Managing Concurrent Endodontic and Periodontal Diseases **W/Prof. Paul V. Abbott AO** --- **Managing Concurrent Endodontic and Periodontal Diseases** **Prof. Paul V. Abbott AO** *BDSc, MDS, FRACDS(Endo), FPFA, FADI, FICD, FACD, FIADT* Specialist Endodontist Winthrop Professor of Clinical Dentistry UWA Dental School The University of Western Australia --- **Managing Concurrent Endodontic and Periodontal Diseases** 2nd Year DMD - 2020 Page 1 # **Managing Concurrent Endodontic and Periodontal Diseases** **W/Prof. Paul V. Abbott AO** *BDSc, MDS, FRACDS(Endo), FPFA, FADI, FICD, FACD, FIADT* Specialist Endodontist Winthrop Professor of Clinical Dentistry UWA Dental School The University of Western Australia # Managing Concurrent Endodontic and Periodontal Diseases W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 2 ## Concurrent Endodontic & Periodontal Diseases - Confusion and uncertainty - why? - Classifications - old and new - Inter-relationships - root canal system & periodontium - Management: - Diagnosis - Which treatment first - ?? Endodontics or ?? Periodontics - Strategies to manage concurrent diseases - Case examples ## Reference **Strategies for the endodontic management of concurrent endodontic and periodontal diseases** **Abbott PV, Castro Salgado J.** *Aust Dent J 2009; 54 (Suppl 1): S70 - S85.* # **Managing Concurrent Endodontic and Periodontal Diseases** ## **Concurrent Endodontic & Periodontal Diseases** > [!info] > Concurrent endodontic and periodontal diseases are particularly difficult cases to treat and are a source of significant confusion for the dental profession. This lecture aims to clarify this uncertainty by discussing classifications, the interrelationship between the pulp and periodontium, and a sequential management strategy. - Confusion and uncertainty - why? - Classifications - old and new - Inter-relationships - root canal system & periodontium - Management: - Diagnosis - Which treatment first - ?? Endodontics or ?? Periodontics - Strategies to manage concurrent diseases - Case examples ## **Reference** **Strategies for the endodontic management of concurrent endodontic and periodontal diseases** **Abbott PV, Castro Salgado J.** *Aust Dent J 2009; 54 (Suppl 1): S70 - S85.* > [!note] > The content of this lecture is primarily based on the principles outlined in this paper. The principles and information remain valid and relevant today. **Managing Concurrent Endodontic and Periodontal Diseases** W/Prof. Paul V. Abbott AO --- **Concurrent Endodontic & Periodontal Diseases** **A Source of Much Confusion and Uncertainty!!!** **TWO main reasons for this confusion:** 1. The “all inclusive” approach 2. The diagnostic classifications used --- **Concurrent Endodontic & Periodontal Diseases** **Broad Interactions** - Cracked cusps - Root caries - Grooved roots - Traumatic occlusion - Lateral periodontal cyst - Developmental anomalies - Orthodontic complications - Resorption - Perforations - Transplanted teeth - Restoration margins - Vertical root fractures - Horizontal root fracture - Dentine hypersensitivity --- 2nd Year DMD - 2020 Page 3 ## **Concurrent Endodontic & Periodontal Diseases: A Source of Confusion** ### **Sources of Confusion** **TWO main reasons for this confusion:** 1. The “all inclusive” approach - ==Many textbooks and journals group various distinct conditions under the umbrella of 'endo-perio lesions' simply because they have both endodontic and periodontal implications.== 2. The diagnostic classifications used - ==Historical and even some modern classifications are often not clinically useful, meaningful, or based on accurate disease terminology.== ### **Broad Interactions (Conditions with Both Endodontic and Periodontal Implications)** - Cracked cusps - Root caries - Grooved roots - Traumatic occlusion - Lateral periodontal cyst - Developmental anomalies - Orthodontic complications - Resorption - Perforations - Transplanted teeth - Restoration margins - Vertical root fractures - Horizontal root fracture - Dentine hypersensitivity **Managing Concurrent Endodontic and Periodontal Diseases** **W/Prof. Paul V. Abbott AO** **2nd Year DMD - 2020** **Page 4** --- **Concurrent Endodontic & Periodontal Diseases** **Broad Interactions** - All may have Endodontic & Periodontal implications / symptoms / signs - BUT they are not “Concurrent Endodontic and Periodontal Diseases” - They are distinct diseases / conditions - with their own causes and specific management options **Cracked cusps** **Root caries** **Grooved roots** **Traumatic occlusion** **Lateral periodontal cyst** **Developmental anomalies** **Orthodontic complications** **Resorption** **Perforations** **Transplanted teeth** **Restoration margins** **Vertical root fractures** **Horizontal root fracture** **Dentine hypersensitivity** --- **Concurrent Endodontic & Periodontal Diseases** **Broad Interactions** - Some examples .... --- - All may have Endodontic & Periodontal implications / symptoms / signs - BUT they are not “Concurrent Endodontic and Periodontal Diseases” - They are distinct diseases / conditions - with their own causes and specific management options Some examples .... Managing Concurrent Endodontic and Periodontal Diseases W/Prof. Paul V. Abbott AO **Root Perforation** - Manifested by rapid increased probing depth, suppuration, increased mobility, pain/awareness with function *Courtesy of Dr Albert Tan - Periodontist* **Horizontal Root Fractures** - Manifested by rapid increased probing depth, suppuration, increased mobility, pain/awareness with function *Courtesy of Dr Albert Tan - Periodontist* 2nd Year DMD - 2020 Page 5 #### **Root Perforation** - ==An iatrogenic event, such as a post-placement error, can cause periodontal pocketing and may lead to an **infected root canal system**.== - ==The primary diagnosis is *root perforation*, not a concurrent disease.== - Manifested by rapid increased probing depth, suppuration, increased mobility, pain/awareness with function #### **Horizontal Root Fractures** - ==A fracture in the root can cause periodontal pocketing and abscess formation.== - ==The primary diagnosis is *horizontal root fracture*.== - Manifested by rapid increased probing depth, suppuration, increased mobility, pain/awareness with function **Managing Concurrent Endodontic and Periodontal Diseases** **W/Prof. Paul V. Abbott AO** --- ### **Vertical Root Fractures** - Manifested by rapid increased probing depth, suppuration, increased mobility, pain/awareness with function --- ### **External Invasive Root Resorption** - Manifested by bleeding on probing, sometimes with ankylosis, sometimes with suppuration if infected, otherwise asymptomatic --- *2nd Year DMD - 2020* *Page 6* ### **Vertical Root Fractures** - ==These fractures can lead to periodontal pocketing, an **infected root canal system**, and apical periodontitis.