CONTENTS

INTRODUCTION

INTER COMMUNICATION BETWEEN PULPAL AND

PERIODONTAL TISSUE

EFFECT OF PULPAL DISEASES AND ENDODONTIC

PROCEDURES ON PERIODONTIUM

EFFECT OF PERIODONTAL DISEASES AND PROCEDURES ON

PULP

PERIODONTAL EVALUATION

CLASSIFICATION OF PULPO-PERIO LESIONS

o COHEN

o GROSSMAN

o WEINE

CLINICAL FEATURES, DIAGNOSIS, TREATMENT OF

DIFFERENT TYPES OF PULPO – PERIO LESIONS

INFLUENCE OF EXTERNAL ROOT RESORPTION

ALTERNATIVE TREATMENT MODALITIES ;

ENDODONTIC STABILIZERS

DIFFERENTIAL DIAGNOSIS OF PULPAL PERIAPICAL AND

PERIODONTAL LESIONS

ROLE OF ANTIBIOTICS IN THE MANAGEMENT OF ENDO

PERIO LESIONS

REFERENCES

CONCLUSION

INTRODUCTION :

No tooth is an island. A dynamic relationship exists between pulp and

periodontium. A tooth to function efficiently the health and vitality of these

tissues forming a biologic unit is necessary. A close relationship exists

between the disease process of pulp and periodontium which are responsible

for more than 50% of tooth mortality.

As pulp and periodontium share a common nerve, blood and lymphatic

supply, they produce a number of clinical symptoms and radiographic

appearances very puzzling to the diagnostician whether either of them or both

are in diseased state.

A concise knowledge of pulpal and periodontal disease is very much

necessary if the lesion has to be correctly identified and appropriately treated.

Though diagnosis is not always a simple process.

INTERCOMMUNICATION BETWEEN PULPAL AND

PERIODONTAL TISSUE :

The possible channels that lead to the interaction of the disease process

between pulp and periodontium are :

A) Physiologic :

1. Apical foramen

2. Lateral canals

3. Dentinal tubules

4. Periodontal ligament

5. Alveolar bone

6. Neural pathways

7. Vasculolymphatic pathway

B) Iatrogenic :

1. Palatogingival grooves

2. Vertical root fractures

3. Perforations

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APICAL FORAMEN AND LATERAL CANALS :

Apical foramen is the most direct route of communication to the

periodontium. Egress of irritants form necrotic pulps via apical foramen into

periapical tissues initiates an inflammatory destruction of apical PDL and

resorption of bone, cementum and even dentin.

In the event of retro infection where in plaque covers the entire length of

the root, the periodontal disease may lead to pulp necrosis through apical

foramen which is a rare condition.

Lateral and accessory canals mainly in the apical area and in the

furcation of molars also connect the dental pulp with periodontium, which can

carry toxic substances from pulp to periodontium or vice-versa to induce

pathologic changes such as atrophy, calcification, irreversible inflammation

and necrosis of pulp.

DENTINAL TUBULES :

The dentinal tubules with their odontoblastic processes extend from the

pulp-dentin border to the CDJ. They can communicate pulp chamber with

external root surface especially when the cementum is denuded, thus

channelising toxic metabolites during pulp or periodontal disease in both

direction.

PALATOGINGIVAL GROOVES :

These are developmental anomalies of the maxillary incisors with more

incidence among lateral incisors, they usually begin in the central fossa, cross

cingulum and extend apically with varying distances.

Everett and Krammer reported that 0.5% extends till the root apex

contributing to an endodontic pathologic condition.

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PERFORATIONS :

Perforation of root creates a communication between root canal system

and PDL. They occur as a result of over instrumentation of root canal, internal

and external root resorption or caries invading through floor of pulp chamber.

Perforations in the middle or apical 1/3rd of root have greater chance of

healing, closer the perforation to the gingival sulcus particularly in the coronal

3rd of the root or furcation region, the likelihood of apical migration of gingiva

in initiation of periodontal lesion.

VERTICAL ROOT FRACTURE (VRF) :

A VRF can produce a “halo” effect around the tooth radiographically.

Deep periodontal pocket and localized destruction of alveolar bone are often

related to long standing root fractures.

Radiographically mimics profile of occlusal trauma with localized loss

of lamina dura, altered trabecular pattern and widened PDL. The fracture site

provides portal of entry for irritants from root canal to the surrounding PDL.

