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Periodontal therapy deals with many aspects of the supporting structures, including the prevention and repair of lesions of the gingival sulcus. Endodontics deals primarily with disease of the pulp and periapical tissues. The success of both periodontal and endodontic therapy depends on the elimination of both disease processes, whether they exist separately or as a combined lesion.
The tooth, the pulp tissue within it and its supporting structures should be viewed as one biologic unit. The interrelationship of these structures influences each other during health, function and disease. The interrelationship between periodontal and endodontic diseases has aroused much speculation, confusion and controversy.
Anatomical pathways
The most important among the anatomical pathways are vascular pathways such as the Apical foramen and the Lateral canals and Tubular pathways. Apical Foramen: The pulp and periodontal tissues are derived from highly vascular mesenchymal tissues of the tooth germ. The blood supply maintains a connection between these tissues via the apical foramen and lateral canals throughout the development of the tooth. The apical foramen is the principal and most direct route of communication between the periodontium and the pulp.
incorporated, either due to dentine formation around existing blood vessels or breaks in the continuity of the Hertwigs root sheath, to become lateral or accessory canals.
Lateral canals normally harbor connective tissue and vessels
which connect the circulating system of the pulp with that of the periodontal ligament.
The possible anatomic pathways of communication between the pulp and the periodontium; apical foramen, lateral canals and dentinal tubules
Diagrammatic representation of the etiopathogenesis of endo perio lesions. (Modified from Rotstein I, Simon JHS. Diagnosis, prognosis and decision making in the treatment of combined periodontal-endodontic lesions. Periodontology 2000 2004:34;265-303)
Diagrammatic representation of possible endo perio problems based on the classification of Simon JH, Glick DH, Frank JL 26, 27
An acute exacerbation of a chronic apical lesion on a tooth with a necrotic pulp may drain coronally through the periodontal ligament into the gingival sulcus. This condition may clinically mimic the presence of a periodontal abscess. In reality, however, it would be a sinus tract originating from the pulp that opens into the periodontal ligament. Primary endodontic lesions usually heal following root canal therapy.
may become secondarily involved with periodontal breakdown. Plaque accumulation at the gingival margin of the sinus tract leads to plaque induced periodontitis in this area. Root perforation during RCT, or where pins and posts may have been misplaced during restoration of the crown. Symptoms may be acute, with periodontal abscess formation associated with pain, swelling, pus or exudates, pocket formation, and tooth mobility. Root fractures
Whether there is a functional need for the tooth, whether the tooth is restorable after the lesion has been treated and whether the patient is suitable for a lengthy, costly and invasive treatment are factors that should be taken into consideration.
When the pulp is nonvital and infected, conventional endodontic therapy alone will resolve the lesion. Surgical endodontic therapy is not necessary, even in the presence of large periradicular radiolucencies and periodontal abscesses. If primary endodontic lesions persist, despite extensive endodontic treatment, the lesion may have secondary periodontal involvement or it may be a true combined lesion.
instituted immediately and the cleaned and shaped root canal is filled with calcium hydroxide paste, which has bactericidal, anti inflammatory and proteolytic property, inhibiting resorption and favoring repair. It also inhibits periodontal contamination of instrumented canals via patent channels connecting the pulp and periodontium before periodontal treatment removes the contaminants. Treatment results should be evaluated after two to three months and only then should periodontal treatment be considered. This allows sufficient time for initial tissue healing and better assessment of the periodontal condition. Prognosis of primary endodontic disease with secondary periodontal involvement depends on periodontal treatment and patient response
involvement may present as reversible pulpal hypersensitivity, which can be treated purely by periodontal therapy. Periodontal treatment removes noxious stimuli, and secondary mineralization of dentinal tubules allows the resolution of hypersensitivity. If pulpal inflammation is irreversible, root canal treatment is carried out, followed by periodontal treatment. In some cases, periodontal surgical intervention is advantageous. The prognosis of periodontal lesions is poorer than endodontic lesions and is dependent on the apical extensions of the lesion. A favorable endodontic prognosis is obtained only when the tooth is in a closed and protected environment. As the lesion advances the prognosis approaches that of a true combined lesion
endodontic lesions with secondary periodontal involvement. Prior to surgery, palliative periodontal therapy should be completed and root canal treatment carried out on the roots to be saved. The prognosis of a true combined perio-endo lesion is often poor or even hopeless, especially when periodontal lesions are chronic, with extensive loss of attachment. Root amputation, hemisection or bicuspidization may allow the root configurations to be changed sufficiently for a part of the root structure to be saved. The prognosis of an affected tooth can also be improved by increasing bony support, which can be achieved by bone grafting and guided tissue regeneration.
