Endodontic and periodontal damage
I-INTRODUCTION:
Endodontics, like periodontics, seeks to prevent or eliminate lesions that alter the tooth’s attachment system; the relationships between the endodontium and the periodontium are close. These two anatomical structures are actually in contact through the foramen and the accessory and/or lateral canals.
The communication pathways between the periodontium and the endodontium explain the secondary effects of periodontal disease on the pulp. Conversely, pulp pathology can also directly affect the periodontal tissues.
II. INTERCOMMUNICATIONS BETWEEN THE ENDODONTIC AND THE PERIODONTIC:
2.1 Physiological pathways of communication between the endodontium and the periodontium:
The physiological communication pathways between the endodontium and the periodontium are numerous:
– Apical foramen.
– Secondary canal: located in the apical region, it goes from the main canal to the alveolodental ligament.
– Accessory canal: located in the apical region, it goes from a secondary canal to the alveolodental ligament.
– Lateral canal: equivalent of the secondary canal in the coronal and middle thirds of the root (De Deus, 1975).
– Interadicular space: area particularly rich in lateral canals.
– Dentin tubules.
Classification of De Deus.
B. Multiple foramina. D. View of an apex: multiple foramina under scanning electron microscope (SEM).
2.2 Pathological pathways of communication between the endodontium and the periodontium:
The pathological pathways of communication between the endodontium and the periodontium are also numerous:
-Root cracks
-Root perforations
-Perforations of the pulp floor.
The periodontal pocket can lead to cemento-dentin resorptions (external resorptions).
III. DEFINITION OF ENDO-PERIODONTAL LESIONS:
An apical inflammatory lesion of endodontic origin may not have to extend too far coronally to communicate with the lesion of periodontal origin. Apicomarginal communications of this type have been termed “true combined endo-periolesions” (Simon, 1976; Harrington, 1979). These lesions are characterized by considerable loss of attachment resulting from both intracanal infection and plaque accumulation on the root surface.
IV-ETIOLOGIES OF ENDO-PERIODONTAL LESIONS:
The etiologies are those of periodontal diseases and those of pathologies affecting the hard tissues of the tooth (carious and traumatic pathologies). There are also specific contributing factors to the interadicular spaces:
- Enamel beads:
These enamel pearls are most often located at the bifurcation of the roots of the upper molars, more rarely on the vestibular or lingual surface of the roots of the lower molars.
- Enamel projections:
Enamel projections are enamel growths that take the form of a spur, a plate, a ridge, or a tongue. They are located near the neck, usually on the buccal surface of the lower second molars, less often on the upper first molars.
These morphological anomalies can induce a periodontal defect with secondary necrosis of the pulp.
- Occlusal trauma
- Orthodontics
- Pulp pathology
- Periodontal pathology
- Root perforation
- Root fracture
- Endodontic therapies
- Periodontal therapies
V- PATHOGENESIS OF ENDOPARODONTAL LESIONS:
5.1. Influences of pathological pulp conditions on the periodontium:
Teeth affected by pulpitis may occasionally show radiographic signs of inflammation in the periapical periodontal ligament, but it is important to emphasize that pulpitis, whether reversible or irreversible, does not cause pronounced destruction of periodontal tissues. This is not the case with pulp necrosis, which causes chronic or acute lateroradicular periapical lesions.
5.1.1 Chronic lesion : Within the dead pulp tissue, microorganisms find favorable conditions for their growth. Bacteria release various substances (enzymes, metabolites, antigens, etc.) that will reach the periodontium through the canals and foramina that connect the pulp to the periodontal ligament. Once in the periodontium, bacterial products can induce inflammatory changes that lead to the destruction of periodontal tissue fibers and the resorption of the adjacent alveolar bone.
5.1.2 Acute lesion: during an acute phase, a chronic lesion maintained by infection from a necrotic pulp can cause rapid and widespread destruction of periodontal tissues. Similarly, an acute periapical lesion (periapical abscess) can be the direct extension of pulp necrosis; this abscess seeks to drain its purulent contents through a path of least resistance called a “fistula” if the tooth is hermetically closed.
The fistula tract can externalize into the gingivodental sulcus or an existing pocket and the abscess thus formed, although of endodontic origin, presents the clinical signs of a periodontal abscess.
In such a case, it is important to distinguish between two possible routes:
-The fistula tract develops along the desmodontal space and puts the periapical lesion and the gingivodental sulcus or the existing pocket in direct communication: true desmodontal fistula.
-The abscess perforates the bone cortex near the apex and the fistula tract develops by lifting the soft tissues, including the periosteum, and externalizes into the gingivodental sulcus or the existing pocket.
In multi-rooted patients, these acute lesions of endodontic origin can fistulate in the furcation and present certain clinical and radiological signs of inter-radicular lesions.
Fistular path along the desmodontal space, externalizing in the gingivo-dental sulcus and/or in a pocket: true desmodontal fistula.
- Influence of periodontal disease on the condition of the pulp:
- Gingivitis:
The early inflammatory stages of periodontal disease related to plaque have no influence on the condition of the pulp. As long as the cementum remains intact, the inflammation does not cross this barrier.
- Periodontitis:
Periodontal damage can induce two pulp pathologies: atrophy and degeneration or inflammation through the accessory canals and dentin tubules.
5.3. Influence of endodontic therapies on the periodontium:
-Root canal filling (above or below the canal filling)
-Root perforation
-Root fracture
5.4. Influence of periodontal therapies on the pulp:
-Scaling and root planing
-Treatment of dentin hypersensitivity
VI. CLASSIFICATION OF ENDOPARODONTAL LESIONS:
Generally speaking, endo-periodontal lesions include all cases where pulp pathology and periodontal pathology are related through hard tissues.