Vertical root fractures have contributed to progressive periodontal destruction

in the presence of apparently successful endodontic therapy and over all

periodontal site stability.

Effects of Pulpal Disease and Endodontic Procedures on the

Periodontium:

Pulp pathology as a cause of periodontal disease has received much

attention during the last decade. It is important to understand that vital

inflammed pulp will not cause damage to the periodontium; only pulp necrosis

will result in necrotic debris, bacterial by products and other toxic irritants that

exit through apical foramen causing periodontal tissue destruction apically and

potentially migrating towards gingival margin. Simring and Goldberg termed

this “retrograde periodontitis” to differentiate from “marginal periodontitis” in

which the disease proceeds physically from gingival margin toward root apex.

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This inflammation often results in dysfunction of the PDL, resorption of

alveolar bone, cementum and even dentin. The endodontic infection has been

regarded as local modifying risk factor for periodontitis progression if left

untreated.

In a periodontally involved tooth the endodontic pathogen growth,

infectious products and root canal medicaments may aggravate periodontal

pocket formation, bone loss and impair wound healing to further accelerate

periodontal disease development and progression. However nature and extent

of periodontal destruction depends on the virulence of the organism, duration

of disease and host defense mechanism.

Manifestations of Endolesions in Marginal Periodontium from Lateral

Canals :

Inflammatory lesions may develop at the lateral aspects of root from

root canal infection, where the bacterial byproduct reach periodontium through

lateral canals along the lateral aspects of root and into furcation area. This type

of lesion is very rare as the lateral canals, most of them are either blocked and

narrowed by dentin deposition or covered by cementum deposition.

Manifestation of Acute Endodontic Lesions in the Marginal Periodontium

(fig.)

Acute endodontic lesions may destroy and expand into the periodontium

to an extent that apical marginal communication may emerge.

This drainage of endodontic lesion follows one of the two routes.

1. Along the PDL space (PDL fistulation), this results into narrow opening

of the fistula into the gingival sulcus/ pocket which can be readily

probed down to the apex of the tooth where no increased probing depth

exists around the other surfaces of the tooth. In multirooted teeth the

fistulation can drain off into furcation area resembling a thorough and

through furcation defect form periodontal disease.

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2. The lesion can perforate the cortical bone close to the apex and elevate

the soft tissue including periostuem from the bone surface and drains

into gingival sulcus / pocket resulting in wide opening of fistula into

pocket and is most often seen in the buccal aspect of the tooth. Since

the type of fistula is not associated with loss of bone tissue at the inner

walls of the alveolus, as periodontal probe cannot penetrate into the PDL

space.

These acute manifestations of root canal infections can result in rapid

and extensive destruction of attachment apparatus. These lesions heal

following proper endo therapy.

The periodontium regeneration on a pulpless teeth is questionable,

according to Saunders, whereas Diem et al reported that all tissues of

periodontium regenerate after periodontal therapy irrespective of its pulpal

status. It has been suggested that endodontic treatment should occur before

periodontal therapy for successful results.

Endodontic Procedures :

During root canal therapy iatrogenic alterations of periodontium can

occur leading to the development of periodontal lesion.

For Example :

Pulp extirpation may develop an acute inflammatory reaction in

periodontium.

Pushing of root canal debris beyond apex during canal instrumentation.

Over instrumentation and over obturation

Perforation of pulp chamber floor and root during access, cleaning and

shaping and post space preparation

Vertical root fracture during obturation and post placement.

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Effect of Periodontal Disease and Procedures on the Pulp :

Clinically its not uncommon to observe a tooth with advanced

periodontal lesion without any signs of decay being non-vital. Disease form

periodontal pocket can spread to the pulp most commonly through accessory

canals at the furcation and apex of the teeth.

Teeth with large canals and periodontal breakdown extending to the

apex are the teeth more affected.

The pulpal reaction is not only influenced by the stages of periodontal

disease but also by periodontal treatment procedures such as scaling, root

planning and administration of medication.

During deep curettage the blood vessels supplying the pulp via

accessory canals may be damaged. Scaling and root planning removes

cementum resulting in exposing dentinal tubules and sometimes also lateral

canals. These procedures lead to easy entry of irritants through exposed

dentinal tubules and lateral canals on the root surface endangering pulp.

