ENDO-PERIODONTAL INTERRELATIONS

ENDO-PERIODONTAL INTERRELATIONS

Introduction :

• The tooth and the surrounding periodontium are closely linked on an anatomical and physiological level.
• There is a connective and vascular continuity between the pulp and the periodontium. Thus, any pathology affecting one will necessarily have repercussions on the other.

1. Reminders on the dental organ:
   1. Odonte:

• It is the tooth itself, it is composed from the outside to the inside of: Enamel, dentin and pulp.

2. Endodont:

• Corresponds to the internal part of the tooth composed of the pulp chamber and the root canals, within which is housed a richly vascularized and innervated loose connective tissue called the pulp.

3. Periodontium:

• It is the set of tissues that surround and support the tooth. It includes:
  • Superficial periodontium: Gingiva
  • Deep periodontium consisting of alveolar bone, cementum and periodontium.

2. Endo-periodontal communication pathways:
   1. Physiological:
      1. Apical foramen:

• Main endo-periodontal communication route, allowing the passage of blood vessels and nerve fibers from the periodontium to the endodontium.
• It also represents a high-potential pathway for bacteria.

2. Side channels and accessories:

• Extend from the main canal to the periodontium, establishing communication between the pulp and the periodontium.

3. Dentin tubules:

• They penetrate the dentin in its entire thickness and are protected by the cementum at the root level, and can be exposed in the event of: trauma, caries, periodontal pathology or an iatrogenic act (repeated surface treatment). From then on, they become a route of endo-periodontal communication.

2. Non-physiological:
   1. Iatrogenic root perforation:

• May occur during endodontic or prosthetic procedures (preparation for coronal-radicular reconstructions).

2. Root fracture:

• A real route of microbial contamination, which may be of traumatic or iatrogenic origin: oversized cast or crushed coronal-radicular reconstruction or overpressure during obturation by condensation.

3. Reciprocal endo-periodontal interrelationships:
   1. Influence of pulp pathology on the periodontium:
      1. Pulpite – Living pulp:

• Desmodontal enlargement in some cases, but without pronounced destruction of the attachment apparatus;

2. Necrosis – Mortified pulp:

• The periodontium could be affected by bacterial metabolites from the dead pulp through the root canals and apical foramen, resulting in destruction of desmodontal fibers and resorption of adjacent alveolar bone.
• The induced periodontal changes are referred to as periradicular lesions (periapical, lateral).

1. Chronic periapical lesion:

• Characterized by the presence of granulation tissue and an infiltrate of inflammatory cells;
• Cystic transformation is possible

2. Acute periapical lesion:

• Acute exacerbation of a chronic lesion which seeks to drain its purulent contents via a fistula whose path may extend into the gingivo-dental sulcus or into an existing pocket.

2. Influence of endodontic therapy on the periodontium:
   1. Root perforation:

• Periodontal lesions with loss of attachment, suppuration, increased mobility may be due to undetected or unsuccessfully treated root perforation.

2. Iatrogenic root fracture:

• Due to bacterial proliferation in the hiatus created by the root crack/fracture, the adjacent periodontal ligament becomes the site of an inflammatory lesion causing destruction of connective tissue fibers and alveolar bone.

3. Influence of periodontal disease on the pulp:
   1. Gingivitis:

• No influence on the pulp condition.

2. Periodontitis:

• The pulp could be reached by bacterial metabolites coming from the pocket through the accessory canals or dentinal tubules, this process results in retro pulpitis.

4. Influence of periodontal therapy on the pulp:
   1. Scaling and root planing:

• Overly aggressive surfacing removes cementum and the superficial part of the dentin, causing:
  • Dentin hypersensitivity
  • Exposure of dentin tubules with possible bacterial colonization of root dentin.

2. Root acid etching:

• Used in periodontal reattachment therapies (citric acid, tetracycline hydrochloride, EDTA) May cause dental abscess or pulp necrosis and dentin hypersensitivity.

4. Endodontic lesions LEP:
   1. Definition :

• It is a pathological communication between the pulp and the periodontal tissues of the same tooth and can present in an acute or chronic form.

2. Microbiology:

• We find bacterial species common to the endodontium and the periodontium represented by bacteria belonging to the red and orange complexes:
  • P. gingivalis
  • B. forsythia
  • T. denticola
  • As well as bacteria of the genus Fusobacterium and Prevotella .

3. Classification:
   1. Classification of Gulabivala and Darbar 2004

• Class I: Lesion of primary endodontic origin (with or without secondary periodontal involvement)
• Class II: Lesion of primary periodontal origin (with or without secondary endodontic involvement)
• Class III: True combined lesions.

