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Management of Periodontitis Associated with Endodontically Involved Teeth: a Case Series

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Management of Periodontitis Associated with Endodontically Involved Teeth: a Case Series Management of Periodontitis Associated with Endodontically Involved Teeth: A Case Series Abstract The pulp and the periodontal attachment are the two components that enable a tooth to function in the oral cavity. Lesions of the periodontal ligament and adjacent alveolar bone may originate from infections of the periodontium or tissues of the dental pulp. The simultaneous existence of pulpal problems and inflammatory periodontal disease can complicate diagnosis and treatment planning. The function of the tooth is severely compromised when either one of these is involved in the disease process. Treatment of disease conditions involving both of these structures can be challenging and frequently requires combining both endodontic and periodontal treatment procedures. This article presents cases of periodontitis associated with endodontic lesions managed by both endodontic and periodontal therapy. Keywords: Endodontic-periodontic, periodontitis, pulp, periapical periodontitis, combined lesions Citation: Anand PS, Nandakumar K. Management of Periodontitis Associated with Endodontically Involved Teeth: A Case Series. J Contemp Dent Pract 2005 May;(6)2:118-129. © Seer Publishing 1 The Journal of Contemporary Dental Practice, Volume 6, No. 2, May 15, 2005 Introduction It has long been recognized that an intimate relationship exists between the pulp of a tooth and the surrounding periodontium.1 Much of the focus has been on the possible pathways for the spread of inflammation and infection from one component to the other. The periodontium communicates with pulp tissues through many channels or pathways. These channels may be involved in extending pulpal infections to the periodontium and vice versa. Thus, lesions of the periodontal ligament and adjacent alveolar bone may originate from infections of the periodontium or tissues of the dental pulp. The simultaneous existence of endodontic and inflammatory periodontal lesions can complicate diagnosis and treatment planning processes. It can also affect the sequence of treatment to be performed.2 vital. But necrosis of the pulp tissue can result in bone resorption at the root apex, furcation Etiology regions, or anywhere along the length of the It has been proved unequivocally the primary root, which may be observed on the dental etiologic agent in periodontitis is bacterial plaque radiographs as radiolucent lesions.9, 10 These adhering to the teeth and other hard surfaces lesions may be a peri-radicular abscess, in the oral cavity. Besides this primary factor, cyst, or a granuloma. When the infection there is a wide array of secondary factors that spreads through the lateral canals, the lesion contribute to the disease process either by may develop along the lateral surface of the increasing the chance of plaque accumulation or root. These lateral canals are more common in by accelerating the disease process by altering the posterior teeth and more in the apical portion the response of the host to bacterial plaque.3 of the root.11 Although evidence exists for such channels of communication, a mechanism for It is also accepted irreversible pulpal disease the direct transmission of periodontal infection occurs when trauma inflicted on the pulpal tissues into the pulpal tissues is not yet clear, and exceeds their reparative capacity.4 Such a only a weak explanation for pulpal pathology pathological insult can occur through the invasion resulting in periodontal attachment loss has been of bacteria or biochemical toxins in deep carious established.3 Nevertheless, based on existing lesions, or by direct trauma to the pulp during evidence, it is reasonable to believe endodontic restorative therapy.5, 6 lesions can induce a loss of periodontal attachment. Impact of Pulpal Disease on the Periodontal Tissues Impact of Periodontal Pathoses on Pulpal infection may cause a tissue-destructive Pulp Tissue process that proceeds from the apical region of The pathogenic bacteria and inflammatory a tooth toward the gingival margin. The term products of periodontal disease may gain “retrograde periodontitis” was suggested in access to the dental pulp through accessory order to differentiate this condition from marginal canals, apical foramina, or dentinal tubules.2 periodontitis, where the infection spreads from the This process is referred to as “retrograde gingival margin toward the apical portion of the pulpitis.”7 Histologic studies of teeth extracted root.7, 8 due to severe periodontal disease suggest periodontitis seldom produces significant changes Even in the presence of significant in the dental pulp.12, 13 Irreversible pulpitis or inflammation, pulpal tissue may not affect