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Endodontic Periodontal Lesion Diagnosis and Treatment Decision Analysis

Journal of Research in Medical and Dental Science
eISSN No. 2347-2367 pISSN No. 2347-2545

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Research - (2021) Volume 9, Issue 2

Endodontic Periodontal Lesion Diagnosis and Treatment Decision Analysis

Keerthika R and Nivedhitha MS*

*Correspondence: Nivedhitha MS, Department of Conservative dentistry and Endodontics, Saveetha Dental College and Hospitals, Saveetha Institute of Medical And Technical Sciences, Saveetha University Tamilnadu, India, Email:

Author info »

Abstract

The relationship between periodontal and endodontic disease has been a controversial aspect for more than a century. Differentiating between these periodontal and endodontic disease is very difficult due their developmental, embryonic, anatomic and functional similarities. Nature pain is often considered as the first clue which should be supported by the radiographic and clinical evaluation for the correct diagnosis of the condition. The aim of this review was to develop a decision tree for easier and accurate diagnosis of periodontal and endodontic disease. A brief pubmed search was performed on endodontic and periodontal lesion using “MESH” terms “endo-perio lesion”, “diagnosis of endo perio lesion”,” decision making of endo-perio lesion”. In addition some websites and local guidelines were screened. By following the correct and appropriate diagnostics methods ,accurate diagnosis of Endodontic -Periodontal disease can be done and the treatment for the particular condition could be achieved. With a decision tree, the diagnosis and pharmacological management of the pulpal and periapical diseases becomes easier for the dentist in regular clinical practice. A decision tree and a flow chart for daily practice which should be started up as soon as the patient presents with pain or swelling due to pulpal or periodontal periapical pathology. In this aspect active management of the infection can be done with sound knowledge on the endodontic periodontal lesions.

Keywords

Endoperio lesion, Periodontal, Pulpal, Diagnosis, Treatment plan

Introduction

Skin and soft tissue infections (SSTIs) have variable etiology and clinical presentation and is commonly seen in both in ambulatory and hospital The interrelation between the pulp and the periodontium are very difficult to understand and also have been a controversial topic over years which could be owed to their developmental, embryonic, anatomic and functional similarities [1,2]. It was first described by Simring et al. [3]. Differentiating the disease being a pulpal or periodontal origin presents various challenges due to the complexity in the communicating pathways between the pulp and the periodontium [3,4]. The endodontic and periodontal lesion is closely interrelated presenting both the signs of pulpal and periodontal involvement which makes their diagnosis quite complex. The disease can be a result of one or other or even can be from two different unrelated processes which gets related with the advancement of disease. Diagnosing the disease is the most challenging aspect of this disease which requires deeper knowledge and insight into subject [5].

We have numerous highly cited publications on well-designed clinical trials and lab studies [6-21]. This has provided the right platforms for us to pursue the current study. Thus the aim of this review was to develop a decision tree for easier and accurate diagnosis of periodontal and endodontic diseases.

Classification

Based on the primary cause of the disease, Simon et al. has given classification of endodonticperiodontal lesion as [2,5,22,23]

(i) Primary endodontic lesions,

(ii) Primary endodontic lesions with secondary periodontal involvement,

(iii) Primary periodontal lesions,

(iv) Primary periodontal lesions with secondary endodontic involvement,

(v) True combined lesions.

In 1999, the world workshop for classification of periodontal diseases gave classification of periodontitis associated with endodontic disease as

(i) Endodontic-periodontal lesion,

(ii) Periodontal-endodontic lesion,

(iii) Combined lesion.

Pathways of communications

Three main pathways which were considered as prime route for endodontic-periodontal lesions are [3-5,22,24],

Apical foramen.

Dentinal tubules.

Lateral and accessory canals.

Etiopathogenesis of endo-perio lesions

Etiological factors [3,24,25]

✓ Live pathogens-bacteria, fungi, viruses.