It has been reported that canals of teeth with longstanding periodontal

disease develop fibrosis and became narrower, which suggests reparative

process than inflammatory response.

Although consensus supports the influence that a degenerating or

inflamed effects of periodontium on pulp, not all researchers are in agreement.

Another school of thought says when pathologic changes occur in the

pulp as a result of periodontal disease, the pulp usually does not degenerate as

long as the main canal is not involved, as long as the blood supply through the

apical foramen remains intact, the pulp is capable of withstanding

physiologic insults induced by periodontal disease.

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Periodontal Evaluation :

No dental examination is complete without careful evaluation of teeths

periodontal support. Periodontal probing and recording pocket depths provide

information with respect to possible etiology and prognosis. There is little

question that pulpal necrosis can lead to loss of periodontal support. Whether

periodontal disease can cause pulpal degeneration is a question not clearly

answered. However there is an agreement that potential interaction exists

between pulp and periodontium.

Diagnosis :

For endodontic purpose of a single tooth, probing maybe limited to the

involved tooth and atleast the adjacent teeth.

Periodontal Disease :

Periodontal stability is a basic requirement for any tooth being

considered for endodontic therapy. This stability is determined by the amount

of bony support, health of the support and health of the overlying soft tissue.

Examination alone cannot guarantee the future health of these tissues,

but usually it can determine the existing disease.

Examination :

As part of the examination, probe the sulcus of the tooth in question and

record pocket depth.

Record the mobility of the tooth using a system of 0 to 3.

Grade 0 : Normal mobility (Physiologic)

Grade 1 : Slight mobility

Grade 2 : Marked mobility

Grade 3 : Mobility with depressibility

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Record for

Bleeding on probing

Palatal grooves in single rooted teeth.

Furcas in multirooted teeth.

Other anomalies like enamel projections as they may aggravate gingival

conditions and make for unstable future periodontal health.

Interpretation :

3-5 mm pocket and Grade I mobility – “Moderate Periodontitis’.

When this is found, the entire mouth should be examined of periodontal

disease.

More than 5 mm pocket with or without Grade II/III mobility indicates

“Severe periodontitis”.

Referral to a periodontist must be considered.

Periodontal Pocket :

Presence and distribution on each tooth surface.

Depth

Level of attachment on root

Type of pocket (suprabony / infrabony) should be examined for

periodontal pocket evaluation.

Signs and Symptoms :

Although probing is the only accurate method for detecting pockets.

Clinical signs such as ;

Bluish red marginal gingiva / vertical zone extending form marginal to

attached gingiva.

“Rolled” edge separating gingival margin form tooth surface.

Enlarged edematous gingiva may suggest their presence.

Bleeding, suppuration, loose extruded teeth.

Symptoms :

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Usually painless, but sometimes

Localized or radiating pain or sensation of pressure after eating which

gradually diminishes.

Foul taste in localized areas.

Sensitivity hot and cold

Tooth ache in absence of caries are present

Detection of Pockets :

Gutta percha points or calibrated silver points can be used with

radiographs to determine the level of attachment of periodontal pockets.

Their use in localized cases is feasible when used in generalized cases it

would be cumbersome.

Clinical Probing is more efficient

Two different pocket depths are ;

1) Biologic depth / histologic depth

2) Clinical / probing depth

“Biologic depth” is ascertained in histologic sections, it’s the depth form

gingival margin to base of pocket (coronal end of junctional epithelium).

“Probing depth” is the depth to which an adhoc instrument (probe) penetrates

into the pocket.

Technique :

Probe is held parallel to the long axis of tooth and walled

circumferentially around each surface of each tooth to detect areas of deepest

penetration (Fig.).

Force : 0.75 N.

To detect interdental craters probe must be placed obliquely form both

facial and lingual surfaces (Fig.).

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Bleeding on Probing :

Insertion of probe to the bottom of the pocket elicits bleeding if the

gingiva is inflamed and the pocket epithelium atrophic / ulcerated.

Bleeding on probing is early sign of inflammation than colour changes.

Test :

Probe is carefully inserted to the bottom of the pocket and gently moved

laterally along pocket wall. Sometimes bleeding appears immediately after

probing, where as sometimes it may take few seconds (30 to 60 seconds after

probing).

When to Probe :

In moderate or advanced cases probing is done twice as profuse bleeding

impairs clinical examination.