== - ==The primary diagnosis is *vertical root fracture*.== - Manifested by rapid increased probing depth, suppuration, increased mobility, pain/awareness with function ### **External Invasive Root Resorption** - ==This condition can manifest with periodontal abscesses and ankylosis.== - ==The diagnosis is *external invasive resorption* (e.g., a Class 4 Heathersay type), which often necessitates extraction.== - Manifested by bleeding on probing, sometimes with ankylosis, sometimes with suppuration if infected, otherwise asymptomatic **Managing Concurrent Endodontic and Periodontal Diseases** W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 7 --- **Caries, Restorations, Cracks** - 36 - caries, restoration breakdown, root-filled & infected root canal system - Distal root - crack and periodontal pocketing --- **Concurrent Endodontic & Periodontal Diseases** **Broad Interactions** - All have Endodontic & Periodontal implications / symptoms / signs - **BUT they are not “Concurrent Endodontic and Periodontal Diseases”** - **They are distinct diseases / conditions - with their own causes and specific management options** > **Cracked cusps** > **Root caries** > **Grooved roots** > **Traumatic occlusion** > **Lateral periodontal cyst** > **Developmental anomalies** > **Orthodontic complications** > **Resorption** > **Perforations** > **Transplanted teeth** > **Restoration margins** > **Vertical root fractures** > **Horizontal root fracture** > **Dentine hypersensitivity** *All have Endodontic & Periodontal implications / symptoms / signs* **BUT they are not “Concurrent Endodontic and Periodontal Diseases”** **They are distinct diseases / conditions - with their own causes and specific management options** ### **Caries, Restorations, Cracks** - ==Dental caries, failing restorations (e.g., with overhangs), or cracks (e.g., cracked cusp) can independently lead to both pulp disease and **periodontal problems**.== - ==These are specific causative factors and should be diagnosed accordingly.== - 36 - caries, restoration breakdown, root-filled & infected root canal system - Distal root - crack and periodontal pocketing ### **Clarification on Broad Interactions** - All have Endodontic & Periodontal implications / symptoms / signs - **BUT they are not “Concurrent Endodontic and Periodontal Diseases”** - **They are distinct diseases / conditions - with their own causes and specific management options** > [!warning] > This lecture focuses exclusively on *true* cases of concurrent endodontic and periodontal diseases, where a tooth simultaneously presents with both an endodontic disease (originating from the pulp) and a separate **periodontal disease** (originating from the marginal periodontium). **Managing Concurrent Endodontic and Periodontal Diseases** W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 8 --- **Concurrent Endodontic & Periodontal Diseases** **A Source of Much Confusion and Uncertainty!!!** **TWO main reasons for this confusion:** 1. The “all inclusive” approach 2. The diagnostic classifications used --- **Concurrent Endodontic & Periodontal Diseases** - **Confusion and uncertainty - why?** - **Classifications - old and new** - **Inter-relationships - root canal system & periodontium** - **Management:** - Diagnosis - Which treatment first - ?? Endodontics or ?? Periodontics - Strategies to manage concurrent diseases - Case examples --- **Managing Concurrent Endodontic and Periodontal Diseases** **W/Prof. Paul V. Abbott AO** **2nd Year DMD - 2020** **Page 9** --- **“Endo-Perio Lesions”** → **Problematic Terminology!!!** - **Classification: Simon, Glick & Frank (1972)** - **1° Endo lesion** - **1° Endo lesion with 2° Perio involvement** - **1° Perio lesion** - **1° Perio lesion with 2° Endo involvement** - **“True” Combined lesion** --- Diagram illustrating 6 labeled tooth cross-sections: A: 1° Endo B: 1° Endo (furcation) C: 1° Endo, 2° Perio D: 1° Perio E: 1° Perio, 2° Endo F: True combined lesion # **Classifications of Endodontic and Periodontal Conditions** ## **Problematic Terminology: “Endo-Perio Lesions”** > [!bug] > The term 'lesion' is defined as an injury or wound. A periapical radiolucency is a host defense reaction to infection, not an injury itself. Therefore, 'disease' is a more accurate term. The term 'endo-perio lesion' is problematic and should be avoided. - **Classification: Simon, Glick & Frank (1972)** - 1° Endo lesion - 1° Endo lesion - ==Describes a draining sinus tract from an apical abscess that exits through the gingival sulcus, mimicking a **periodontal pocket**.== - ==This is purely an endodontic problem. The drainage pathway is through bone, not the periodontal ligament, and resolves with **root canal treatment** alone.== - ==A furcation radiolucency caused by an accessory canal from an **infected root canal system** is also just an endodontic problem.== with 2° Perio involvement - 1° Perio lesion - 1° Perio lesion - ==Describes a deep **periodontal pocket** extending to the apex, causing a radiolucency that mimics an endodontic lesion, but the pulp remains vital.== - ==This is purely a periodontal problem. Pulp sensibility tests are normal, and the bone loss resolves with **periodontal treatment** alone.== with 2° Endo involvement - ==These categories attempt to describe a situation where one disease process initiates the other.== - ==Clinically, it is impossible to determine which disease came first once both are established.== - “True” Combined lesion Managing Concurrent Endodontic and Periodontal Diseases W/Prof. Paul V. Abbott AO 1° Endo From: Bergenholtz G. IN: Lindhe J. Textbook of Clinical Periodontology 1993 **Unlikely....!!!** 2nd Year DMD - 2020 Page 10 ### **1° Endo Lesion** Unlikely....!!! Managing Concurrent Endodontic and Periodontal Diseases W/Prof. Paul V. Abbott AO From: Abbott & Castro Salgado - ADJ 2009 21 22 **1° Endo** **1° Endo (furcation)** 2nd Year DMD - 2020 Page 11 - **1° Endo** - **1° Endo (furcation)** Managing Concurrent Endodontic and Periodontal Diseases W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 12 Radiographic comparison of Pre-op, Post-op RCF, and 6 mth Review for endodontic treatment. Diagrams illustrating 1° Endo and 1° Endo (furcation) under the heading "Endodontic Diseases". Managing Concurrent Endodontic and Periodontal Diseases W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 13 Endodontic Diseases diagram with labels: 1° Endo, 1° Endo (furcation), 1° Perio, 1° Endo, 2° Perio, 1° Perio, 2° Endo — True combined lesion Diagram showing X-ray beam passing through periodontal pocket to film, with inset clinical photo of periodontal pocket. Label: From: Abbott - Endo Topics 2004 Managing Concurrent Endodontic and Periodontal