Endodontic and Periodontal Interrelationship...± Extensive bony radiolucencies (endo + perio), may...
Transcript of Endodontic and Periodontal Interrelationship...± Extensive bony radiolucencies (endo + perio), may...
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Endodontic and Periodontal
Interrelationship
Dr János Vág Phd
Department of Conservative Dentistry
Semmelweis University
Based on
Mahmoud Torabinejad, Richard E. Walton, ENDODONTICS: PRINCIPLES AND PRACTICE 4th edition, Chapter 6
And
Cohen’s Pathways of the Pulp th edition, Chapter 8
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Practical relevance
• Diagnosis: – Pulpitis/necrosis in sound tooth due to periodontal
reason
– Differential diagnosis: • apical abscess vs periodontal abscess
• apical abscess/periodontal abscess vs vertical root fracture
• Prognosis: – Endodontal (well anticipated) and periodontal (less
anticipated)
• Treatment: – Endo + perio
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(Differential) Diagnosis of
endodontic-periodontal lesions
• Subjective Signs and Symptoms
• Clinical findings
– Inspection, Palpation, Percussion
– Sensibility testing
– Pocket probing
• Radiographic findings
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Anatomical background
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Communication between the dental
pulp and the periodontium
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Communication I.
Dentinal tubules
tubules / mm 2
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• Developmental grooves
• Congenital absence of cementum
exposing tubules
• Loss of gingival recession
• Following root planing
Reasons of the Dentin exposure
18%
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Communication II.
Lateral and Accessory Canals
• 2%
• 9%
• 17%
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Identification of the accessory/lateral
canals
• X-ray
– Discrete lateral lesion
– Notch on the lateral surface
– Filling material extrusion
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Communication III.
Apical foramen
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EFFECT OF ENDODONTIC DISEASE
ON THE PERIODONTIUM
• Spreading of the infection
• normal endodontic therapy resulting short term inflammation
• Procedural errors
Perforation: floor, strip, root
Inadvertent irrigation
obturation
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EFFECT OF PERIODONTAL
DISEASE ON THE PULP
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CLASSIFICATION AND DIFFERENTIAL
DIAGNOSIS
True Combined lesion
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Primary Endodontic Disease Etiology:
caries, restorative manipulations, traumatic injury
Clinical Findings
refer to (pulpal)/ periapical pathosis
Pulp Tests
completely absent (necrosis, except multirooted teeth)
Probing
normal sulcus or narrow drainage to the sulcus
Radiographic Findings
Radiolucency: apical, lateral, furcation
Prognosis/treatment
good after rct
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Treatment of the primary endodontal
disease
Ext. RCT
Due to the reccurent pain
and suppuration
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Primary Endodontic Disease with Secondary
Periodontal Involvement
Etiology
If the primary endodontic disease is not treated properly
Clinical Findings
Plaque and calculus at the gingival margin due to the drainage
Adjacent teeth are not necessarily involved.
Pulp Tests
Pulp tests will usually reveal absence of response (necrosis)
Probing
A solitary but wider pocket extending toward the apex
‼Differential Diagnosis: vertical fracture
Radiographic Findings
Radiolucency: apical, lateral, furcation
Widening of the PDL space extending from apical to cervical
Angular defects can be seen
Prognosis/treatment
rct may enough but reevaluation of periodontal status in 2 to 3
months, if necessary periodontal therapy can occur
If it is not treated
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Primary Endodontic Disease with Secondary
Periodontal Involvement
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Primary Endodontic Disease with Secondary
Periodontal Involvement
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Primary Periodontal Disease
Radiographic Findings:
Gradually lost marginal bone: horizontal or vertical (angular) bone defect, furcation
lesion
Pulp Tests
normal
Prognosis/treatments
The prognosis depends on the stage of periodontal disease and the efficacy of
periodontal treatment.
Periodontal therapy, Extraction, hemisection
Probing
wide pockets that do not
necessarily
extend toward the apex.
Progression of the periodontal disease
Clinical Findings
Attachment loss, gingival
bleeding, tooth mobility,
calculus, plaque
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Radiographic view of periodontal
disease
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Primary perio versus primary endo
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Primary Periodontal Disease with Secondary
Endodontic Involvement
Clinical Findings – History of extensive periodontal disease, generalized
periodontitis is common but not always
– pain originating from an inflamed pulp are common at the early stages of the disease. As the disease progresses, the pulp is expected to lose its vitality.
Pulp Tests – Abnormal/absence
Probing – wide pocket sometimes extending apically
Radiographic Findings – angular bone loss extend from the cervical region toward the
apex.
Prognosis – In single-rooted teeth, the prognosis is usually poor. -
extraction
– In molar teeth, the prognosis may be better since all the roots may not suffer the same loss of supporting tissues. In such cases, root resection can be considered as a treatment alternative.
Vascular
supply
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Primary Periodontal Disease with Secondary
Endodontal Involvement
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Primary Periodontal Disease with Secondary
Endodontic Involvement
deep periodontal pocket at the 17 induced pulp necrosis
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Clinical and Radiographic findings
no sign of generalized periodontitis
pulp test:
RCT usually
enough RCT + surgery
Non-vital:
Primary endo + sec. perio
Vital:
Primary perio + sec. endo
Localized periodontitis at 36 due to the inadequate
contact point
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Primary Endodontic Disease with Secondary
Periodontal Involvement
hemisection & periosurgery prosthetic rehab.
rct
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True Combined Diseases
Clinical Findings – History of extensive periodontal disease, generalized
periodontitis is common but not always
– severe attachment loss
Pulp Tests – absence
Probing – wide and conical pocket
Radiographic Findings – Extensive bony radiolucencies (endo + perio), may or may
not communicate.
– may be similar to that of a vertically fractured tooth
Prognosis – periapical healing may be anticipated after successful
endodontic treatment.
– The periodontal healing depends on the severity of the condition.
True Combined lesion
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True Combined Diseases
Generalized periodontitis and incomplete rct in 15&16
rct & pros.rehab.
Perio-surgery
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e.g. Rapidly developed periodontal
abscess. Both molars were free of pulpal
disease
e.g. acute exacerbation
of chronic apical lesion
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furcation lesion hemisection/bicuspidization post&core, PFG crown
rct with strip perforation, MTA
Coronal leakage, pulp necrosis, periapical
radiolucency, no periodontitis
sinus tract at the distal root further marginal bone loss
inspite of the curettage Vertical fracture
Primary Endodontic Disease with Secondary
Periodontal Involvement
Procedural errors in rct
2 y
ea
rs l
ate
r:
1 y
ea
r la
ter:
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2 hét
Treatment: curettage and monitoring
3 év
Differential Diagnosis of
Primary endo with secondary perio versus vertical tooth fracture
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Primary endodontic
origin
Primary periodontal
origin
Combined
Pain, inflammation Acut chronic ±
Extensive caries or
restorations
+ - ±
Sensibility test - + -
Percussion ± especially vertical ± especially lateral ±
Probing defect narrow wide -
Angular or vertical
bone loss
- + +
Apical bone loss + - ±
Nature of treatment Root canal therapy Periodontal therapy Root canal and
periodontal
therapy
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Take home messages
• History
• X-ray
• Follow up
• The secundary disease develop due to the
non-treated primary one