Initial Probing : is done to determine whether the tooth can be saved or

extracted along with clinical and radiographic examination.

After adequate plaque control measures.

Second probing is done to determine the level of attachment, degree of

involvement of roots and furcation.

Probing around Implants :

To prevent scratching of implant surface, plastic periodontal probes

should be used instead of steel probes.

Amount of Attached Gingiva :

Width of attached gingiva is the distance between the mucogingival line

and the projection on the external surface of the bottom of gingival sulcus.

Specially designed Naber’s probe allows easier and accurate exploration of

horizontal component of furcation lesions.

“Pocket Depth” is the distance between base of the pocket and gingival

margin. It keeps changing with the position of gingival margin and maybe

unrelated to the existing attachment of the tooth.

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Level of Attachment :

It is the distance between the base of the pocket and a fixed point on the

crown such a CEJ.

Level of attachment affords a better indication of the degree of

periodontal destruction.

Shallow pockets attached at the level of apical third of root indicate

more severe destruction than deep pockets attached at the coronal third of the

roots.

Determining the Level of attachment :

When gingival margin is on the anatomic crown :

Depth of pocket - Distance between gingival margin to CEJ = Level of

attachment.

When gingival margin is at CEJ

Loss of attachment = Pocket depth

Gingival margin apical to CEJ.

Because loss of attachment is greater than pocket depth. So distance

between CEJ and gingival margin is added to pocket depth. Width of attached

gingiva is determined by substracting the sulcus or pocket depth form the total

width of gingiva (gingival margin to mucogingival line). This done by

stretching the lip to demarcate mucogingival line.

When width of attached gingiva is less, the free gingival margin moves

on stretching of lip / cheek.

Degree of Gingival Recession :

Distance between CEJ and gingival margin.

PERIODONTAL PORTRAIT :

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During the course of treatment of Class I Endo-Perio Lesion (Weine) the

rapid healing that immediately follows the canal preparation appointment, the

dentist may confuse when seeing the patient at the succeeding visit.

Where was the pocket before?

How deep was it

Was it on buccal or lingual of the root.

Attempting to reprobe incorrectly may damage the sensitive healing

tissue or injure the normal areas. Therefore prior to initiation of therapy an

accurate recording of preoperative conditions must be made. An easy and

useful accurate one is the periodontal portrait (by Melton) (Fig.).

CLASSIFICATION OF ENDO-PERIO LESIONS :

According to SIMON GLICK FRANK (Cohen)

Primary endodontal lesions

Primary endodontal lesion with secondary periodontal involvement

Primary periodontal lesion

Primary periodontal lesion with secondary endodontal involvement

True combined lesion

According to Oliet, Pollock (Grossman) :

1) Lesions that require endodontic treatment procedures only : -

- Any tooth with necrotic pulp and apical granulomatous tissue

replacing periodontium and bone with or without sinus tract.

- Chronic periapical abscess with a sinus tract draining through the

gingival crevice thus passing through a section of the attachment

apparatus in its entire length along the side of the root.

- Longitudinal and horizontal root fractures.

- Pathologic and iatrogenic root perforations

- Teeth with incomplete apical root development

- Endodontic implants

- Teeth requiring hemisection / radisectomy

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- Root submergence.

II) Lesions that require periodontal procedures only :

- Occlusal trauma causing reversible pulpitis

- Occlusal trauma plus gingival inflammation resulting in pocket

formation and reversible pulpitis.

- Suprabony or infrabony pocket formation treated with

overzealous root planning and curettage leading to pulpal

sensitivity.

- Extensive infrabony pocket formation extending beyond the root

apex and sometimes coupled with lateral or apical resorption yet

with pulp that responds within normal limits to clinical testing.

III) Lesions that require combined endodontic – periodontic treatment

procedures :

- Any lesion in group I that results in irreversible reactions in the

attachment apparatus and requires periodontal treatment.

- Any lesion in group II that results in irreversible reactions in pulp

tissue and also requires endodontic treatment.

According to Weine :

Class I Tooth in which symptoms clinically and radiographically

simulate periodontal disease but are infact due to pulpal

inflammation and/or necrosis.

Class II Tooth that has both pulpal or periapical disease and periodontal

disease concomitantly.

Class III Tooth that has no pulpal problem but require endodontic therapy

plus root amputation to gain periodontal healing.

Class IV Tooth that clinically and radiographically simulated pulpal or

periapical disease but infact has periodontal disease.