Diseases W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 14 **Pre-op** | **1 Year Review** --- | --- **CO₂** + | **CO₂** + **EPT** 34 | **EPT** 15 Courtesy of Dr Ehsan Mellati - Periodontist **Pulp Sensibility Tests** | Date | 1/3/17 | 1/6/17 | 10/7/17 | 11/8/17 | |----------|--------|--------|---------|---------| | **CO₂** | + | + | + | + | | **EPT** | 22 | 20 | 20 | 15 | Courtesy of Dr Michael Khoury Radiographs and pulp sensibility test results for endodontic and periodontal case management. ### **Case Examples & Pulp Sensibility** **Case 1** | Pre-op | 1 Year Review | | :--- | :--- | | **CO₂** + | **CO₂** + | | **EPT** 34 | **EPT** 15 | **Case 2: Pulp Sensibility Tests** | Date | 1/3/17 | 1/6/17 | 10/7/17 | 11/8/17 | | :--- | :--- | :--- | :--- | :--- | | **CO₂** | + | + | + | + | | **EPT** | 22 | 20 | 20 | 15 | Managing Concurrent Endodontic and Periodontal Diseases W/Prof. Paul V. Abbott AO **Pulp Sensibility Tests** | Date | 19/8/16 | 4/7/17 | 1/9/17 | |---------|---------|--------|--------| | CO₂ | + | + | + | | EPT | 22 | 51 | 17 | Courtesy of Dr Michael Khoury **Endodontic Diseases** - 1° Endo - 1° Endo (furcation) **Periodontal Disease** - 1° Perio 2nd Year DMD - 2020 Page 15 **Case 3: Pulp Sensibility Tests** | Date | 19/8/16 | 4/7/17 | 1/9/17 | | :--- | :--- | :--- | :--- | | CO₂ | + | + | + | | EPT | 22 | 51 | 17 | ### **Disease Categories** - **Endodontic Diseases** - 1° Endo - 1° Endo (furcation) - **Periodontal Disease** - 1° Perio **Managing Concurrent Endodontic and Periodontal Diseases** W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 16 Diagram illustrating types of concurrent endodontic and periodontal diseases with labeled tooth diagrams and a highlighted box stating "A Source of Much Confusion !!" **Managing Concurrent Endodontic and Periodontal Diseases** W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 17 --- **“Endo-Perio Lesions”** *Problematic Terminology!!!* - Classification: Simon, Glick & Frank (1972) - 1º Endo lesion - 1º Endo lesion with 2º Perio involvement - 1º Perio lesion - 1º Perio lesion with 2º Endo involvement - “True” Combined lesion > **Possible** > **Meaningful** > **Useful** --- **Clinical Classification** *(Modified from Torabinejad and Trope 1996)* - Based on the origin of the periodontal pocket: - **Endodontic Origin** Diagram showing tooth with arrows indicating endodontic origin of periodontal pocket ## **Critique of Traditional Classifications** ### **Simon, Glick & Frank (1972) Classification Issues** - 1º Endo lesion - 1º Endo lesion with 2º Perio involvement - 1º Perio lesion - 1º Perio lesion with 2º Endo involvement - “True” Combined lesion - ==This describes a tooth with both endodontic and periodontal disease, which is functionally identical to the 'primary/secondary' categories.== > **Possible** > **Meaningful** > **Useful** > [!failure] > **Conclusion:** This classification is not clinically useful. The terms are not meaningful (e.g., they don't specify the type of pulp or periodontal disease), and it wrongly includes conditions that are purely endodontic or purely periodontal. ### **Clinical Classification (Modified from Torabinejad and Trope 1996)** - Based on the origin of the periodontal pocket: - **Endodontic Origin** **Managing Concurrent Endodontic and Periodontal Diseases** **W/Prof. Paul V. Abbott AO** **2nd Year DMD - 2020** **Page 18** --- **Clinical Classification** *(Modified from Torabinejad and Trope 1996)* - Based on the origin of the periodontal pocket: - **Endodontic Origin** - **Periodontal Origin** --- **Clinical Classification** *(Modified from Torabinejad and Trope 1996)* - Based on the origin of the periodontal pocket: - **Endodontic Origin** - **Periodontal Origin** - **Combined Endo-Perio Lesions:** - Separate endodontic & periodontal lesions - *No communication* - Lesions communicate **Problematic Terminology** --- Figure showing radiographic image and schematic of tooth with periodontal pocket classification - Based on the origin of the periodontal pocket: - **Endodontic Origin** - **Periodontal Origin** - **Combined Endo-Perio Lesions:** - Separate endodontic & periodontal lesions - *No communication* - ==A separate periapical radiolucency and a **periodontal pocket** exist, but they do not connect.== - Lesions communicate **Problematic Terminology** Managing Concurrent Endodontic and Periodontal Diseases W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 19 **Combined Endo-Perio Lesions** - Separate lesions - No communication - Lesions communication **Problematic Terminology** **Clinical Classification** *(Modified from Torabinejad and Trope 1996)* - Based on the origin of the periodontal pocket: - **Endodontic Origin** - Not “Endo-Perio” - only Endo. - **Periodontal Origin** - Not “Endo-Perio” - only Perio. - **Combined Endo-Perio Lesions:** - Separate endodontic & periodontal lesions - No communication - Lesions communicate - ✅ Possible - ? Meaningful - ? Useful **Problematic Terminology** 37 38 ### **Issues with "Combined Endo-Perio Lesions"** - **Combined Endo-Perio Lesions:** - Separate endodontic & periodontal lesions - No communication - Lesions communicate - ==**WITH communication:** The **periodontal pocket** probes directly to the periapical lesion.== - ✅ Possible - ? Meaningful - ? Useful - **Endodontic Origin** - ==Same as the 'primary endo lesion' from the 1972 classification; it is a purely endodontic disease.== - Not “Endo-Perio” - only Endo. - **Periodontal Origin** - ==Same as the 'primary perio lesion'; it is a purely **periodontal disease**.== - Not “Endo-Perio” - only Perio. **Problematic Terminology** **Managing Concurrent Endodontic and Periodontal Diseases** **W/Prof. Paul V. Abbott AO** **2nd Year DMD - 2020** **Page 20** --- ### **A New Clinical Classification** *(Abbott and Castro Salgado - ADJ 2009)* - **Concurrent Endodontic & Periodontal Diseases** → Without communication → With communication **Combined** ❌ brought together, united or joined **Concurrent** ✅ occurring simultaneously - *www.dictionary.com* --- ### **A New Clinical Classification** *(Abbott and Castro Salgado - ADJ 2009)* - **Concurrent Endodontic & Periodontal Diseases** → Without communication → With communication **Lesion** ❌ an injury or a wound **Disease** ✅ a pathological condition; a harmful deviation from normal - *www.dictionary.com* --- **39** **40** ## **A New Clinical Classification (Abbott and Castro Salgado - ADJ 2009)** - **Concurrent Endodontic & Periodontal Diseases** - → Without communication - → With communication ### **Terminology Definitions** - **Combined** ❌ brought together, united or joined - **Concurrent** ✅ occurring simultaneously - ==*Concurrent* is a more accurate descriptor for teeth that have both diseases, whether they are communicating or not.