Managing Concurrent Endodontic and Periodontal Diseases Flashcards
Why is there a lot of confusion about strategies to manage concurrent endodontic and periodontic diseases?
2 main reasons:
The all inclusive approach
The diagnostic classifications that are used
Why can root perforation or horizontal and vertical root fractures as well as external invasive root resorption cause confusion?
They manifest by rapid increased probing depths, suppuration, increased mobility, and pain/awareness with function
Why is it a misnomer to call a primary endo lesion that leads to a drainign sinus through the gingival sulcus a combined endo and perio problem?
Because the inflammation does not involve the periodontium. It is just a draining sinus that passed through bone
What were the classifications of Torabinejad and Trope in 1996?
Endodontic origin
Periodontal origin
Combined endo-perio lesions: Serparate endodontic and periodontal lesions (No communication)
Combined endo-perio Lesions: Communicate
How is the abbott and castro salgado classification most appropriate?
It refers to the endo-perio conditions as concurrent with or without communication
What are the communication pathways between endo and perio conditions that can exist?
Accessory canals from the pulp chamber to the furcation (commonly in 1st molars both max and mand)
Apical foramen
Lateral canals in the apical 1/3rd of the tooth root
Developmental grooves
Cracks
What kind of organisms are found in both endodontic and periodontic concurrent diseases?
Highly motile organisms that survive in highly reduced environments.
Precautions must be taken to prevent in vivo cross seeding of these micro-organisms during treatment
Especially in compromised teeth.
What kind of periodontitis symptoms is intracanal infection associated with?
In periodontitis prone patients, intracanal infection was significantly correlated with:
Deeper periodontal pockets
Significantly more attachment loss over 6 years
How does intracanal infection affect pocket depths?
Intracanal infection was the most important contribution to increased pocket depth
Intracanal infections stimulate epithelial downgrowth along denuded dentine surfaces with marginal communication
THUS INTRACANAL INFECTIONS MUST NOT BE OVERLOOKED WHEN TREATMENT PLANNING FOR PERIODONTAL DISEASES
What must be ensured to ensure appropriate diagnosis?
Must differentiate between endodontic and periodontal diseases in order to provide appropriate management.
What must be taken into account when assessing the diagnosis of concurrent endodontic and periodontal diseases?
History
Subjective signs and symptoms
Visual appearance of tissues
Caries, restorations, etc
Radiographic findings
Clinical tests: Pulp sensibility, periodontal probing, palpation and percussion
What are the 4 absolute essentials for diagnosis?
CO2 pulp tester
Electric pulp tester
Periodontal probe
Periapical radiograph
When is it difficult to differentiate periodontal and endodontic diseases?
Previous endodontic treatment
Full crown restorations
Pulp canal calcification
Pulp necrobiosis
Test results are inconsistent with the signs and/or symptoms
What are the potential hints into whether a problem is endo or perio related?
Is the problem localized to one tooth?
Extensive caries/restorations
Pulp sensibility tests (no response is a pulp/periapical response)
Percussion and palpation don’t help
Bone loss most likely perio problem
Nature of periodontal probing defect. (endo problems often have narrower problems)
What are the management options for concurrent perio and endo infections?
Depends on diagnosis.
If acute:
Diagnose source of pain (periapical or periodontal).
Treat this problem first.
Follow soon after with the other treatment.
If chronic:
Ideally sequence treatment to avoid any cross-seeding of bacteria and the effects of intracanal infection on the periodontal tissues
Is it better to start with perio or endo infection?
Endo treatment until the point where RCF needs to be done. Then delay RCF until the periodontal infection has been cleared.
This is the case with communication. Without communication it’s still a better idea but treatment can be done right away after RCF as well.
Why is it a bad idea to start with perio treatment first?
Root canal infection significantly affects periodontal healing.
Pocket depth reduction is significantly less in the presence of root canal infection
More marginal epithelium over cementum defects if the root canals are infected
Cementum removal during perio treatment exposes dentinal tubules leading to:
If bacteria in the root canal this promotes external inflammatory resorption.
May expose periodontal tissues to toxic medicaments if used in the root canal. (not so critical in areas with recession)
Why is it a good idea to start with endo treatment first?
Cementum layer is kept intact until the root canal infection is removed: No exposed dentine on root surface, reduced chance of external root resorption, and improved periodontal healing.
But root canal fillings do not seal canals. (Nothing we have today can seal dentine) This means root canals can be reinfected if the periodontal treatment is delayed.
Canal sterility is more likely while there is a dressing in the root canal.
Which medicaments should be used for managing teeth with concurrent endodontic and periodontal diseases?
Ledermix + Ca(OH)2 pastes
What is the point of mixing ledermix with calcium hydroxide for the canals?
Advantages of both materials without reduction in therapeutic effects.
Maintains all active components in the canal for a llonger period of time.
Ledermix paste reduces toxicity of calcium hydroxide.
Why isn’t calcium hydroxide used alone for treating the canals in concurrent perio and endo conditions?
It can cause tissue necrosis.
If there is no cementum increases risk of ankylosis and replacement resorption.
What should be done in initial management of concurrent endo and perio conditions?
Remove existing restorations and caries. (Assess suitability of tooth for further treatment)
Chemo-mechanically prepare the root canals
Medicate canals (ledermix paste, if severe, or ledermix + Ca(OH)2)
Interim restoration (Ketac silver or ketac fil +/- ortho band but avoid the band if possible)
What should be done in follow-up management of concurrent endo and perio conditions?
Change intracanal dressing after 3 - 4 weeks
Provide initial periodontal treatment
Review healing after 3 months
Reassess need for further periodontal treatment
If more periodontal treatment required change intra-canal medication again
If healing response favourable complete root canal filling.
When should root filling be deferred?
Need for more periodontal treatment or surgery assessed
Periodontal treatment/surgery completed with satisfactory outcome
Overall prognosis has been assessed to be adequate enough to justify further endodontic and restorative treatment and their costs
What alternate treatments can be used for teeth with concurrent endodontic and periodontal diseases?
Root resection
Hemisection
Extraction + other prosthesis