PRIMARY ENDODONTAL LESIONS :

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These are the lesions, which arise form the diseased pulp. These lesions

sometimes may show as drainage form the gingival sulcus or swelling of the

facial attached gingiva. So initially when you see the lesion, it may appear as

periodontal in origin but in reality it is fistula formed as a result of periapical

infection that instead of opening on the buccal or lingual mucosa, drains along

the periodontal ligament into the sulcus.

Clinical Features :

- Drainage may be evident in sulcus area.

- Swelling may be present especially in bifurcation area simulating

periodontal abscess.

- Vitality test will reveal necrotic pulp or atleast an altered response in case

of multi rooted teeth indicating that at least one canal is necrotic.

- Periodontal probing usually shows normal sulci around the tooth except in

one area with a narrow defect. Placement of silverpoint, gutta percha cone

or periodontal probe in this sinus tract shows that the defect is deep and

will go towards the source of irritation generally the root apex or the

lateral canal.

- Pain is usually not present though the patient may have some minor

discomfort.

Radiographic Appearance :

Radiograph may show deep dental caries, deep filling or fractured

restoration. The drainage through the sulcus often appears as a radiolucency

along the mesial or distal root surface or in the bifurcation area.

Treatment :

Because this lesion is an endodontic problem that has merely fistulated

through the periodontal ligament, complete healing is usually anticipated after

routine endodontic therapy.

Periodontal curettes are used to plane the root surface to be sure it is free

of plaque and deposits.

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PRIMARY ENDODONTAL LESION WITH SECONDARY

PERIODONTAL INVOLVEMENT :

This is merely an extension of the endodontic lesion when the patient

ignores the draining fistulas. As the drainage persists through the gingival

sulcus, super imposition of the plaque and the calculus into the pocket like

defect occurs resulting in periodontal pocket and apical migration of the

attachment.

To differentiate these lesions form the lesions of primary periodontal

origin you should consider the following factors.

If the problem is primarily endodontic, there must be an etiologic factor

for the pulp necrosis like presence of caries, extensive restorations,

fractured restorations or teeth, discolored crowns, severe attrition etc.

Periodontal disease usually has generalized nature. Usually periodontal

lesions are not isolated to a single tooth (but this also may occur

sometimes. Additional tests and findings are needed).

Vitality Tests : Vitality tests reveal necrotic pulp.

Treatment :

Localized periodontitis complicates the prognosis and the tooth now

requires both endodontic and periodontal therapy the bone loss of endodontic

origin will heal if appropriate root canal treatment is performed but not the

secondary pocket, it requires curettage and root planning.

PRIMARY PERIODONTAL LESION :

Unchecked or untreated periodontitis progresses along the root surface

until the Periapex is reached. Important diagnostic finding is to see whether the

cervical lesion is isolated to a single tooth or is generalized. Periodontal

disease is usually generalized. It may be localized because of traumatic

occlusion. Teeth show periodontitis as a result of accumulation of plaque

and/or calculus formation.

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Vitality tests : Shows positive indicating vital pulp.

Mobility : Teeth may be associated with various degrees of mobility.

Clinical examination : We may find plaque, calculus and soft tissue

inflammation associated with a purulent exudates.

Probing : Clinically probing detects broad based (infrabony) pocket formation

and causes bleeding of the tissue.

Treatment :

Treatment is only periodontal therapy and depends on the extent of the

periodontal disease and the patients ability to comply with possible long term

treatment and maintenance therapy. Prognosis depends on the outcome of the

periodontal therapy and care must be taken not to devitalize the pulp during

deep therapy.

PRIMARY PERIODONTAL LESIONS WITH SECONDARY

ENDODONTAL INVOLVEMENT :

- Progression of the periodontal disease may involve lateral or accessory

canals or may extend to the apex leading to the pulp. When the lesion

involves the primary pulp vessels at the apex retroinfection takes place

and the pulp becomes inflamed and necrotic.

- Progressive periodontal disease results in the apical migration of the

attachment and root surface exposure to the oral cavity and to irritants

such as bacterial plaque. “Seltzer” states that oral flora can transmit

toxic products into the pulp via the lateral canals or dentinal tubules to

cause atrophic, degenerative, inflammatory and resorptive alterations.

- Periodontal therapy may also lead to pulp death if neurovascular bundle

entering a mid root lateral canal is severed during deep periodontal

therapy.