== - **Concurrent** ✅ occurring simultaneously - *www.dictionary.com* - **Lesion** ❌ an injury or a wound - **Disease** ✅ a pathological condition; a harmful deviation from normal - ==*Disease* better describes the processes involved.== - **Disease** ✅ a pathological condition; a harmful deviation from normal - *www.dictionary.com* > [!success] > The recommended terminology is **Concurrent Endodontic and Periodontal Diseases**. **Managing Concurrent Endodontic and Periodontal Diseases** W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 21 --- ### **A New Clinical Classification** *(Abbott and Castro Salgado - ADJ 2009)* **Concurrent Endodontic & Periodontal Diseases** → Without communication → With communication **Applies to teeth that have BOTH:** 1. An infected root canal system causing some form of apical periodontitis 2. **AND:** some form of marginal periodontal disease *Abbott - Endod Topics 2004* *Abbott & Yu - ADJ 2007* --- ### **Classifications of Pulp, Root Canal and Periapical Conditions** Figure showing two referenced publications: "Abbott & Yu - ADJ 2007" and "Abbott - Endod Topics 2004" ### **Application of the New Classification** **Concurrent Endodontic & Periodontal Diseases** → Without communication → With communication **Applies to teeth that have BOTH:** 1. An infected root canal system causing some form of apical periodontitis 2. **AND:** some form of marginal periodontal disease *Abbott - Endod Topics 2004* *Abbott & Yu - ADJ 2007* > [!todo] > This approach requires the clinician to make two separate diagnoses for the same tooth: > 1. A specific endodontic diagnosis for the pulp, **root canal**, and periapical tissues. > 2. A specific periodontal diagnosis using the standard periodontal classification. ### **Classifications of Pulp, Root Canal and Periapical Conditions** **Managing Concurrent Endodontic and Periodontal Diseases** W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 22 --- **In Particular ... Teeth With:** **PULP / ROOT CANAL CONDITIONS** - Necrotic and infected pulp - Pulpless and infected root canal system, or - Root-filled and infected root canal system **PERIAPICAL CONDITIONS** - 2° acute apical periodontitis - Chronic apical periodontitis - 2° acute apical abscess - Chronic apical abscess - Extra-radicular infection - Pocket cyst - True cyst, or - Foreign body reaction --- **Plus ...** - **Advanced chronic periodontitis** ➤ Loss of attachment to the apical foramina ■ With pulp implications - **Or PERHAPS teeth with early-moderately advanced chronic periodontitis** ➤ If a lateral canal foramen is involved ■ Since may be pulp implications ### **Specific Conditions Included** **In Particular ... Teeth With:** #### **PULP / ROOT CANAL CONDITIONS** - Necrotic and infected pulp - Pulpless and infected root canal system, or - Root-filled and infected root canal system #### **PERIAPICAL CONDITIONS** - 2° acute apical periodontitis - Chronic apical periodontitis - 2° acute apical abscess - Chronic apical abscess - Extra-radicular infection - Pocket cyst - True cyst, or - Foreign body reaction **Plus ...** - **Advanced chronic periodontitis** - ➤ Loss of attachment to the apical foramina - ■ With pulp implications - **Or PERHAPS teeth with early-moderately advanced chronic periodontitis** - ➤ If a lateral canal foramen is involved - ■ Since may be pulp implications **Managing Concurrent Endodontic and Periodontal Diseases** W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 23 **Concurrent Endodontic & Periodontal Diseases** - **Confusion and uncertainty - why?** - **Classifications - old and new** - **Inter-relationships - root canal system & periodontium** - **Management:** - Diagnosis - Which treatment first - ?? Endodontics or ?? Periodontics - Strategies to manage concurrent diseases - Case examples 45 46 Concurrent Endodontic and Periodontal Diseases From: Abbott & Castro Salgado 2009 Without communication | With communication **Managing Concurrent Endodontic and Periodontal Diseases** **W/Prof. Paul V. Abbott AO** **2nd Year DMD - 2020** **Page 24** --- **Concurrent Endodontic & Periodontal Diseases** **Communication Pathways** *From: Abbott & Castro Salgado 2009* --- **Concurrent Endodontic & Periodontal Diseases** **Communication Pathways** **Apical Foramen** **Dentine Tubules** --- 47 48 # **Inter-relationships: Root Canal System & Periodontium** ## **Communication Pathways** - **Apical Foramen** - **Dentine Tubules** Managing Concurrent Endodontic and Periodontal Diseases W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 25 --- **Concurrent Endodontic & Periodontal Diseases** **Communication Pathways** **Lateral Canals** *From the main canal laterally to the PDL* *From: Bergenholtz G. In: Lindhe J. Textbook of Clinical Periodontology 1993* **Accessory Canals** *Canals from the pulp chamber to the furcation* *From: Dr Robert Bower* --- **Concurrent Endodontic & Periodontal Diseases** **Communication Pathways** **Developmental Grooves** **Cracks / Fractures** --- 2nd Year DMD - 2020 Page 25 - **Lateral Canals** - ==More common in the apical third of the root (approx. 8.8%) and less common in the coronal third (1.6%), where periodontal pockets typically begin.== - *From the main canal laterally to the PDL* - **Accessory Canals** - *Canals from the pulp chamber to the furcation* - **Developmental Grooves** - ==Such as palato-radicular grooves, which can harbor plaque and provide a direct pathway to the pulp.== - **Cracks / Fractures** **Managing Concurrent Endodontic and Periodontal Diseases** **W/Prof. Paul V. Abbott AO** **2nd Year DMD - 2020** **Page 26** --- **Concurrent Endodontic & Periodontal Diseases** **Communication Pathways** *From: Abbott & Castro Salgado 2009* --- **Similarities in the microflora of root canals and deep periodontal pockets** *Kerekes K, Olsen I.* *Endod Dent Traumatol 1990; 6: 1-5* - Review showing similarities between microflora of infected root canals and deep periodontal pockets - Evidence supports the concept that infection can spread from one site to the other --- 51 52 ## **Microbiological Evidence** ### **Similarities in the microflora of root canals and deep periodontal pockets** - ==There are significant similarities in the types of anaerobic bacteria found in infected **root canals** and **deep periodontal pockets**.== *Kerekes K, Olsen I. Endod Dent Traumatol 1990; 6: 1-5* - A review showing similarities between the microflora of infected root canals and deep periodontal pockets provides evidence supporting the concept that infection can spread from one site to the other. **Managing Concurrent Endodontic and Periodontal Diseases** W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 27 --- **Evidence for the concept that infection can spread from one site to the other** **Cross-infecting organisms:** - Highly motile - Survive in highly reduced environments **Precautions must be taken:** - To prevent *in vivo* cross seeding of these micro-organisms during treatment - Especially in compromised teeth → i.e. those with concurrent diseases *Kerekes & Olsen 1990* --- **Influence of endodontic infection on marginal periodontal status.