the pulpal necrosis has not been consistently found in periodontium.2 This is true so long as the pulp is such teeth. But pathological changes in the pulp 2 The Journal of Contemporary Dental Practice, Volume 6, No. 2, May 15, 2005 may occur once the periodontal disease reaches the involved tooth should be determined.3 The a terminal stage-when the bacterial plaque techniques commonly employed for diagnosis involves the apical foramina.13 Since the pulp has include radiographic examination, diagnostic good capacity for defense, retrograde pulpitis, probing, and vitality testing.15 even if it occurs, is rare.14 According to Harrington, lesions that are Classification purely endodontic and draining through the Various classifications have been put forward sulcus should be apparent by careful tactile for classifying periodontitis associated with probing.16 Vitality testing is the most widely endodontic lesions. Simon et al. have classified used test in endodontics.17 These tests measure the lesions based on the primary source of the neural response providing little information infection.10 It is as follows: regarding the vascularity of the pulp. These tests are advantageous when it indicates a 1. Primary periodontal lesions necrotic pulp, which assures the clinician the 2. Primary endodontic lesions pulpal disease is contributing to the periodontal 3. Primary periodontal lesions with secondary breakdown and endodontic therapy is indicated. endodontic involvement 4. Primary endodontic lesions with secondary Recent advances in diagnosis include the use of periodontal involvement Doppler devices, pulse oximetry, and magnetic 5. True combined lesions resonance imaging.18, 19 A true combined lesion is said to be present when Laser Doppler Flowmetry is a non-invasive, an endodontic lesion extends and communicates electro-optical technique which allows the semi- with a pre-existing periodontal lesion.2 quantitative recording of pulpal blood flow.20 Over the past decade, this technology has been Diagnosis used experimentally to monitor the blood flow of Diagnosis of combined periodontal-endodontic dental pulp in humans and animals.21, 22 It has lesions can prove difficult and frustrating. They been reported Laser Doppler Flowmetry is more are often characterized by extensive loss of reliable than other pulp vitality tests and could be periodontal attachment and alveolar bone, used as an exclusive and reliable tool to assess and their successful management depends on tooth vitality.23 In a recent study assessing the careful clinical evaluation, accurate diagnosis, use of Laser Doppler Flowmetry in detecting and a structured approach to treatment planning short- and long-term changes of pulpal blood for both the periodontic and endodontic flow values of luxated permanent maxillary components. First, the endodontic status of central incisors after repositioning and splinting, 3 The Journal of Contemporary Dental Practice, Volume 6, No. 2, May 15, 2005 The following are three clinical situations of periodontitis associated with endodontic lesion that were managed with a combined approach: Case 1 This report describes a situation in which a lesion of primary endodontic origin with secondary periodontal involvement was treated by a combined approach. A 17-year old female patient presented with complaints of pain and swelling in relation to an upper anterior tooth. There was it was found this technique may be useful in the a history of trauma two years back with avulsion detection of ischemic episodes.24 and replantation of tooth 23. There was grade I mobility of this tooth. Radiographic examination The pulse oximeter is a non-invasive oxygen revealed a large radiolucency in relation to tooth saturation-monitoring device widely used in 23 involving the entire length of the distal aspect medical practice for recording blood oxygen of the tooth and root resorption on the mesial saturation levels during the administration of aspect at the coronal third of the root (Figures 1 intra-venous anesthesia. The device is currently and 2). under investigation in dental practice to detect pulpal blood circulation by virtue of its non- invasive and atraumatic nature. Schnettler and Wallace compared the pulse oximeter with thermal and electrical pulp tests to evaluate the vitality of maxillary central incisors in 49 adults and reported the pulse oximeter indicated a pulse rate and oxygen saturation reading for the vital teeth and no readings for the teeth previously endodontically treated. This suggests the pulse oximeter has a high degree of accuracy in evaluating pulp vitality.25 Figure 1: Abscess in relation to tooth 23. Magnetic resonance imaging is another method of assessing pulpal perfusion and pulp vitality. Lockhart et al. compared the magnetic resonance imaging with routine Hematoxylin and Eosin histology on a cross sectional view of a molar tooth
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