Clinical Features :

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- The tooth with primary periodontal and secondary endodontic

disease will have deep pockets and history of extensive

periodontal disease.

- When the pulp becomes involved the patient reports accentuated

pain and clinical signs of pulpal disease.

Vitality Tests : Once the pulp becomes involved, pulp tests will confirm pulp

neurosis.

Mobility : Various degrees of mobility.

Clinical Examination : Plaque, calculus and soft tissue inflammation is seen.

Treatment :

Both endodontic and periodontal therapy will be necessary to provide a

successful result. The endodontic treatment should be completed first because

the toxic reservoir in the root canal will continue to abort the desired

periodontal healing.

Prognosis in these cases of primary periodontal etiology is not as good

as when the primary lesion is endodontal because all periodontal therapy has a

much more guarded prognosis than endodontal therapy.

TRUE COMBINED LESIONS :

These lesions occur where a pulpally induced periapical lesion exists on

a tooth that is also periodontally involved. These consists of two concurrent

lesions, one is an independent periapical lesion originating from a necrotic

pulp and other is an independent periodontal lesion that has progressed apically

towards the periapical lesion. Depending on the stage of their development, the

lesions may or may not communicate. The infrabony defect occurs when the

two lesions meet and merge. A new term “concomitant pulpal-periodontal

lesion” has given to those teeth which have both disease processes occurring

but do not communicate.

Clinical Features :

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In a combined lesion,

Periodontal Examination : Probing of tooth shows presence of plaque, calculus,

periodontitis and a wide and conical periodontal pocket characteristic of

periodontal defect of periodontal disease origin.

Vitality tests : Confirm pulp necrosis.

Radiographic Examination : Shows periodontal infra bony pocket

communicating the periapical lesion and degrees of crestal bone loss.

The character of the combined lesion may mimic the lesion of

endodontic origin.

Treatment :

Treatment of combined lesions consists of endodontic and periodontal

therapy. The overall prognosis depends on the prognosis of each individual

factor. In cases in which periapical and periodontal lesions communicate,

complete cleaning and obturation of the root canal system prevents egress of

the irritants form the periapical lesion into the periodontal defect. Then the

prognosis of the affected tooth then depends totally on the outcome of the

periodontal therapy.

If a combined lesion is found in a mouth otherwise free of periodontal

disease, we can suspect vertical root fracture, particularly if the lesion does not

respond to combined therapy (it may be necessary to lay a flap to find the

defect which has hopeless prognosis).

COMBINED LESION TREATMENT :

These patients in contradiction to Class I (Weine) exhibit periodontal

disease in a number of areas of the mouth.

3 distinctly different types of lesions occur :

1. Two separate lesions (Pulpo-periapical and periodontal)

with no communication between them (concomitant pulpo periapical

lesions).

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2. Single lesion that involves both endodontic and

periapical pathoses.

3. Separate endodontic and periodontal lesions that later

communicate.

1. Separate unrelated lesions :

First it must be determined if periodontal condition is treatable.

Performing endodontic therapy on teeth with hopeless periodontal lesions is

disastrous. Endodontic therapy is performed first and then periodontal therapy.

2. Single lesion with both pulpal and periodontal pathoses.

This is most difficult to treat successfully.

Clinical Features :

Involved teeth has single lesion radiographically.

Probes as a routine deep periodontal pocket

Patient has periodontal condition involving other teeth

Endo therapy should be initiated followed by periodontal therapy.

Results are not predictable and patients must be forewarned concerning

doubtful prognosis.

3. Periodontal and Endodontic Lesion that have merged :

A periapical endo lesion merges with periodontal pocket eventhough

separate lesions are present. Portion of lesion extending form apical area

towards the crestal bone is periapical due to pulpal damage. Whereas the

lesion from the sulcus extending apically is periodontal breakdown.

Treatment :

If endodontics is only performed the periapical lesion heals to the site

where periodontal lesion begins.

If periodontal therapy only is performed, the crestal bone may heal upto

where the periapical lesion begins.

Both pulpal therapy followed by periodontal should be performed.

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ALTERNATIVE TREATMENT MODALITIES :

When traditional endodontic and periodontal treatments prove

insufficient to stabilize an affected teeth, the clinician must consider other

treatment alternatives like root amputation and hemisection.

