Periodontitis Associated With Endodontic Lesions Question And Answers

Periodontitis Associated With Endodontic Lesions 

• The dental pulp and periodontal tissues are closely related. The pulp originates from the dental papilla and the periodontal ligament from the dental follicle and is separated by Hertwig’s epithelial root sheath.
• Infection from one of the components can infect the other through communication channels between them.

Question 1. What are the pathways of communication between pulp and periodontium?
Answer:

Ways Of Communication: Pulp communicates with periodontium through apical foramen, lateral and accessory canals, and dentinal tubules, and certain anatomic variations like palatogingival groove alterations of cementum during periodontal therapy may result in communication between pulp and periodontium through the exposed dentinal tubules.

Apical Foramen

• The apical foramen is the main pathway between pulp space and the periodontal ligament. Movement of irritants from the necrotic pulp through the apical foramen into periapical periodontal tissues initiates an inflmmatory response.
• This can further lead to the destruction of periodontal ligament and the resorption of hard tissues. Periodontal disease can affect pulp tissue if plaque covers the entire length of the root and reaches the apical foramen.

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Lateral Or Accessory Canals

• A lateral canal is located at approximately perpendicular to the main root canals while accessory canals are braces of from the main root canal, usually in the apical region of the root.
• Generally, lateral and accessory canals are noticed in greater numbers in posterior teeth of younger patients.
• Bacteria and their toxins present in the necrotic pulp tissue can induce periodontal inflammation through patent lateral and accessory canals.
• Similarly, periodontal infection located adjacent to patent lateral canals can lead to pathologic changes in pulp such as atrophy, calcification, and inflammation in that order.

Dentinal Tubules

• Patent tubules extend from pulp to dentin enamel junction and cement dentinal junction.
• With age, chronic irritation can lead to calcification of these tubules and patency decreases.
• Cementum covers the root dentin and tubules which acts as an effective barrier against bacteria and their toxins.
• Periodontal procedures like scaling and root planning can lead to the removal of cementum and exposure of dentinal tubules to the oral cavity.
• These open tubules could carry toxins produced during pulpal or periodontal disease in either direction.

Palatogingival Groove

• It is a morphological defect that predominantly occurs in maxillary incisors and can be a predisposing factor for the onset of inflammatory processes.
• The predominance of the palatal-gingival groove in the maxillary lateral incisors suggests the possibility that the groove results from an undesirable position of the lateral incisor during the period of maxillary growth.
• The tooth, in its germ phase, becomes surrounded by the central incisors, canine, and first premolar which are in a comparatively more advanced phase of development.
• Mineralization of the crown of the maxillary lateral incisor starts later, compared with the others, making this germ, under given situations, highly susceptible to folding.
• The palatogingival groove starts at the junction of the cingulum with one of the lateral marginal ridges and continues apically along the proximal surface of the root, and in some cases extends till the apex.
• Variations in groove depth can make a communication pathway possible with pulp space.
• The funnel shape of the palate-gingival groove promotes the accumulation of plaque and calculus which is difficult to remove for both patient and dentist.
• Bacteria from the gingival sulcus enter the groove and are protected from the host’s immune response. This can lead to endo-period lesions of primary periodontal origin.

Question 2. Classify endo-period lesions. Describe their clinical and radiographic features. Add a note on their management.
Answer:

1. A primary endodontic lesion with secondary periodontal involvement (also known as retrograde Periodontitis)
2. A primary periodontal lesion with secondary endodontic involvement (also known as retrograde pulpitis)
3. True combined lesion.

Question 3. Describe the diagnosis of endo-period lesions.
Answer:

Primary Endodontic with Secondary Periodontal Lesion

• In this condition, the root canal is infected as a result of dental caries, trauma, etc. resulting in nonvital teeth.
• Long-standing infection from the pulp can extend to the periodontal ligament, resulting in the destruction of supporting structures of the teeth and a draining sinus through the gingival sulcus.
• The true source of the sinus can be diagnosed by placing a gutta percha point through the tract and radiographed it.
• Intra-oral periapical radiographs would demonstrate the bone destruction in relation to only non-vital tooth and it extends from apical to the cervical region.

The vitality of the teeth may be determined by the following tests:

• Cold and heat test
  • Ice sticks, carbon dioxide ice (dry ice), and ethyl chloride are generally used methods for cold testing.
  • Alternatively, a heated instrument, gutta-percha sticks can be used. The absence of response may indicate pulpal death.
• Electrical test
  • The device used are battery powered which deliver a direct current of high frequency controlled by a rheostat. Newer devices are available with a digital display.
  • Painful response indicates pulp vitality and absence of it indicates non-vital pulp.

Primary Periodontal Lesion with Secondary Endodontic Involvement

• The progression of periodontal tissue apically, may result in the pulp becoming necrotic, due to the spread of infection into the pulp from the periodontium via apical foramen or lateral canals.
• In this condition, the involved tooth is non-vital along with a draining sinus and a periodontal pocket, but the periodontal pocket may also be present in relation to other vital teeth as well.
• Intra-oral periapical radiographs of periodontal and endodontic lesions can mimic each other.
• The bone destruction in periodontal pathology is angular and extends from the cervical to the apical direction. Bone loss is usually generalized and not limited to one tooth.

Combined Lesion: A truly combined lesion occurs by the extension of an endodontic lesion into an existing periodontal pocket, demonstrating clinical features of both diseases.

Question 4. Write a note on the management of endo-period lesions.
Answer:

• The treatment protocol is to treat the primary disease (either pulpal or periodontal) first if the second disease is in its initial stage.
• When the second disease is established and chronic both primary and secondary disease must be treated.
• Endodontic therapy precedes periodontal therapy if the tooth is non-vital. In a primary endodontic lesion, the periodontal lesion may heal following endodontic therapy.
• Persistent periodontal lesion may have to be treated with periodontal therapy.
• The primary periodontal lesion may be managed by periodontal therapy alone (non-surgical or surgical) if the tooth is vital.
• If the involved teeth is non-vital, the lesion is first managed by endodontic therapy followed by periodontal therapy.
• Combined periodontal and endodontic lesions are first managed by endodontic therapy and then followed by periodontal therapy.

Endo-Perio Lesions Conclusion

• Endo-period lesions have to be categorized according to their clinical and etiological basis so as to institute proper management.
• Recent evidence seems to suggest that it is advisable to treat the primary origin and then wait before the secondary involvement is treated.
• In case of true combined lesions, a rule of the thumb is that the endodontic lesion is treated prior to periodontal management.