** *Experimental studies in monkeys and clinical studies in periodontitis-prone patients.* **Leif Jansson – 1995** *D. Odontol Thesis - Karolinska Institute, Sweden* - Swed Dent J 1983; 17: 85-93 - J Clin Period 1993; 20: 117-23 - J Periodontol 1993; 64: 947-53 - J Clin Period 1994; 21: 577-82 - J Clin Period 1995; 22: 598-602 - J Clin Period 1995; 22: 729-34 ### **Infection Spread and Treatment Precautions** **Evidence for the concept that infection can spread from one site to the other** - **Cross-infecting organisms:** - Highly motile - Survive in highly reduced environments - **Precautions must be taken:** - To prevent *in vivo* cross seeding of these micro-organisms during treatment - Especially in compromised teeth - → i.e. those with concurrent diseases - ==It is crucial to take precautions during treatment to prevent **cross-seeding** of bacteria, e.g., from an infected pocket into a cleaned **root canal** or vice-versa.== *Kerekes & Olsen 1990* ### **Influence of endodontic infection on marginal periodontal status.** *Leif Jansson – 1995, D. Odontol Thesis - Karolinska Institute, Sweden* - Swed Dent J 1983; 17: 85-93 - J Clin Period 1993; 20: 117-23 - J Periodontol 1993; 64: 947-53 - J Clin Period 1994; 21: 577-82 - J Clin Period 1995; 22: 598-602 - J Clin Period 1995; 22: 729-34 **Managing Concurrent Endodontic and Periodontal Diseases** *W/Prof. Paul V. Abbott AO* *2nd Year DMD - 2020* *Page 28* --- **In periodontitis-prone patients, intracanal infection was significantly correlated with:** - Deeper periodontal pockets - Significantly more attachment loss over 6 years → **1.1mm -v- 0.4mm** **Intracanal infection was the most important contribution to increased pocket depth** **Intracanal infections stimulate epithelial downgrowth along denuded dentine surfaces with marginal communication** **Intracanal infections must not be overlooked when treatment planning for periodontal disease** *Jansson 1995* --- **Concurrent Endodontic & Periodontal Diseases** - Confusion and uncertainty - why? - Classifications - old and new - Inter-relationships - root canal system & periodontium - Management: - Diagnosis - Which treatment first - ?? Endodontics or ?? Periodontics - Strategies to manage concurrent diseases - Case examples --- *2nd Year DMD - 2020* *Page 28* ### **Key Findings from Jansson (1995)** > [!quote] A series of studies on patients with periodontitis over six years revealed critical findings: - In periodontitis-prone patients, intracanal infection was significantly correlated with deeper periodontal pockets and significantly more attachment loss over 6 years (**1.1mm -v- 0.4mm**). - Intracanal infection was the most important contributor to increased pocket depth and stimulates epithelial downgrowth. - Intracanal infections must not be overlooked when treatment planning for periodontal disease. - ==If **periodontal treatment** is performed while ignoring an existing endodontic infection, the healing response is compromised, leading to epithelial downgrowth rather than new attachment.== - **==Conclusion:** To achieve predictable periodontal healing, the **infected root canal system** *must* be treated.== # Managing Concurrent Endodontic and Periodontal Diseases **W/Prof. Paul V. Abbott AO** **2nd Year DMD - 2020** **Page 29** --- ## Managing Teeth with Concurrent Endodontic and Periodontal Diseases ### Diagnosis - **Must differentiate between Endodontic and Periodontal Diseases** *In order to provide appropriate management* --- ### Diagnosis must be based on **ALL** of the following: - History - Symptoms - Visual appearance of tissues - Caries, restorations, etc - Radiographic findings - Clinical tests: - Pulp sensibility tests - Periodontal probing - Palpation, percussion, mobility, etc. > **i.e., a THOROUGH Examination !!** # **Managing Teeth with Concurrent Endodontic and Periodontal Diseases** ## **Diagnosis** - **Must differentiate between Endodontic and Periodontal Diseases** - *In order to provide appropriate management* ### **Basis for Diagnosis** Diagnosis must be based on **ALL** of the following: - History - Symptoms - Visual appearance of tissues - Caries, restorations, etc - Radiographic findings - Clinical tests: - Pulp sensibility tests - Periodontal probing - Palpation, percussion, mobility, etc. > **i.e., a THOROUGH Examination !!** Managing Concurrent Endodontic and Periodontal Diseases W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 30 **Managing Teeth with Concurrent Endodontic and Periodontal Diseases** - Four “absolute essentials” - CO₂ Pulp Tester - Electric Pulp Tester - Periodontal Probe - Periapical Radiograph **Periodontal Probing** *(Illustration showing probing technique with green checkmarks indicating correct placement)* Periodontal probing diagram with labeled tooth and probe insertion points ### **Essential Diagnostic Tools** - Four “absolute essentials” - CO₂ Pulp Tester - ==For cold testing.== - Electric Pulp Tester - ==Both cold and electric tests are necessary as teeth may respond to one but not the other.== - Periodontal Probe - ==A narrow, ball-ended probe is ideal for detecting the deep, narrow pockets often associated with endodontic issues or root cracks.== - Periapical Radiograph - ==For assessing bone levels and periapical status.== **Periodontal Probing** **Managing Concurrent Endodontic and Periodontal Diseases** W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 31 --- **Managing Teeth with Concurrent Endodontic and Periodontal Diseases** *What treatment should be done first?* **Depends on the DIAGNOSIS !!!** - **Key decision:** → Is there an **ACUTE** condition? OR → Are both the periapical & periodontal diseases **CHRONIC**? --- **Managing Teeth with Concurrent Endodontic and Periodontal Diseases** *Acute cases* - Diagnose the source of the pain &/or swelling → ? Periapical or ? Periodontal - Treat this problem first → Convert the acute problem into a chronic one - Follow soon after with other treatment ## **Treatment Sequencing** *What treatment should be done first?* **Depends on the DIAGNOSIS !!!** - **Key decision:** - → Is there an **ACUTE** condition? - OR - → Are both the periapical & periodontal diseases **CHRONIC**? ### **Acute Cases** - Diagnose the source of the pain &/or swelling - → ? Periapical or ? Periodontal - Treat this problem first - ==This emergency treatment effectively converts the acute problem into a chronic one, which can then be managed comprehensively.