8/13/2019 Endo Perio Lesion an Interdisciplinary Approach to Solve the Dilemma of Which Came First the Chicken or the Egg

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Endo-Perio Lesion: INDIAN DENTAL ASSOCIAT IONWEST DELHIAn Interdisciplinary Approach To Solve TheDilemma Of Which Came First

-The Chicken Or The Egg?Dr Harpreet Singh Grover Dr Shailly Luthra Dr ShrutiMaroo

ABSTRACTThe interrelation ship bet ween periodonta l and endodont ic disease has aroused confusion, queries andcon troversy. The actual re la ti onshi p between periodontal and pulpal disease was first described by Simring andGoldberg in 1964. Since then, the term perioendo lesion has been used to describe lesions att ri butable toinf lammatory product s found in va rying degrees in both the periodontium and the pulpal tissues. The pulp andperiodontium have embryon ic, anatomic and function al in terrelationships. The simu ltaneous existence ofpulpal problems and infl ammatory periodonta l disease can obscure diagnosis and treatment planning. A perio'endo lesion can have a diverse pathogenesis which ranges from qu ite simple to somewhat complex. Knowledgeof th ese d isease processes is essentia l in coming to the correct diagnosis. This is achievable by ca reful histo rytaking, examination and the use of radiographs. Th e prognosis and treat'l1ent of each endodontic periodontaldisease type varies. Prim ary periodontal disease w ith secondary endodontic involvement and tru e combinedendodontic'periodon tal d iseases requ ire both endodontic and periodonta l therapies. The prognosis of thesecases equally depends on the severity of periodontal disease and the response to periodonta l treatm ent. This-20 Ies the operator to const ruct a suitable t reat ment plan w here unnecessary, pro longed or even detrimental

: , = : . ~ : s avoided.lCeyword : erio Les ions, Periodontal, Pu Ipal, Diagnosis, Treatment

,,- :;oc 0eriodonta esion t reatment is a ch allenge to the cl inician and treatment often requ ires a combinedtherapeutic effort.The classification of periodontal disorders by the American Academy of Periodontology, 1999', co ntains'periodontitis in connection with endodontalle sions' (commonly referred to as perio-enda lesion s as one ofthetotal of e ight disorder groups. This is comprehended to mean pathological disorders that can be determ ined,cl inically or through the use of radiographs, to be comm on to both t he periodontium and the endodontium of atooth.

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relationship between periodonta l and pulpal disease was fi rst described by simring and Goldberg in-'since then , the term, 'perio-endo lesion' has been used to describe lesions due to inflammato ry products

nd in varying degrees in both the periodontium and the pulpal tissues. The dental pulp an d periodontalsues are closely related . The pu lp or iginates from the dental papilla while the periodontal ligament from the

l fo ll icle and is separated by Hertwig 's epithel ial root sheet As the toot h matu res and the root is formed,e main apertures for exchange of infectious elements and other irri ta nts between the two compartments

created bytubules,

ateral and accessory canals, andThe apica l foramen. When the pulp becomes inflamed/infected, it elicits an inflammatory response of the

riodonta l ligament at the apica l foramen and/or adjacent to openings of accessory canals.'Noxious elementspulpal origin, includ ing inflammatory mediators and bacterial byproducts, may leach out through the apex,

teral and accessory canals, as wel l as the dentinal tubules, triggering an inflammatory response in theinclud ing a n early expression of antige n presentation.'

endodontal bacterial disorders are anaerobic mixed infections. In general as well as inicular cases, th is has been evident by f ind ing extensive bacterial colonisation of periodonta l pocket s and

root canals time and again.lesions are often ini t ially not clin ically visible or are accompanied by non-specific discomfort, such as

nsitiv ity when biting. Sometimes this may lead to fistula formation or an abscess. The diagnosis of perio-endooften results from coincidental findings, e.g. due to co nspicuous radiograph results and in particular due

significantly increased exploratory depths at one particular aspect of a tooth .most commonly used classification was given by Simon, Glick and Frank in 1972 According to this

perio-endo lesions can be classified into:1. Primary endodontic lesion2. Primary periodontal lesion3. Primary endodontic lesion with secondary periodontal involvement4. Pr imary periodontal lesion with secondary endodontic involvement5. True combined lesion

of a chronic apical lesion in a tooth with a necrotic pulp may drain coronally through th ental ligament into the gingiva l su lcus. This condition may clinically mimic a peri odonta l abscess. Primary

lesions usua lly heal follow ing root canal treatment. The sin us tract extending into the gingival sulcusarea disappears at an early stage once the affected pulp has been removed and the root canals have

well cleaned, sh aped and obturated. If, after a period of time, a suppurating primary endodontic diseasemains untreated, it may then become secondarily involved with marginal periodontal breakdown . Plaque

gingival margin of the sinus tract and leads to marginal per iodontitis. The t ooth subsequent lyboth endodontic and periodonta l treatment. Primary endodontic lesions with secondary periodonta l

should fi rst be treated with endodontic therapy followed by periodontal therapy. 'This reduces the