2. Classification from the New Classification of Periodontal Diseases (Chicago 2017):

• Endodontic lesion with loss of root integrity:
  • Fracture – Perforation – External root resorption.
• Endodontic lesion without loss of root integrity:
  • With periodontitis:
    • Grade 1 : narrow pocket involving a dental surface;
    • Grade 2 : large pocket involving a dental floss ;
    • Grade 3 : Deep pockets involving more than one tooth surface
  • Without periodontitis: same grade description as the previous one.

4. Diagnosis:
   1. Means :
      1. Questioning:

• The anamnesis, the reason for consultation and the history of the disease contain sometimes very important elements regarding the origin and age of the problem and to look for possible notions of trauma or endodontic instrumentation.

2. Visual examination

• Looking for cavities, defective restorations, erosions, abrasions, cracks or fractures on the one hand, and dental plaque, tartar and gum inflammation on the other.

3. Palpation

• Palpation of the mucosa and external bone cortices is performed by firm pressure with the index fingers at the apical level of the dental organs. This allows the detection of a painful area, a sign of an acute inflammatory phenomenon.

4. Mobility review:

• Mobility reflects the integrity of a tooth’s attachment apparatus and inflammation of the periodontal ligament.
• It increases in cases of active periodontal disease, acute apical abscess, trauma or orthodontic displacement.

5. Pulp vitality test:

• This is the determining element for the diagnosis. We distinguish: Cold test – Hot test – Electrical test – Cavity test (milling).

6. Periodontal survey:

• Its objective is to check the integrity of the epithelial-connective tissue attachment.
• The gentle introduction of a graduated periodontal probe into the gingival sulcus and then its movement parallel to the tooth, from near to far, allows the clinician to understand the morphology of the defect:
  • A narrow (punctiform, V-shaped) probe indicates the presence of a narrow desmodontal fistula related to a lesion of endodontic origin or a root fracture.
  • The periodontal pocket accepts several probes, the probing is then described as arcuate (U-shaped) indicating a periodontal defect.
  • An arcuate probe associated with a punctiform probe characterizes the true endo-periodontal lesion

7. X-ray

It makes it possible to objectify the presence of:

• Coronary lesions (cavities), root lesions (resorptions), bone lesions (alveolysis)
• It is essential in the presence of a fistula to objectify the route using a gutta-percha cone.
• An arcuate probe associated with a punctiform probe characterizes the true endo-periodontal lesion.

Positive diagnosis (According to the classification of Gulabivala and Darbar 2004):

8. Lesion of endodontic origin:

• Pulp vitality test: negative;
• V-shaped punctiform survey;
• Apical or juxta-radicular bone lysis.

9. Periodontal lesion

• Pulp vitality test: positive;
• U-shaped arcuate survey;
• Bone lysis: marginal.

10. True combined endo-periodontal lesion

• Pulp vitality test: negative;
• Punctiform and arciform survey;
• Marginal and apical bone lysis;

5. Treatment (According to the classification of Gulabivala and Darbar 2004):
   1. Lesion of endodontic origin:

• Endodontic treatment is sufficient;
• If this fails, endodontic surgery may be considered.

2. Periodontal lesion:

• Etiological periodontal therapy, associated or not with surgical therapy, must be undertaken.

3. True endo-periodontal lesion:
   1. Endodontic treatment:

• Always start by cleaning the endodontium;
• If the periodontal lesion is significant, endodontic treatment will only be completed after periodontal disinfection.

2. Re-evaluation:

• After 3 months, we reassess:
  • Mucosal healing: disappearance or not of the fistula.
  • Initial bone healing clinically and radiologically.

3. Periodontal treatment:
   1. Non-surgical treatment:

• Motivation for hygiene;
• Scaling, root planing;
• Drug treatment (ATB, ATS, NSAIDs)

2. Surgical treatment:
3. Regenerative surgery:

• It consists of putting in place one of the following materials:
  • Guided Tissue Regeneration Membrane RTG;
  • Bone graft: autogenous bone or bone substitute materials MSO;
  • DMA enamel matrix derivatives (Emdogain);
  • Association: MSO + membrane or MSO + DMA.

2. Resective surgery:

• Hemisection or premolarization
• Root amputation:
• Coronal-radicular amputation:

Conclusion

• Knowledge of the potential for periodontal and periapical repair allows for a better assessment of the therapeutic approach to be taken and the chances of success.
• The close complementarity of periodontics and endodontics makes it possible to preserve or restore the functions of the dental organ and its periodontal environment.

ENDO-PERIODONTAL INTERRELATIONS

  Wisdom teeth can cause infections if not removed in time.
Dental crowns protect teeth weakened by cavities or fractures.
Inflamed gums can be a sign of gingivitis or periodontitis.
Clear aligners discreetly and comfortably correct teeth.
Modern dental fillings use biocompatible and aesthetic materials.
Interdental brushes remove food debris between teeth.
Adequate hydration helps maintain healthy saliva, which is essential for dental health.

ENDO-PERIODONTAL INTERRELATIONS