== - → Convert the acute problem into a chronic one - Follow soon after with other treatment **Managing Concurrent Endodontic and Periodontal Diseases** W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 32 --- **Managing Teeth with Concurrent Endodontic and Periodontal Diseases** *What treatment should be done first?* **Chronic cases** - i.e. - no pain or swelling - Ideally sequence the treatment to avoid any cross-seeding of bacteria and the effects of the intracanal infection on the periodontal tissues and the healing response --- **Managing Teeth with Concurrent Endodontic and Periodontal Diseases** *What treatment should be done first?* **Chronic cases** - Periodontal treatment first ??? **OR** - Endodontic treatment first ??? **OR** - Do them simultaneously ??? 63 64 ### **Chronic Cases** - i.e. - no pain or swelling - Ideally sequence the treatment to avoid any cross-seeding of bacteria and the effects of the intracanal infection on the periodontal tissues and the healing response - Periodontal treatment first ??? - **OR** - Endodontic treatment first ??? - **OR** - Do them simultaneously ??? **Managing Concurrent Endodontic and Periodontal Diseases** W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 33 --- **Managing Teeth with Concurrent Endodontic and Periodontal Diseases** **Debate - ? Perio first** > Root canal infection significantly affects periodontal healing > Pocket depth reduction is significantly less in the presence of root canal infection > More marginal epithelium over cementum defects if the root canals are infected --- **Managing Teeth with Concurrent Endodontic and Periodontal Diseases** **Debate - ? Perio first** > Cementum removed - will expose dentinal tubules: > - If bacteria in the root canal > → Promotes Ext. Inflammatory Resorption > - May expose periodontal tissues to toxic medicaments if used in the root canal > → Not so critical in areas with recession ### **The Debate: Periodontal Treatment First?** > [!failure] This approach is **not recommended** for several reasons: - Root canal infection significantly affects periodontal healing. - ==The existing **infected root canal system** will significantly impair periodontal healing, leading to less pocket depth reduction and more epithelial downgrowth (Jansson, 1995).== - Pocket depth reduction is significantly less in the presence of root canal infection. - More marginal epithelium over cementum defects if the root canals are infected. - Cementum removed - will expose dentinal tubules: - If bacteria in the root canal - → Promotes Ext. Inflammatory Resorption - ==Scaling and root planing removes cementum, exposing dentine tubules. This can allow bacteria from the infected canal to cause external inflammatory root resorption.== - May expose periodontal tissues to toxic medicaments if used in the root canal - → Not so critical in areas with recession - ==Exposed tubules can also allow toxic intra-canal medicaments to leak out and damage periodontal tissues.== Managing Concurrent Endodontic and Periodontal Diseases W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 34 **Managing Teeth with Concurrent Endodontic and Periodontal Diseases** **Debate - ? Endo first** ✓ Cementum layer is kept intact until the root canal infection is removed  ➤ No exposed dentine on root surface  ➤ Reduced chance of ext. root resorption  ➤ Improved periodontal healing **Managing Teeth with Concurrent Endodontic and Periodontal Diseases** **Debate - ? Endo first** ➤ BUT root canal fillings do **NOT** seal canals  ➤ All we can do is **FILL** the main root canal(s)  ➤ But **NOT** the root canal **SYSTEM** ➤ **FILLING** and **SEALING** are **NOT** the same thing!!! ### **The Debate: Endodontic Treatment First?** > [!tip] > This is the preferred approach as it addresses the endodontic infection, which is critical for successful periodontal healing. However, there is a significant caveat. - ✓ Cementum layer is kept intact until the root canal infection is removed - ➤ No exposed dentine on root surface - ➤ Reduced chance of ext. root resorption - ➤ Improved periodontal healing - ➤ BUT root canal fillings do **NOT** seal canals - ➤ All we can do is **FILL** the main root canal(s) - ➤ But **NOT** the root canal **SYSTEM** - ➤ **FILLING** and **SEALING** are **NOT** the same thing!!! # Managing Concurrent Endodontic and Periodontal Diseases W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 35 ## Bacterial Migration - Many studies have demonstrated that bacteria can readily migrate through root-filled roots - Coronal → Apical ## Bacterial Migration Representative Studies from the Literature <table> <thead> <tr> <th>Year</th> <th>Reference</th> <th>Comparison</th> <th>Bacteria Used</th> <th>Days Taken to Reach Apex</th> </tr> </thead> <tbody> <tr> <td>1990</td> <td>Torabinejad et al</td> <td>2 x Bacterial Species</td> <td>S. epidermidis<br>P. Vulgaris</td> <td>10 - 73</td> </tr> <tr> <td>1993</td> <td>Khayat et al</td> <td>2 x RCF Techniques</td> <td>Saliva bacteria</td> <td>2 - 48</td> </tr> <tr> <td>1999</td> <td>Barthel et al</td> <td>3 x RCF Cements</td> <td>S. epidermidis</td> <td>8 - 14</td> </tr> <tr> <td>1996</td> <td>Chailertvanitkul et al</td> <td>2 x RCF Techniques + Smear Layer</td> <td>S. sanguis</td> <td>7 - 86</td> </tr> <tr> <td>1997</td> <td>Chailertvanitkul et al</td> <td>2 x RCF Cements + 6 Months Storage</td> <td>P. intermedia</td> <td>10 - 71</td> </tr> <tr> <td>2001</td> <td>Timpawat et al</td> <td>3 x RCF Cements</td> <td>E. faecalis</td> <td>16 - 30</td> </tr> <tr> <td>2002</td> <td>Jacobson et al</td> <td>2 x RCF Techniques</td> <td>S. pneumonia</td> <td>2 - 72</td> </tr> <tr> <td>2002</td> <td>Carratù et al</td> <td>2 x RCF Techniques</td> <td>P. mirabilis + S. epidermidis</td> <td>13 - 37</td> </tr> <tr> <td>2009</td> <td>Eldeniz & Ørstavik</td> <td>2 x RCF Techniques + 8 x RCF Cements</td> <td>S. mutans</td> <td>2 - 40</td> </tr> </tbody> </table> **Range: 2 – 86 days** Diagram showing bacterial migration from coronal to apical through a root canal filled (RCF) tooth, with labels for "Bacteria," "RCF," and "Broth." ## **Bacterial Migration in Root-Filled Teeth** - **==Root fillings do not seal canals.==** ==They only fill the space.