endoperio inter relation presentation

7/28/2019 EndoPerio Inter relation Presentation

http://slidepdf.com/reader/full/endoperio-inter-relation-presentation 1/102



Endodontic Periodontic

Considerationspresent

ed by:

Mashael Foudah



Endodontic Periodontic

Considerations

presented by:

Mashael Foudah



Relationship between endodontics &periodontics

Effect of endodontics on

periodontics

Effect of periodontics onendodntics

Classification of endo-perio lesionsDiagnosis

Treatment & prognosis



Endodontic–periodontallesions present challenges to

the clinician as far asdiagnosis, prognosis and

treatment.



The dentalpulp and

periodontaltissues are

closely related.three main

avenues forexchange ofinfectiouselements

between thetwo

compartmentsare created by :



De Deus 1975Vertucci 2005

(1) dentinal tubules(2) lateral and accessory canals(3) the apical foramina

+ Non-physiologic

Pathways



Endodontic disease and theperiodontium



Developmental Trauma Iatrogenic



Developmental

Trauma

Iatrogenic



-4- Inadequate endodontic treatment

- 3- Coronal leakage

- 2- Trauma

- 6- ResorptionsNon-infective infective

- 5- Perforations

- 1- Developmental malformations



-4- Inadequate endodontic treatment

- 3- Coronal leakage- 2- Trauma

- 6- ResorptionsNon-infective infective

Transient

Pressure-induced Chemical-induced

Replacement

Extracanal invasive

- 5- Perforations

- 1- Developmental malformations

Internal

External



PIRR EIRR

Andreasen (1981) classification:

* Replacement resorption* Surface resorption

* Inflammatory resorption



PIRR

EIRR

= Transient

= Extracanal invasive

* Surface resorption

= External



-1-Provide a nidus for accumulationof bacterial biofilm and an avenue

for the progression of periodontaldisease that may also affect thepulp.

PGG



concussion

SubluxtionluxationAvulsion

Intrusion

-2-Trauma



Vertical root fracture



1. loss of tooth structure and loss of fracture resistanceafter overzealous root canal preparation and subsequent

restorative procedures leaving thin dentin walls.

2. Notches, ledges, and cracks induced by root canalpreparation, root canal filling procedures, and seating

of threaded pins and posts.

3. teeth serving as terminal abutments in cantilever

bridges



Molars and premolars appear moreoften affected than incisors and canines

Clinical signs and symptoms

associated with vertical rootfractures vary hugely



- pronounced pain and abscess

formationtenderness on mastication with

mild dull pain and discomfort

- Sinus tracts may emerge- narrow, local deep periodontal

pocket

or



Radiographic signs:

- Lateral radiolucency along oneor both of the lateral root surfaces

- Thin halo-like apical radiolucency

- Widening of the PDL



Often the diagnosis of a verticalroot fracture has to be confirmed

by surgical exposure



Treatment:

- There are reports of successful management offractured teeth by re-attaching the fragments after

extraction followed by re-implantation.

- Fractured teeth are normally candidates forextraction.

- In multi-rooted teeth a treatment alternative ishemisection.



-3-Root canals may become

recontaminated by microorganismsdue to delay in placement of acoronal restoration and fracture

of the coronal restoration and/orthe tooth

Leakage



-4-Poor endodontic treatment allowscanal re-infection and treatment

failure. Endodontic failures can betreated either by orthograde orretrograde retreatment techniques.

Poor RCT



-5-Root perforations may resultfrom:

extensive carious lesions

resorptionduring RCT or post preparation

Perforations



prognosis of root perforationsdepends on:

*size

*location*time of diagnosis and treatment*degree of periodontal damage

*sealing ability and biocompatibility of the repairmaterial



MTA, Super EBA, Cavit , IRM,glass ionomer cements,composites, and amalgam

*controlled root extrusion*



Transient (Remodeling) rootresorption:

is a reparative process that

occurs in response to minor

trauma to the normal functioningteeth.

-6-

Resorptions



Pressure-induced

. Succedaneous teeth

. Impacted teeth. Expanding lesions. Iatrogenic pressure, such as

excessive orthodontic movements



Chmeical-induced:

intracoronal bleaching withhighly concentrated oxiding

agents.



Replacement root resorption:

occurs following extensive necrosisof the periodontal ligament with

formation of bone onto a denuded area of the root surface.

This condition is most often seenas a complication of luxation and

avulsion injuries.

E t l i i



Extracanal invasive:

uncommon form of rootresorption.characterized by its cervical

location, and invasive nature.There may be no signs or symptoms

unless the resorption is associated with pulpal or periodontal infection.

Heithersay GS. 1999



The etiology of invasive cervicalresorption is not fully understood.

but, predisposing factors like

traumatic injuries, orthodontictreatment, and intracoronalbleaching may be associated.



- Surgical exposure and removal of

the granulation tissue, filling thedefect followed by re-suturing theflap.

"apically"

- Orthodontic extrusion of the tooth.

- GTR has also been advocated



External Resorption

caused by stimuli such as:

pulpal and/or sulcular infection

traumatic displacement injuries

tumors

cysts

certain systemic diseases



It can usually be stopped byfocusing the treatment on the

endodontic infection



Internal Resorption

The etiology of this type of rootresorption is usually trauma.

Extreme heat was suggested as apossible cause.



Removal of the inflammed pulpaltissue and obturation of the rootcanal system is the treatment of

choice

P i d t l di d th l



The effect of periodontal inflammation on the pulp iscontroversial. It has been suggested that periodontaldisease has no effect on the pulp before it involves

the apex. On the other hand, several studies suggested

that the effect of periodontal disease on the pulp isdegenerative.