✓ Nonliving etiological agents -foreign bodies, cholesterol crystals, Russell bodies, Rushton hyaline bodies.

Contributing factors [3,24,25]

✓ Poor endodontic treatment.

✓ Coronal leakage.

✓ Root resorption.

✓ Perforations.

✓ Trauma.

✓ Developmental malformations [26].

✓ Cracked tooth syndrome.

Characteristics of diseases

The characteristics of diseases are mentioned in Table 1 [3,5,24,25].

  Pathogenesis Clinical Features Treatment Prognosis
Primary Endodontic Lesion It arises as a sequel of pulpitis from dental caries, wear defects, trauma and fracture. A primary endodontic lesion presents a necrotic pulp and a chronic periapical abscess with a sinus tract draining through periodontal ligament space or gingival sulcus. The lesion presents an ‘isolated’ periodontal problem in relation to the affected tooth only, without a generalized periodontal disease. H/O pulpitis. A sinus tract, originating from apex, is  present in sulcus. Negative pulp vitality test. Endodontic therapy  must be performed in multiple appointment, to reevaluate healing process between the beginning and completion of treatment. Periodontal therapy isn’t required usually. They exhibit good prognosis. Radiographic and clinical healing occurs rapidly.  A sinus tract heals soon after canal debridement -within 3-6 months.
Primary Periodontal Lesion The lesion develops as sequelae of progressing periodontal problem extending to the apex. Plaque represents the prime etiologic factor. Patients present with generalized chronic periodontitis. Minimal or no pain. Positive pulp vitality test. Surgical/ non-surgical periodontal therapy. Re-evaluation must be done periodically to check for retro-infection of pulp The prognosis is entirely dependent on periodontal therapy and hence, extent of periodontal damage.
Primary Endodontic Lesion with Secondary Periodontal Involvement It arises when periodontal problem develops on teeth with PEL. Plaque and calculus is often deposited in draining sinus tract; creating a secondary periodontal problem Negative pulp vitality test. Presence of plaque and calculus, in the way of sinus tract. Endodontic therapy. Periodontal therapy – should not be employed until complete debridement of canal is achieved Prognosis of endodontic therapy is predictable. Regeneration of periodontal tissue depends upon the extent of tissue destruction
Primary Periodontal Lesion with Secondary Endodontic Involvement It arises as retro-infection of pulp, when periodontal lesion extends to apex. It may also follow the path through a lateral canal. Negative/ altered pulp vitality test (as pulp can be necrotic/ partially vital, especially in multi-rooted teeth) Surgical/ non-surgical periodontal therapyEndodontic therapy The prognosis depends upon periodontal therapy and hence, extent of periodontal damage.
True Combined Lesion Here pulpal and periodontal lesions develop and unite independently. Features are similar to primary periodontal lesions. In addition, there must be some caries, trauma, fracture, wear defects, deep restoration or history of endodontic therapy. Negative pulp vitality test. Endodontic therapy and periodontal therapy. Root resection can be in need with regenerative therapy. Prognosis of lesion is related to extent of periodontal damage.

Table 1: Characteristics of diseases.

Diagnosis [5,22,24,27]

Table 2 describes the diagnostic features of endo perio lesion.

Clinical Pulpal Periodontal
Vitality Non vital Vital
Restorative Deep or extensive Not related
Plaque/calculus Not related Primary cause
Inflammation acute chronic
Pockets Single, narrow Multiple, wide coronally
pH value Often acid Usually alkaline
Trauma Primary or secondary Contributing factor
Microbial few complex
Radiographic    
Pattern localized generalised
Bone Loss Wider apically Wider coronally
Periapical radiolucent Not often related
Vertical bone loss no yes
Histopathological    
Junctional epithelium No apical migration Apical migration
Granulation tissue apical coronal
Gingival normal recession
Treatment Root canal therapy Periodontal treatment

Table 2: Diagnosis.