== - Many studies have demonstrated that bacteria can readily migrate through root-filled roots from Coronal → Apical. ### **Representative Studies on Bacterial Migration** <table> <thead> <tr> <th>Year</th> <th>Reference</th> <th>Comparison</th> <th>Bacteria Used</th> <th>Days Taken to Reach Apex</th> </tr> </thead> <tbody> <tr> <td>1990</td> <td>Torabinejad et al</td> <td>2 x Bacterial Species</td> <td>S. epidermidis<br>P. Vulgaris</td> <td>10 - 73</td> </tr> <tr> <td>1993</td> <td>Khayat et al</td> <td>2 x RCF Techniques</td> <td>Saliva bacteria</td> <td>2 - 48</td> </tr> <tr> <td>1999</td> <td>Barthel et al</td> <td>3 x RCF Cements</td> <td>S. epidermidis</td> <td>8 - 14</td> </tr> <tr> <td>1996</td> <td>Chailertvanitkul et al</td> <td>2 x RCF Techniques + Smear Layer</td> <td>S. sanguis</td> <td>7 - 86</td> </tr> <tr> <td>1997</td> <td>Chailertvanitkul et al</td> <td>2 x RCF Cements + 6 Months Storage</td> <td>P. intermedia</td> <td>10 - 71</td> </tr> <tr> <td>2001</td> <td>Timpawat et al</td> <td>3 x RCF Cements</td> <td>E. faecalis</td> <td>16 - 30</td> </tr> <tr> <td>2002</td> <td>Jacobson et al</td> <td>2 x RCF Techniques</td> <td>S. pneumonia</td> <td>2 - 72</td> </tr> <tr> <td>2002</td> <td>Carratù et al</td> <td>2 x RCF Techniques</td> <td>P. mirabilis + S. epidermidis</td> <td>13 - 37</td> </tr> <tr> <td>2009</td> <td>Eldeniz & Ørstavik</td> <td>2 x RCF Techniques + 8 x RCF Cements</td> <td>S. mutans</td> <td>2 - 40</td> </tr> </tbody> </table> **Range: 2 – 86 days** - ==Numerous laboratory studies show that bacteria placed at the coronal end of a root-filled tooth can migrate to the apex in as little as 2 to 86 days.== Managing Concurrent Endodontic and Periodontal Diseases W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 36 **The Dentine-Pulp Complex** Cementum Root Canal Filling **Managing Teeth with Concurrent Endodontic and Periodontal Diseases** **Debate - ? Endo first** × BUT root canal fillings do **NOT** seal canals  ■ Filled canals may be re-infected from the periodontal bacteria if the periodontal treatment is delayed × Especially when “Concurrent Diseases with communication” between the two sites  **“Cross-seeding”** ### **Implications of Bacterial Migration** - × BUT root canal fillings do **NOT** seal canals - ■ Filled canals may be re-infected from the periodontal bacteria if the periodontal treatment is delayed - × Especially when “Concurrent Diseases with communication” between the two sites - ==If a tooth with a communicating concurrent disease is root-filled while the **periodontal pocket** is still infected, bacteria from the pocket can reinfect the **root canal system** via the apical foramen, lateral canals, or exposed dentine tubules.== - **“Cross-seeding”** **Managing Concurrent Endodontic and Periodontal Diseases** W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 37 --- **Managing Teeth with Concurrent Endodontic and Periodontal Diseases** **Debate - ? Endo first** ✔ Canal sterility is more likely while there is a dressing in the root canal ■ Therefore delay the RCF until the periodontal infection has been removed  ○ To reduce chance of bacterial “cross-seeding” --- **Managing Teeth with Concurrent Endodontic and Periodontal Diseases** **WITHOUT communication** ■ Do Endodontic treatment first  → Can complete RCF after usual medication period ■ Then do Periodontal treatment soon after Radiographic and schematic illustrations of endodontic and periodontal anatomy ### **Revised Endodontic-First Approach** > [!info] > To prevent reinfection, the final **root canal filling** should be **delayed** until the periodontal infection has been resolved. The canal should be kept dressed with an antibacterial medicament during this period. - ✔ Canal sterility is more likely while there is a dressing in the root canal - ■ Therefore delay the RCF until the periodontal infection has been removed - ○ To reduce chance of bacterial “cross-seeding” ## **Treatment Strategy by Communication Status** ### **WITHOUT communication** - **==Sequence:** Perform **root canal treatment** first, followed by **periodontal treatment**.== - ==The final root filling can be placed after the usual medication period, as the risk of reinfection from the separate periodontal pocket is low.== - ■ Do Endodontic treatment first - → Can complete RCF after usual medication period - ■ Then do Periodontal treatment soon after # Managing Concurrent Endodontic and Periodontal Diseases W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 38 ## Managing Teeth with Concurrent Endodontic and Periodontal Diseases ### WITHOUT communication - **Root-filled & Infected RCS with 1° acute apical periodontitis** - **Post-op RCF** - **3 year Review** - **22 year Review** ### WITH communication - **Start the Endodontic treatment first** - Use long-term dressings and defer RCF until overall prognosis re-assessed and favourable - **Do the Periodontal treatment while the root canals are still medicated** Radiographic comparison of teeth managed with and without communication between endodontic and periodontal treatments, including 3-year and 22-year reviews. #### **Case Example: WITHOUT communication** - **Root-filled & Infected RCS with 1° acute apical periodontitis** - **Post-op RCF** - **3 year Review** - **22 year Review** ### **WITH communication** > [!warning] This situation requires a more prolonged, staged approach. - **==Sequence:** Start **endodontic treatment** first, but **defer the final root filling.**== - ==Use long-term intra-canal dressings while the **periodontal treatment** is performed and healing is assessed.== - **Start the Endodontic treatment first** - Use long-term dressings and defer RCF until overall prognosis re-assessed and favourable - **Do the Periodontal treatment while the root canals are still medicated** **Managing Concurrent Endodontic and Periodontal Diseases** *W/Prof. Paul V. Abbott AO* *2nd Year DMD - 2020* *Page 39* --- **Managing Teeth with Concurrent Endodontic and Periodontal Diseases** **Which medicament(s)? - CS/AB (e.g. Ledermix paste)** - **Corticosteroid (triamcinolone)** → Anti-inflammatory → Inhibits clastic cells → Prevents & arrests inflammatory resorption - **Antibiotic (demeclocycline)** → Anti-bacterial - *BUT limited* → Increased mineralisation of bone → Inhibits clastic cells --- **Managing Teeth with Concurrent Endodontic and Periodontal Diseases** **Which medicament(s)? - Calcium hydroxide** - Anti-bacterial - Prevent & arrest inflammatory resorption - Stimulates hard tissue formation - **BUT - it is toxic:** → Tissue necrosis → If no cementum: • Increased ankylosis • Increased replacement resorption ## **Intra-canal Medicaments** ### **CS/AB (e.g. Ledermix paste)** - **Corticosteroid (triamcinolone)** - → Anti-inflammatory - → Inhibits clastic cells - → Prevents & arrests inflammatory resorption - **Antibiotic (demeclocycline)** - → Anti-bacterial - *BUT limited* - → Increased mineralisation of bone - → Inhibits clastic cells ### **Calcium hydroxide** - Anti-bacterial - Prevent & arrest inflammatory resorption - Stimulates hard tissue formation - **BUT - it is toxic:** - → Tissue necrosis - → If no cementum: - • Increased ankylosis - • Increased replacement resorption # Managing Concurrent Endodontic and Periodontal Diseases W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 40 ## Managing Teeth with Concurrent Endodontic and Periodontal Diseases ### Which medicament(s)? - **? Ledermix + Ca(OH)₂ pastes** - Combines advantages of both materials with no reduction in therapeutic properties - Maintains all active components in the canal for a longer period of time - Ledermix paste reduces the toxicity of the calcium hydroxide and therefore reduces the harmful side effects ## Managing Teeth with Concurrent Endodontic and Periodontal Diseases ### Initial Management - Remove existing restorations and caries - *To assess suitability of tooth for further treatment* - Chemo-mechanically prepare the root canals - Medicate the root canals: - **Ledermix and Ca(OH)₂ pastes (50:50 mixture)** - Interim restoration: - **Ketac Silver or Ketac Fil** - **+ Ortho Band** ### **? Ledermix + Ca(OH)₂ pastes** - **==Recommended Combination:** A 50/50 mixture of Ledermix and Calcium Hydroxide is often the best choice.