Root amputation procedures are a logical way to eliminate a weak,

diseased root and allow the strongest to survive, where as retained together

they would collectively fail. Hemisection is the most common method of

removing a pathologically involved root. Before carrying out any such

procedures the occlusal forces, restorability and the value of the remaining

roots must be examined.

Root amputation or radisectomy denotes the removal of one or more

roots of a molar. Hemisection refers to sectioning of the crown of a molar

tooth, with either the removal of half the crown and its supporting root

structures or retention of both the halves to be used after reshaping and

splinting as two premolars. Radisectomy and Hemisection are often desirable

for periodontal reasons.

At times, a multi rooted tooth has an untreatable periodontal lesion on

one or more of its roots but the remaining root/roots are well supported and

treatable. For example, one root may have an extensive infrabony pocket with

concomitant bone loss and the other root may be surrounded by normal gingiva

and supporting bone. To retain a portion of this strategic tooth and to avoid

extraction of the entire tooth, hemisection or radisectomy can be performed.

Whenever possible, Endodontic treatment should precede root removal

because it is difficult to treat a tooth properly when it has been sectioned

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through the pulp chamber because asepsis is impossible and anatomic

guidelines used in the treatment are destroyed.

The role of root amputation procedures is gradually decreasing because

of the problems associated with long term success of the teeth treated with

amputational therapy, now guided tissue regeneration has come which provided

the regeneration of the lost periodontal structures without any root amputation.

GTR appears to be an excellent alternative choice as it is less destructive

regenerative and requires less time.

HEMISECTION AND ROOT AMPUTATION :

First attempted by G.V.Black in 1880. However until late 1950s interest

was not shown by dental profession. Teeth formerly considered hopeless now

may be retained.

With Hemisection and root amputation endodontics should be

completed before surgery to avail easy isolation and prevent contamination.

Indications :

Hemisection and root amputations are indicated when one or two roots

of multirooted teeth becomes untreatable because of ;

1. Endodontic reasons (separated instrument, root preparations (resorption)

obstructed canals).

2. Periodontal reasons (furcation involvement, severe bone loss around one

root).

3. Restorative reasons (caries destruction, erosion of large part of crown

and root, perforations during posterior preparation / #).

4. Combination of these.

Hemisection :

This is a procedure to retain half of the tooth in an essence of converting

molar into two premolars (Bicuspidization) or one premolar.

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Root canals are obturated and pulp chamber filled with amalgam before

surgery.

Flap may not be necessary all the time. In case of periodontal

involvement of furca.

Sectioning can be done with a pencil diamond or long shanked fissure

bur with initial cut at the extent of the root to be removed, so that there is

enough tooth structure to aid in preparing the crown for post crown restoration,

part of overdentures, bridge abutment.

When the defect periodontally is in the furcation both the roots can be

retained with opening up the furcation and restored to form 2 premolars –

Bicuspidization is the procedure termed as;

SURGICAL CONSIDERATIONS :

Periodontal evaluation plays a very important role in surgical

endodontics.

Flap design will dictate health of periodontal attachment and gingiva.

If sufficient attached gingiva is present envelop type flaps can be given.

If little or no attached gingiva exists a full flap must be raised and

repositioned apically to create new attached gingiva.

Flap edges should be sutured over round bone to promote healing and to

avoid post surgical recession or soft tissue defects.

When a full flap is raised in the presence of periodontal disease,

necessary scaling, curettage or osseous contouring procedures should be

performed at the same time.

Both these procedures are excellent if used when indicated and if used

properly. If observed the techniques can lead to predictable failure both

periodontally and restoratively.

In 10 years study all the failures in teeth which had undergone

hemisection and root amputation were attributed to endodontic or

restorative failures, not periodontal disease.

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Endodontic Implant :

This is indicated in cases of less crown root ratio and stabilization in

advanced periodontally involved teeth or secondary to eliminate secondary

occlusal trauma. However endodontic implant does not cure periodontal

disease.

Currently ADA classifies the endo implants as an experimental

procedure.

Root Amputation :

After the root canal system is obturated with gutta percha, a No.4 – No.6

slow speed, long shanked round bur is used to drill 2 to 3 mm into root/s

to be amputated. The roots prepared and entire pulp chamber are filled

thoroughly with well condensed amalgam to ensure complete seal of the

pulp chamber after too is removed.