Table 3 describes the findings of endo perio lesion [3,24]

Examination/
tests
Primary
Endodontic
lesion
Primary periodontal
lesion
Primary endodontic
secondary periodontal
Primary periodontal
secondary
endodontic
True combined
lesion or concomitant lesions
Visual Presence of sinus opening. Presence of decay/large restoration, fractured
restoration or tooth/erosions/ abrasions/cracks/
discolorations/ poor RCT
Inflamed gingiva/gingival
recession,
Accumulation of plaque and subgingival calculus
around multiple teeth. Intact teeth
Presence of periodontal
abscess
Plaque forms at the gingival margin of the sinus tract and
leads to inflammation
of marginal gingiva exudate
Root perforation /fracture/ displaced post
Presence of plaque,
subgingival calculus
and swelling around
multiple teeth
Presence of pus,
Exudate. Presence of localized/
generalized gingival
recession and
exposure of root
Plaque, calculus and periodontitis will be present in varying degrees.
Swelling around single or
multiple teeth
Presence of pus, exudate
Pain Sharp Usually dull ache
Sharp only in acute condition
Usually sharp shooting. Dull ache in chronic
conditions
Usually sharp shooting. Dull ache in chronic
conditions
Dull ache usually
Only in acute conditions it
is severe
Palpation It does not indicate the origin Pain on palpation Pain on palpation Pain on palpation Pain on palpation
Percussion Tender on percussion Tender on percussion Tender on percussion Tender on percussion Tender on percussion
Mobility Fractured roots and recently
traumatized teeth often present high mobility
Localized to generalized
mobility of teeth
Localized mobility Generalized mobility Generalized mobility with
higher grade of mobility related to the involved  tooth
Pulp vitality using cold test, electric pulp test A lingering
response‐irreversible pulpitis. No response in necrotic pulp
The pulp is vital and responsive to testing Pulp vitality tests
negative
Pulp vitality may
be positive in
multirooted teeth
Usually negative. Positive response in multirooted
teeth
Pocket probing None unless sinus tract Moderate Evident or sinus tract Severe Severe, connects with periapex
Sinus tracing A radiograph with gutta percha points to apex or
furcation area in molars
Sinus tract mainly at the
lateral aspect of the root
Sinus tract mainly at the apex or furcation area Sinus tract mainly at the lateral aspect of the root Difficult to trace out the origin of the lesion
Radiographs Possible periapical radiolucency Decreased crestal bone height Radiolucency from apex to
sulcus,decreased crestal bone
height
Bone loss approaching apex Bone loss extending to apex
Cracked tooth Painful response to chewing No symptoms Painful response to chewing No symptoms Painful response to chewing

Table 3: Findings of endo perio lesion.

Figure 1 shows the decision analysis for diagnosis of endodontic-periodontal lesion.

medical-dental-science

Figure 1. Decision analysis for diagnosis of endodontic-periodontal lesion.

Figure 2 Shows decision analysis for diagnosis of endodontic-periodontal lesion [22].

medical-dental-science

Figure 2. Decision analysis for diagnosis of endodontic-periodontal lesion.

Decision analysis for the treatment of endodontic and periodontal lesion (Figure 3) [24,28-31].

medical-dental-science

Figure 3. Decision analysis for the treatment of endodontic and periodontal lesion.

Acknowledgement

The authors would like to acknowledge all the faculties of the Department of Conservative Dentistry and Endodontics for their constant encouragement with my work during all stages.

Conflict of Interest

There is no conflict of interest.

References

Author Info

Keerthika R and Nivedhitha MS*

Department of Conservative dentistry and Endodontics, Saveetha Dental College and Hospitals, Saveetha Institute of Medical And Technical Sciences, Saveetha University Tamilnadu, Chennai, India
 

Citation: Keerthika R, Nivedhitha MS, Endodontic Periodontal Lesion Diagnosis and Treatment Decision Analysis, J Res Med Dent Sci, 2021, 9 (2): 140-145.

Received: 23-Sep-2020 Accepted: 02-Feb-2021

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