6.1. Classification of Simon, Glick and Frank (1972):
It is based on the origin of the progression of the lesions:
Class I: Pure endodontic lesions.
Class II: Primary endodontic lesions with secondary periodontal involvement.
Class III: Pure periodontal lesions.
Class IV: Primary periodontal lesions with secondary endodontic complications.
Class V: Associated lesions without interference between them.
Class VI: Combined lesions: true endo-periodontal lesions.
6.2. Hiatt classification (1977):
Class I: Periodontal lesions with endodontic interferences.
Class II: Endodontic lesions with periodontal interferences.
Class III: Combined endo-periodontal lesions.
Class IV: Traumatic endodontic lesions secondary to periodontitis
Class V: Traumatic periodontal lesions secondary to endodontics.
6.3. Wine Classification:
Class I: tooth whose clinical and radiological symptoms simulate periodontal disease but whose etiology is in fact inflammation and/or pulp necrosis.
Class II: tooth that presents periodontal disease and pulp or periapical disease at the same time.
Class III: periodontal disease, absence of pulp disease but need for endodontic treatment with a view to root amputation.
Class IV: clinical and radiological simulation of pulp or periapical disease when it is actually periodontal disease.
6.4 Classification of Guldener and Langeland 1982:
Class I: primary endodontic lesions
Class II: primary periodontal lesions
Class III: combined endodontic and periodontal lesions
A: Class I: Primary endodontic lesions: infection passing through the apex or accessory canals (furcation),*drainage canal*generally narrow and difficult to probe towards the margin
B: Class II: primary periodontal lesions: infection of the pulp from the pocket via the furcation, the apex, the lateral canals, probable pocket*large*
C: Class III: combined endo-paro lesions.
6.5. Classification of inter-radicular lesions:
Many authors have proposed classifications of lesions of periodontal origin.
The one by Hamp and Nyman, which takes into account the importance of horizontal destruction, is the most used:
Class I (initial): beginning of furcation involvement and the disease does not extend more than one-third (3 mm) inside the furcation in the horizontal direction;
Class II (partial): the damage covers a horizontal depth greater than 3 mm, without crossing it completely;
Class III (total): the damage is complete, and the probe can pass completely between the roots.
VII DIAGNOSIS OF ENDOPERODONTAL DISEASE:
- Diagnosis:
For a lesion to be qualified as endo-periodotal, two criteria are necessary:
-The tooth involved, at the level of the lesion, must have lost its pulp vitality
-The periodontal attachment system must be broken from the gingivo-dental sulcus to the apex or; at least; to the level of a lateral and/or accessory canal which could be involved in the lesion
It is therefore necessary, when diagnosing endo-periodontal lesions, to jointly assess pulpal and periodontal involvement.
Endodontic lesion Periodontal lesion
Secondary periodontal disease Secondary pulp disease
True combined injury
In endo-periodontal pathology, the diagnosis must be made with precision and attention, based on the etiology and pathogenesis of the lesions.
Two circumstances complicate the diagnosis:
-An endodontic lesion can cause a periodontal lesion and vice versa.
-Two lesions that are originally independent can grow, come into contact and merge.
| Clinical examinations | Endodontic lesions | Periodontal lesions |
| Sensitivity tests | Negatives | Positives |
| Lesion architecture | U-shaped | Triangular |
| Soft/hard deposits | Absent | Present |
| Cavity or filling | Presents | Absent |
| Mobility | Absent | Presents |
| Occlusal trauma | Absent | Generally present |
| X-ray | Periapical image | Coronal or lateral bone loss, not involving the apex |
| Periodontal pocket | If it exists, it is narrow | Wide and deep |
| Gum | At the healthy limit | Inflammation and recession |
| Mobility | Absent | Presents |
| Treatment | Endodontics | Endo-periodontics |
| Prognosis | Good | Depends on periodontal treatment |
7.2 Differential diagnosis of endo-periodontal disorders:
These lesions are to be differentiated from certain cases where a periodontal lesion coexists with an endodontic lesion, without any topographical relationship.
Periodontal lesion coexisting with the beginning of an endodontic lesion due to poorly conducted treatment. These lesions have no topographical relationship. (Documents J.-L. Giovannoli. 1980)
VIII. THERAPEUTIC ATTITUDES:
Therapeutic choices are made based on the etiology:
– Endodontic etiology:
Endodontic treatment is sufficient to eliminate bone lesions.
– Periodontal etiology:
Periodontal treatment is necessary for stabilization of bone lesions. However, endodontic treatment may be necessary for hemisection or in cases of pulp necrosis secondary to periodontitis.
– Endo-periodontal etiology:
The healing potential of endodontic lesions is very high. This is why endodontic treatment is always undertaken before periodontal treatment (Machtou and Cohen, 1996). The healing time varies between individuals. Radiographic monitoring is therefore necessary before undertaking periodontal treatment.
Operative chronology in the treatment of endo-periodontal lesions
IX. CONCLUSION:
Endo-periodontal relationships are not limited to inflammatory and/or degenerative lesions and can be extended to various traumatic injuries and resorptions that bring the endodontium and the periodontium into contact.
The close complementarity of endodontics and periodontics makes it possible to preserve the dental organ as well as its periodontal environment.
Most often, in cases of true endoperiodontal lesions, perirapical healing can be expected after successful endodontic treatment. However, periodontal tissues may not respond well to treatment and will depend on the severity of the combined lesion.
Endodontic and periodontal damage
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