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potential risk of introducing bacteria and their by-products during the initial healing phase. If the endodonticis adequate, the prognosis depends on the severity of the marginal periodontal damage and the

efficacy of the periodontal treatment. Wi t h endodontic treatment alone, only part of the lesion wi l l heal to thelevel ofthe secondary periodontal lesion.While scaling and root planing remain the initial t reatment modalities in periodontal therapy, subgingivalcurettage can be used as an adjunct along with routine endodontic treatment for treatment of his malady.CASE REPORT

34-year-old female patient reported to the outpatient Department of SGT Dental College, Hospital andResearch Institute, Gurgaon with the chief complaint of pain for the last f ifteen days and a swelling since two

the lower right back region of the jaw. Patient did not give any releva nt medical history and there were nounderlying systemic conditions .

intraoral examination, revealed grossly carious 45 along with an intraoral swelling present in relation with 45 .10PA also showed widening of periodontal ligament space in relation wi th the mesial

root and radiolucency in the furcation area. (Fig 1)(Fig 1) (Fig 2)

The horizontal probing depth (HPD) with Naber's probe and vertical probing depth (VPD) with the UNC-15 probemeasured which were found to be 6 mm and 7 mm, respectively.

c treatment was taken up first under Local Anesthesia using Xylocaine with Adrenaline 1:200,000.were prepared.Cleaning and shaping of the canals was done w ith 5.25 sodium hypochlorite

and a single sitting Root Canal Treatment was completed and a temporary dressing was placed (Fig 2).F ig 3) (Fig 4) (FigS)

followed by Subgingival scafing along with subgingival curettage being performed in the same sitting.Fig 3) The patient was prescribed Ofloxacilin+ Ornidazole SOOmg B.D. for S days along with Ibuprofen 400 mg

for 5 days .she was advised proper plaque control, using 0.2 chlorhexidine mouthwash twice daily for t woweek post operatively there was complete resolution of the abscess and a reduced probing dept h r

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Fig:4) A post- operative 10PA X-ray revea led decreased radiolucency and bone fill in the fu rcation area inone week after the combined perio-endo treatment.(Fig: 5)

ISCUSSION:ndo-perio lesions can persist if not treated properly. To obtain excellent results patient's case history with al l

ibl e routes, an accurate diagnosis and correct treatment plan are necessary:Based on treatment plan,(1988) classified endo-perio lesions into 3 types:

pe 1- Requ iri ng endodontic treatment only;- Requiring periodontal treatment only and;

pe 3 - Requiring combined endo-perio treatment. a consequence of the sha red root and anatomically predetermined connect ion paths between the

and the endodontium , a bacter ial infection originating in one of these tis sues may transfer to thehe r Endo-Perio lesion always poses a cha llenge to the cl inician for correct diagnosis and treatment planning.

term prognosis after t reatment of perio-endo lesions is determined by correct pr imary diagnosis andful endodontic treatment, followed by periodontal treatment. It is imperative that both endodontic lesionperiodonta Ilesion be addressed individually and sequentially.

USIONthis case performing endodontic- periodontal treatment of the tooth sequentially the lesion reduced and

com plete ly. Hence this case report demonstrates th e nature of periodonta l lesion as a seconda ryto an origina Ily endodont ic lesion involving the tooth. In th s case both endodontic and periodonta l

t men ts were carried out sequentially in the same appointment resulting in shorter chair side time,need for a second separate appoint ment for periodontal surg ica l procedures. Thus, t his line of

may hold better prospect sof treating endodontic periodontal lesions in a shorter time.IBLIOGRAPHY

American Academy of Periodontology. International workshop for a classification of per iodontal diseasesand conditions. Ann PeriodontoI1999;4:1 -112 .Th e pulpal pocket approach: Retrograde Periodontitis . Simring M, Goldberg M . J PeriodontoI1964:35:22-48The densi ty and branching of dentinal t ubu les in human teeth. Mjo r lA, Nordahl . Arch Ora l Bioi 1996:41:401- 412.Shetty A, Ramachandra BK, Shubhashini NS, Anjali K Niharika J Diode Laser Assisted Management ofEndo-perio Les ion in Maxilla ry inc isor using LANAP: A Case Report. Internation l ntistry S 2010;12: 38-43.Kipioti A, Nakou M Legakis N, Mitsis F Microbio logica l fi nd ings of infected root cana ls and adjacent

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