atrophic and other degenerative changes like reduction in the number of pulp cells, dystrophic mineralization, fibrosis, reparative dentin formation, inflammation and resorption.
Case report
Unusual endo-perio lesion: A Case Report Gauri Srindhi, Srinidhi S.R. INTERNATIONAL JOURNAL OF DENTAL CLINICS 2011:3(1):87-89
Endo-perio lesions primarily occur by way of the intimate anatomic and vascular connections between the pulp and the periodontium. Diagnosis is often challenging because these diseases have been primarily studied as separate entities and may mimic clinical characteristics of each other. When a primarily endodontic lesion changes into a secondary periodontal lesion the resultant clinical features become even more bizarre. This may delay the diagnosis and hence the correct treatment. The case described here also aims at showing the limitations of the traditional diagnostic techniques that are used for diagnosing endo-perio lesion.
Introduction
The intimate anatomic and vascular connection between the pulp and the periodontium is studied in great detail by the periodontists and the endodontists. These lesions initially present themselves as just an endodontic lesion and later slowly start showing signs for periodontal involvement. This type of lesion is called by Simon as Class III type of endo-perio lesion. Periodontal involvement is only for establishing as easy route for drainage of endodontic pathology.
There are many cases documented about established secondary periodontal and primary endodontic lesions but few of them document the events that took place during the conversion, when diagnosis is most confusing. Here is a case that presented itself initially as an endodontic emergency and the bizarre clinical featuresdelayed the correct treatment for several weeks. Its conversion into a secondary periodontic lesion helped in the final diagnosis and correct treatment.
Case Report
A 35 years old healthy female patient reported with the chief complaint of acute pain and swelling with respect to 46 . Patient gave a history that the tooth was treated endodontically and a full coverage metallic restoration was placed on it about a month back. The tooth was asymptomatic for about a month post treatment and suddenly started paining couple of days earlier. The pain was acute and throbbing in nature. Extra oral examination showed a slight swelling in the right mandibular area overlying the tooth and the submandibular lymph nodes were palpable and tender. Intraorally, there was swelling in the vestibular region in relation to 46 and the gingiva in the area was healthy. There were no periodontal pockets with respect to any of the teeth in area. The occlusion was atraumatic. The tooth was severely tender on percussion. It had a metal full coverage crown and the crown seemed normal in all the aspects
The kind of pain the patient had and the signs suggested it was periapical pathology. An IOPA was taken to see the periapical condition and to rule out any inadequacy with the endo treatment. The IOPA did not show any pathology like periapical widening or root fracture and the obturation was satisfactory. The occlusion, contour, margins of the full coverage crown were examined and were considered to be essentially normal.
Treatment
It was decided that in absence of any evidence to suggest otherwise, it is better to treat this injury as a traumatic one. Disturbing a recently placed crown on an adequately endodontically treated tooth for examining the structures underneath without sufficient evidence could not be justified. Hence we drained the lesion by an incision on the most fluctuant part in the vestibule and discharged the patient after giving antibiotics and analgesics for three days. It was expected that the lesion will heal if it was due to a single traumatic incident. The patient reported after three days and was asymptomatic. The swelling was gone and the tooth was non tender.
However, the patient reported back after a week with recurrence. The clinical features and the symptoms were exactly similar to the first incidence. The only difference was a little increase in the probing depth of the gingival sulcus at the mesial root on the buccal aspect. Still the probing depth was within physiologically normal limit (i.e. less than 3mm) and there was no communication with the periapical swelling through the sulcus. Even during the recurrence the clinical signs and symptoms were completely nonspecific. The treatment given was necessarily the same as the First time, i.e. incision, drainage with antibiotics and analgesics. The lesion responded to the treatment given.