Periodontal disease and the pulp

Teeth with caries or restorations that also haveperiodontal disease have more atrophic pulps thanteeth with caries or restorations but no periodontal

disease.



scaling, curettage as well as periodontal surgery

may not induce severe inflammatory changes ofthe pulp

Bergenholtz G and Lindhe J. 1978

The effect of periodontal treatment on the

pulp



Pathogenesis

Living pathogens



Pathogenesis

Living pathogensNon- living pathogenes



BacteriaFungiViruses

Biofilm



A.a

T.f

E.corrodens



~ HSV~ CMV

~ EBV

C. albicans



Foreign bodies(food,calculus, resto.)



Classification



Acute exacerbation of achronic AP on a tooth with a

necrotic pulp to drain throughthe PDL into sulcus mimickinga periodontal abscess, a deep

periodontal pocket or aGrade III furcation in multi-rooted teeth

Primary Endo



Primary Perio

It is the result of progressionof chronic periodontitis

apically along the rootsurface with wide generalized pockets.



Primary Endo withsecondary Perio

When primary endodontic diseaseremains untreated.

Plaque forms at the gingival

margin of the sinus tract and leads to plaque-induced periodontitis in the area



Apical progression of

a periodontal pocketcontinues until theapical tissues are

involved via theapical foramen

Primary Perio withsecondary Endo



Concomitant Lesion

Concomitant endo-perio lesionis an additional classification

that has been proposed todescribe the presence of endoand perio disease as two

separate and distinct entities



True Combined Lesion

True combined endo/perio diseaseoccurs less frequently than other

endo/perio problems



Diagnosis



"Swelling, erythema, sinus/fistula,fracture & any etiologic orcontributing factors"

Inspection



Swelling caused by endodontic

infections often occurs in themucobuccal fold or spreads to thefascial planes.

Swelling associated with periodontal

problems is found in the KAG and rarely spreads beyond themucogingival line.



Palpation



Percussion



When a periodontal abscess is

present, these clinical entities may bepositive.

A tooth with an endodontic problemusually produces tenderness and pain

on percussion and palpation.



Mobility



In the acute stage of anendodontic infection,mobilityinvolves a single tooth.

Generalized mobility suggests

periodontal or occlusal origin.



Ice test

Heat test



Hot gutta-percha applied to the tooth coated with

petroleum jelly to preventsticking to the tooth

surface.

If a crown is present, a

rotating rubberprophylaxis cup can berun on a dried tooth to

create heat.



EPT

f



e.g: Laser Doppler Flowmetry

Blood flow test



Cavity test

Preparation of a test cavity should be done without anesthesia.

A small access preparation ismade through a crown or through

the enamel to determine whethervitality is present in the pulp.



Probing

S t



Sinus tracing



Dx:- Endodontic lesion

-Periodontitis

- Vertical root fracture- Perforation

C k & f t



Craks & fractures

Aided inspection



Transillumination

dyes



y

Bite test



Radiographs

Periodontal and endodontic problems canradiographically mimic

each other;therefore pulptesting and periodontalprobing must be used

along with the radiograph.



Treatment&Prognosis



1ry endo 1ry perio



y y

sequelae-Necrotic pulp with a chronic AP-Draining sinus tract

-Swelling in the mucobuccal fold is pathognomonic.

-Chronic in nature and oftenobserved on other teeth

-Minimal or no pain

Dx

-Negative pulp vitality tests

-Periodontal probing is withinnormal limits

-sinus tracing

-Probing

-Plaque & calculus-Vital pulp

Tx NSRCT Peiodontal Tx

Px Excellent Dependent on the CAL

1ry endo\2ry perio 1ry perio\2ry endo



sequelae plaque and calculus often form

in the draining sinus tract

-Retro infection of the pulptissue may occur

- severe pain

Dx

-Pulp vitality tests are negative

-plaque and calculus in the pocket

-Probing "generalized

periodontitis'-Pulp vitality test results can be

mixed

Tx-NSRCT

-Perio.Tx

Perio. Tx + RCT

PxExcellent for endo.

case dependent for perio.

Depends on the periodontal

condition & Tx

True combined Concomitant



sequelea-Pulpal and periodontal pathoses develop

independently and unite

-Significant periodontalinvolvement

Pulpal lesion separate from the

periodontal lesion BUT occurring at the

same time

Dx

-Different Diagnostic methods for pulp &

periodontium

D.D:vertical root fracture

perforationsresorption

Thorough clinical and radiographicexamination

Tx

-Good conservative NSRCT.

- Periodontal therapy can be performed

before, during, or immediately after the

endodontic treatment.

-Hemisection or root resection.

-SRCT

-Good conservative NSRCT.

- Periodontal therapy can be performed

before, during, or immediately after the

endodontic treatment.

-Hemisection or root resection.

-SRCT

Px Dependent on the periodontal condition. Dependent on the periodontal condition.

References



- Periodontics: Medicine, Surgery and Implants, 1eLouis F. Rose , Brian Mealey , Robert Genco

- Clinical Periodontology and Implant Dentistry, 5eJan Lindhe, Niklaus P. Lang, Thorkild Karring

- Diagnosis, prognosis and decision-making in the

treatmentof combined periodontal-endodontic lesionsby Ilan Rotstein & James H. S. Simon "2000"

- The endo-perio lesion: a criticalappraisal of the

disease condition by ILAN ROTSTEIN & JAMES H. SIMON"2006"

Refere es



! ank Y

"

endoperio inter relation presentation

Documents