Diagnosis and management of concurrent endodontic and periodontal diseases

#D3/S2/W7
#Endo

how to treat infection

• eliminate the cause

• prevent reinfection

• 

• untreated disease in one can cause signs symptoms in the other

• cross seeding of bacteria from one tissue to the other can also occur (in either direction)

Diagnosis

• most important
• history
  • smoking, diabets, immunocompromised
• clinical examination
• radiographic examination
• perio probing
• vitality tests

Med history

• diabetes
  • risk for perio
  • delayed endo healing
  • greater risk apical periodontitis
• Prolia
  • increased risk external cervical resorption

Can moderate perio cause endo?

• maybe
• accessory apical foramen exposed to oral environment
• perio treatment specially when cementum is removed
• canal calcification with respect to associated defect
• is the tooth vital with extensive perio?

Can severe perio cause endo

• yes in cases when disease envelopes apical and possible lateral/accessory foramina resulting in hypoxia and eventual necrosis

Can endo cause perio

• yes
• through accessory and furcation canals
• PA lesion can drain through narrow pocket
• is tooth non vital with associated periodontal defect?
  

**Primary endodontic leisons (endodontic conditions with periodontal manifestations)

• localised collection of pus with draining sinus (CAA)
• drainage might be through gingival sulcus mimicking pocket
• narrow and deep pocket and lack of marginal bone loss
• minimal plaque and calc
• generally no response vitality tests and endo aetiology identified

Endo/perio lesions without communication

• endo infections can stimulate epithelial downgrowth along denuded dentine surfaces (after root planing) thus deepening pockets on instrumented root surfaces
• RCT first, then perio management

Primary Endodontic lesions with secondary periodontal involvement

Primary periodontal lesions (periodontal conditions with endo manifestations)

• generally respond to vitality test despite apex radiolucency
• wide pockets, plaque/calculus, marginal bone loss
• other teeth with plaque calc and perio defect can help diagnosis

Primary endodontic lesion with secondary periodontal involvement

• tooth non vital and generally endodontic aetiology can be identified
• subgingival plaque/calculus present but mostly localised to affected tooth
• radiolucent area extending from apical/furcal region to crestal bone
• pulp therapy does not resolve lesion completely
• endo perio with communication
  • manage concurrently
  • remove infections from both entities before placing final root filling
  • remove pulp and dress canal with calcium hydroxide, complete periodontal management, then place final root filling
• prognosis
  • would be better if no communicatoin
  • home management need to be address
  • exo always option

Primary periodontal lesoin with secondary endodontic involvement

• tooth may exhibit endodontic symptoms or may not respond to vitality tests, but generally endo aetiology cannot be identified
• subgingival plaque/calculus and perio bony defects present at other teeth too
• radiolucency involves crestal bone and may or may not reach apex
• perio treatment does not resolve lesion completely

True combined endodontic periodontal lesion

• non vital, can find endo aetiology
• subging plaque calc and perio defect at other teeth
• radiolucency involves crestal bone and generally reaches apex (J shaped)
• prognosis generally poorer, consider
  • perio
  • endo
  • resto
  • strategic value
  • patient factors
• sequence of treatment
  • pulp extirpation and intracanal dressing, deep double seal
  • perio treatment once evidence of favourable endodontic healing observed
  • NSPT if perio defect can be accessed without flap
  • complete endo in rare cases
  • surgical perio (consider GTR aswell)
  • completion of endo once evidence of favourable perio healing