In some cases flap may not be required when the extent of bone loss and

periodontal involvement is severe. Usually a small triangular flap is

raised.

In Maxillary Molars :

One or even two roots may be amputated.

Procedure is similar to hemsection except the contouring of remaining

crown is complex.

The crown portion supported by the root to be amputated should be

recontoured to accept new occlusal demands and ensure good oral

hygiene.

The crown can be contoured first and then underlying root removed or

crown and root cut off together.

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ROLE OF ANTIBIOTICS IN ENDO-PERIO LESIONS :

In Endodontic Therapy :

The treatment of acute and chronic infections of endodontic origin is

primarily by operative intervention.

Now a days endodontic therapy emphasizes the importance of

debridement procedures there by eliminating or reducing the micro organisms.

Severe infections rarely occur. Even if it occurs, establishing the surgical

drainage is the primary treatment in order to remove the cause of infection.

Antibiotics should be given :

Only when the drainage becomes difficult to obtain.

If there is a diffuse spread of infection (Ex. In case of acute dento

alveolar abscess).

When the host resistance is low (as in case of medically compromised

patients).

When the virulence of the microorganism is very high.

The most commonly prescribed antibiotics are erythromycin,

amoxicillin, penicillin and metronidazole.

In Periodontal Therapy :

The use of antibiotics in the treatment of periodontal disease is base don

the infectious nature of the disease. Many micro-organisms are present in the

oral cavity which cause various periodontal disorders. In the early stages of

periodontal disease gram positive bacteria will be seen where as in the later

stages, gram negative bacteria and spirochaetes lay an important role. The

bacterial cultures and antibiotic sensitivity test should be performed before

selecting an antibiotics.

No single antibiotic at concentrations achieved in body fluids inhibits all

periodontal pathogens. A combination of antibiotics may be necessary to

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eliminate all the pathogens from periodontal pockets. Both systemic and

topical antibiotics have been evaluated.

Topical application has advantages like, the antibiotics can be directed

to their specific target areas, reduced drug dosages and increased

concentrations and reduces side effects.

Antibiotics for Endo Perio Lesions :

There are no authorative studies to support the use of systemic

antibiotics in the management of endo-perio lesions. The treatment of

combined lesions is based upon the basic principles of endodontic and

periodontal therapy and is dependent upon the etiology of the condition.

Endodontic treatment usually involves RCT and sometimes root resection and

repair of the perforation. Periodontal treatment includes curettage, scaling and

root planning procedures and sometimes flap surgery and bone grafting.

Systemic antibiotics are not a substitute for the effective mechanical

debridement of root canal system and the root surface. Topical antibiotics such

as tetracyclines or metronidazole may be applied to the periodontal ligament as

an adjunct to root planning. Tetracycline’s appear to be more useful for both

endodontics and periodontal infections. Tetracyclines are highly effective

against many periodontal pathogens because higher concentration of drug can

be achieved in gingival crevice 2-10 times more than in serum. Systemic

antibiotics can be used prophylactically for patients with a history of rheumatic

heart disease and other systemic conditions. They can be used as an adjunct to

the surgical procedures involving root resection, osseous grafting etc.

Tetracycline 250 mg (4 times a day)

Doxycycline 100 mg (2 times on first day and once thereafter)

Metronidazole 250 mg (3 times a day for 7 days)

Now recently Chlorhexidine is gaining increasing popularity as a

microbial agent. Chlorhexidine is incorporated in the small strip which is

25

placed directly in the periodontal defect and left in place. This is called perio

chip.

CONCLUSION :

A concise knowledge of both pulpal and periodontal diseases is

necessary for proper identification of the lesion. Proper diagnosis, followed by

the removal of the etiological factor and rendering appropriate treatment

utilizing GTR techniques combined with osseous grafting where ever necessary

will restore the tooth damaged by the endo-perio lesion to health and function.

REFERENCES :

1. Pathways of the pulp, 8th edition. – Stephen Cohen.

1. Clinical Implantology, 3rd Edition – Jan Lindhe.

2. Periodontology, 9th Edition – Glickman.

26

COLLEGE OF DENTAL SCIENCES

DEPARTMENT OF CONSERVATIVE DENTISTRY AND

ENDODONTICS

SEMINAR ON

“ENDODONTIC – PERIODONTIC

INTERRELATIONSHIP”

Presented By : -

Dr. GAURAV PATRI