Managing Concurrent Endodontic and Periodontal Diseases

Question 1

Why is there a lot of confusion about strategies to manage concurrent endodontic and periodontic diseases?

Answer 1

2 main reasons:

The all inclusive approach

The diagnostic classifications that are used

Question 2

Why can root perforation or horizontal and vertical root fractures as well as external invasive root resorption cause confusion?

Answer 2

They manifest by rapid increased probing depths, suppuration, increased mobility, and pain/awareness with function

Question 3

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?

Answer 3

Because the inflammation does not involve the periodontium. It is just a draining sinus that passed through bone

Question 4

What were the classifications of Torabinejad and Trope in 1996?

Answer 4

Endodontic origin

Periodontal origin

Combined endo-perio lesions: Serparate endodontic and periodontal lesions (No communication)

Combined endo-perio Lesions: Communicate

Question 5

How is the abbott and castro salgado classification most appropriate?

Answer 5

It refers to the endo-perio conditions as concurrent with or without communication

Question 6

What are the communication pathways between endo and perio conditions that can exist?

Answer 6

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

Question 7

What kind of organisms are found in both endodontic and periodontic concurrent diseases?

Answer 7

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.

Question 8

What kind of periodontitis symptoms is intracanal infection associated with?

Answer 8

In periodontitis prone patients, intracanal infection was significantly correlated with:

Deeper periodontal pockets

Significantly more attachment loss over 6 years

Question 9

How does intracanal infection affect pocket depths?

Answer 9

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

Question 10

What must be ensured to ensure appropriate diagnosis?

Answer 10

Must differentiate between endodontic and periodontal diseases in order to provide appropriate management.

Question 11

What must be taken into account when assessing the diagnosis of concurrent endodontic and periodontal diseases?

Answer 11

History

Subjective signs and symptoms

Visual appearance of tissues

Caries, restorations, etc

Radiographic findings

Clinical tests: Pulp sensibility, periodontal probing, palpation and percussion

Question 12

What are the 4 absolute essentials for diagnosis?

Answer 12

CO2 pulp tester

Electric pulp tester

Periodontal probe

Periapical radiograph

Question 13

When is it difficult to differentiate periodontal and endodontic diseases?

Answer 13

Previous endodontic treatment

Full crown restorations

Pulp canal calcification

Pulp necrobiosis

Test results are inconsistent with the signs and/or symptoms

Question 14

What are the potential hints into whether a problem is endo or perio related?

Answer 14

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)

Question 15

What are the management options for concurrent perio and endo infections?

Answer 15

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

Question 16

Is it better to start with perio or endo infection?

Answer 16

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.

Question 17

Why is it a bad idea to start with perio treatment first?

Answer 17

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)

Question 18

Why is it a good idea to start with endo treatment first?

Answer 18

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.

Question 19

Which medicaments should be used for managing teeth with concurrent endodontic and periodontal diseases?

Answer 19

Ledermix + Ca(OH)2 pastes

Question 20

What is the point of mixing ledermix with calcium hydroxide for the canals?

Answer 20

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.

Question 21

Why isn’t calcium hydroxide used alone for treating the canals in concurrent perio and endo conditions?

Answer 21

It can cause tissue necrosis.

If there is no cementum increases risk of ankylosis and replacement resorption.

Question 22

What should be done in initial management of concurrent endo and perio conditions?

Answer 22

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)

Question 23

What should be done in follow-up management of concurrent endo and perio conditions?

Answer 23

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.

Question 24

When should root filling be deferred?

Answer 24

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

Question 25

What alternate treatments can be used for teeth with concurrent endodontic and periodontal diseases?

Answer 25

Root resection

Hemisection

Extraction + other prosthesis