The patient reported back after another week with third recurrence. Clinical examination revealed that the probing depth with respect to the tooth in the site in question was increased and now an explorer could enter the furcation area from buccal aspect easily. An IOPA taken with a gutta-percha point in the thin periodontal pocket showed the lesion was in relation to the mesial root of the molar. It also showed radiolucency in furcation. This necessitated an exploratory surgical approach to diagnose the exact cause of the problem. The situation was explained to the patient and consent obtained for the same.
Surgical exploration
A 15 No. B.P. blade was used to take a crevicular incision with respect to the buccal aspect of 45, 46 and 47. An envelope flap was elevated and the area underneath was examined. It was noticed that the only tooth involved with periodontal bone loss was 46 and that too only its mesiobuccal aspect and the buccal furcation. The interdental areas that are known to show the earliest of the periodontitis were healthy. The mesial root showed localized bone loss shaped like a crescent that started on the buccal margin and entered into the furcation. This specific bone loss exposed a small root fracture in the middle one third regions. The patient was explained about the findings and the possibility of sealing the root fracture. The patient opted not to go with any further treatment and decided to get the tooth extracted.
Discussion
Cases of root fracture are difficult to diagnose in the initial stage as they do not give rise to any radiological findings nor any specific clinical signs. Many a times only a process of elimination of other etiologies brings us to the correct diagnosis. The other possibilities that need to be eliminated are: failure of endodontic treatment, an acute periodontal abscess, trauma from occlusion and crown fracture. Swelling in an endodontically treated tooth can be due to various reasons like missed canals, inadequate obturation, perforations and crown or root fracture.
In this case, the endodontic treatment procedure was uneventful and the obturation was satisfactory. Furthermore, a full metal coverage crown was placed immediately after the endodontic treatment. So it eliminated the possibility of crown fracture. An acute periodontal abscess normally occurs in the cervical or the middle third of the root. The swelling usually communicates with the gingival sulcus or pocket and drains on dilation of sulcus. A periapical localization of the swelling is unusual to say the least. Also occurrence of acute periodontal abscess in a periodontally healthy mouth and site is uncommon.
Trauma from occlusion can be another reason for having severe pain with respect to a single tooth especially when there is a newly inserted restoration or crown. But the crown was not under traumatic occlusion. No clinical or radiographic signs of trauma from occlusion were observed. Also the relief obtained without adjusting the occlusion is unlikely in a case of trauma from occlusion. Also trauma from occlusion does not give rise to initiation of periodontal pocket the way it was seen in this case.
The only other possibility was a root fracture. As it is documented, a crack on the root is not always evident on the x-ray. The prognosis of a root fracture becomes poorer as we approach the cervical area especially if exposed to oral environment. A root fracture can mimic signs and symptoms of occlusal trauma. Vertical root fractures have contributed to the progression of periodontal destruction in the presence of apparently successful endodontic tooth therapy and overall periodontal site stability.
In this case the initial examination showed no attachment loss over the root fracture. Recurrent abscess formation in the area rapidly resorbed the bone overlying the root crack. This led to periodontal pocketing and furcation involvement to provide an easy route of drainage. Walton et al stated that sometimes the definitive diagnosis of root fracture has to be confirmed by exploratory surgical exposure of the root for direct visual examination.
Another treatment option would have been to try and seal the root crack with MTA or glass ionomer cement and covering the periodontal flap on top with sutures. However, it is stated that no consistently successful techniques have been reported for sealing the fractured root. Also, the patient who had already undergone multiple visits for root canal treatment, full coverage crown and had painful recurrences of periapical swellings thrice and was not ready to accept a treatment plan that was not fool proof. So finally tooth had to be extracted and the extracted tooth showed the crack clearly.
Conclusion
Endo-perio lesions primarily occur by way of the intimate anatomic and vascular connections between the pulp and the periodontium. Diagnosis is often challenging because these diseases have been primarily studied as separate entities and may mimic clinical characteristics of each other. A patient study of behavior of the lesion and a thorough differential diagnosis can help us reach the correct diagnosis.
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