical attachment migration ( perio disease) Diagnosis : Necrosis / Calculus accumulation Treatment : Both

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PRIMARY PERIODONTAL LESION Sulcus

Plaque / Calculus Inflammation

Apex Alv. Bone / Pdl Clinical attachment loss acute Abscess

Lateral root / Furcation / TFO ( isolated lesion ) Diagnosis : Tooth mobility positive pulp test Broad based pocket / Plaque & calculus Generalized Treatment : Periodontal therapy

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osseous defects


PRIMARY PERIODONTAL & SECONDARY ENDODONTIC Periodontium

Pulp

Dentinal tubules Lateral canals Diagnosis : Deep pocket H/O extensive periodontal disease Past treatment Treatment : Both

TRUE COMBINED LESIONS

CONCOMITANT LESIONS

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Oral cavity


DIAGNOSIS OF ENDO PERIO LESIONS History of dentinal / pulpal pain History of periodontal symptoms (bleeding, recur. Infection , mobility) - nature / duration - risk factors Signs and symptoms of pulpal / periapical disease (vitality) Periodontal charting (probing profile) - Recession - Mobility - Furcation involvement - Attachment loss

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Clinical signs of pocket formation : Bluish red marginal gingiva / vertical zone extending from marginal to attached gingiva. “Rolled” edge separating gingival margin form tooth surface. Enlarged edematous gingiva. Bleeding, suppuration, loose extruded teeth.

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Symptoms of pocket formation Usually painless Localized or radiating pain or sensation of pressure after eating which gradually diminishes. Foul taste in localized areas. Sensitivity hot and cold Tooth ache in absence of caries are present

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BIOLOGIC DEPTH PROBING DEPTH FORCE : 0.75N POCKET DEPTH LEVEL OF ATTACHMENT GINGIVAL RECESSION 6 POINT CHARTING

DISTOPALATAL

MID PALATAL www.indiandentalacademy.com

MESIOPALATAL


CONTINUOUS PROBING PROFILE

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LONG NARROW POCKETS: ENDODONTIC ORIGIN

LATERAL ENDODONTIC ABSCESS WIDE AND DEEP POCKET “BLOW OUT” LESION

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RADIOGRAPHIC PATTERN OF BONE LOSS •Apical extent of bone loss •Definite Pdl space absent •Shape of bone defect ( angularity / marginal bone ) Bone defect contributed by pulp infection : - Periodontal intrabony defect – 2/3 root length - Horizontal bone loss - 2/3 root length - periodontal bone loss involving root end

Acute pain generally absent in endo perio – open nature 30 – 60 % spirochaetes 0 – 10 % spirochaetes

- perio origin - endo origin

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Causes: o Endo o Perio o Fracture o Resorption o Anatomy

Endo perio lesion usually isolated, narrow localized pocket

Check endodontic status

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? www.indiandentalacademy.com

MANAGEMENT


Feasible re-treatment? No

Yes

Try OHI + debridement OHI Resolution?

Resolution? No

Yes

No

Yes

oDo first stage endo oClean and shape canals oDress with calcium hydroxide Extract

Resolution? Yes

Extract www.indiandentalacademy.com No


Vitality tests

Negative

Positive

Root canal treatment

Perio treatment

Resolution?

Resolution? Yes

No

No

Yes

Check OHI and perio

Check vitality again: If in doubt- do RCT Still no resolution: look for other causes

Extract, resect , hemisect www.indiandentalacademy.com


TREATMENT ALTERNATIVES ROOT RESECTION

REGENERATIVE TECHNIQUES ROOT RESECTION : “ Sectioning & removal of one or two roots of a multirooted teeth with accompanying odontoplasty.” 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.” www.indiandentalacademy.com


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.”

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ROOT RESECTION Furcation involvement.

( Maxillary / Mandibular - 3 point / Nabers probe )

Classification of degree of Furcation involvement Class I - Horizontal loss of periodontal support< one third of tooth width Class II - Horizontal loss of periodontal support> one third but not encompassing the total width of the tooth Class III - Horizontal through and through destruction of the periodontal tissue in the furcal area

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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 Severe root exposure due to dehiscence

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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

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Contraidications Root fusion making separation impossible Angulation or position of tooth in the arch Root morphology Improperly shaped occlusal contact

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 Poor prognosis  Retained roots

SURGICAL CONSIDERATIONS  Buccal + Palatal flaps  Releiving incision  Intracrevicular incision  Full thickness flap  Undersurface of crown - bevelled .

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Envelop Type Flaps Little Or No Attached Gingiva Flap Edges - Sutured Full Flap - Periodontal Disease - Scaling, Curettage Or Osseous Contouring Procedures

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REGENERATIVE TECHNIQUES GTR – Differential tissue development Barrier

Resorbable

Collagen Synthetic

Non resorbable

Enamel matrix derived protein Barrier – principle - stiff

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ANTIBIOTICS FOR ENDO PERIO LESION

 Tetracycline

250 mg (qid)

 Doxycycline

100 mg ( bd / od )

 Metronidazole 

250 mg ( tid for 7 days)

Chlorhexidine

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REFERENCES

 The use of guided tissue regeneration principles in endodontic surgery for induced chronic periodontic-endodontic lesions: a clinical, radiographic, and histologic evaluation J Periodontol. 2005 Mar;76(3):450-60.  Pathologic interactions in pulpal and periodontal tissues. J Clin Periodontol. 2002 Aug;29(8):663-71.

 The influence of endodontic treatment upon periodontal wound healing. J Clin Periodontol. 1997 Jul;24(7):449-56.

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