== - **==Benefits:** Combines the advantages of both materials. The Ledermix paste reduces the toxicity of the calcium hydroxide, and the combination provides broad-spectrum antibacterial and anti-inflammatory action.== - Combines advantages of both materials with no reduction in therapeutic properties - Maintains all active components in the canal for a longer period of time - Ledermix paste reduces the toxicity of the calcium hydroxide and therefore reduces the harmful side effects ## **Management Protocol** > [!abstract] This protocol applies to cases **WITH communication**. ### **Initial Management** 1. ==**Access and Assess:** Remove old restorations, caries, and cracks to assess the tooth's restorability and periodontal prognosis. Probe again after access is gained.== 2. ==**Chemo-mechanical Preparation:** Clean and shape the **root canal system**.== 3. ==**Medicate:** Place an intra-canal medicament (e.g., 50/50 Ledermix/Ca(OH)₂).== 4. ==**Interim Restoration:** Place a well-sealed interim restoration (e.g., glass ionomer), using an orthodontic band only if necessary and ensuring it does not impede oral hygiene or periodontal access.== 5. ==**Wait:** Leave the initial dressing for a minimum of 4 weeks to allow the medicament to become fully effective within the dentine.== - Remove existing restorations and caries - *To assess suitability of tooth for further treatment* - Chemo-mechanically prepare the root canals - Medicate the root canals: - **Ledermix and Ca(OH)₂ pastes (50:50 mixture)** - Interim restoration: - **Ketac Silver or Ketac Fil** - **+ Ortho Band** # Managing Concurrent Endodontic and Periodontal Diseases **W/Prof. Paul V. Abbott AO** **2nd Year DMD - 2020** **Page 41** ## Managing Teeth with Concurrent Endodontic and Periodontal Diseases - Ensure adequate interim restoration throughout all phases of treatment - Allow normal oral hygiene - Avoid SS band if possible ## Managing Teeth with Concurrent Endodontic and Periodontal Diseases ### Follow-up Management - Minimum 4 weeks later - do initial periodontal treatment - Review healing after 3 months - Reassess need for further periodontal treatment - If more periodontal treatment (e.g. surgery) reqd: - Change intra-canal medication → **Led + Ca(OH)₂** - If / when healing response favourable: - Complete the root canal filling - Place definitive restoration - Ensure adequate interim restoration throughout all phases of treatment - Allow normal oral hygiene - Avoid SS band if possible ### **Follow-up Management** 1. ==**Periodontal Treatment:** After the initial 4-week endodontic phase, the patient undergoes non-surgical **periodontal treatment**.== 2. ==**Review (3 months later):** Reassess the periodontal healing.== 3. ==**Re-treat if Necessary:** If periodontal healing is incomplete, more **periodontal treatment** (e.g., further root planing, surgical access) may be needed. At this point, the intra-canal dressing should be changed.== 4. ==**Repeat Cycle:** Continue the cycle of periodontal management and changing the intra-canal dressing every ~3 months until a favorable and stable periodontal outcome is achieved.== 5. ==**Final Treatment:** Only when the periodontal prognosis is deemed favorable should the **root canal filling** be completed and a definitive restoration placed.== - Minimum 4 weeks later - do initial periodontal treatment - Review healing after 3 months - Reassess need for further periodontal treatment - If more periodontal treatment (e.g. surgery) reqd: - Change intra-canal medication → **Led + Ca(OH)₂** - If / when healing response favourable: - Complete the root canal filling - Place definitive restoration Managing Concurrent Endodontic and Periodontal Diseases W/Prof. Paul V. Abbott AO **Managing Teeth with Concurrent Endodontic and Periodontal Diseases** **WITH communication** - Age: 39 yrs - Diabetic - Dentist - Male 2nd Year DMD - 2020 Page 42 Radiograph showing pre-op, post-op RCF, 6 mth review, and 11 yr review images with arrows indicating progression. ## **Case Studies: WITH communication** ### **Case 1** - ==**Treatment:** Endodontic treatment was initiated and dressed. The periodontist performed root planing and later, surgical debridement. The canal was re-dressed. Once healing was stable, the **root canal** was filled.== - **==Result:** An 11-year review showed stable bone levels and a healthy tooth.== - **Age:** 39 yrs - **Medical History:** Diabetic - **Occupation:** Dentist - **Gender:** Male # Managing Concurrent Endodontic and Periodontal Diseases **W/Prof. Paul V. Abbott AO** **2nd Year DMD - 2020** **Page 43** --- ## Managing Teeth with Concurrent Endodontic and Periodontal Diseases ### *WITH communication* - **Female** - **Solicitor** - **Age: 42 yrs** - **Nil Medically** --- ### Pre-op. ### 2 mths Led/Ca(OH)₂ dressing ### Post-op. RCF ### 3 year Review --- Radiographic images showing pre-operative, post-operative (RCF), and 3-year review stages, with a 2-month Led/Ca(OH)₂ dressing phase indicated. ### **Case 2** - ==A case with a clear communicating pocket.== - **Gender:** Female - **Occupation:** Solicitor - **Age:** 42 yrs - **Medical History:** Nil Medically #### **Treatment Progression** - **Pre-op.** - **2 mths Led/Ca(OH)₂ dressing** - **Post-op. RCF** - **3 year Review** **Managing Concurrent Endodontic and Periodontal Diseases** **W/Prof. Paul V. Abbott AO** **2nd Year DMD - 2020** **Page 44** --- **Managing Teeth with Concurrent Endodontic and Periodontal Diseases** **WITH communication** - **Female** - **Secretary** - **Age: 35 yrs** - **Nil Medically** --- **Pre-op.** **9 mths - RCF** **WL** Radiographic images showing pre-operative, 9 months post-RCF, and WL views of a tooth with concurrent endodontic and periodontal diseases. ### **Case 3** - ==A bridge abutment with an ill-fitting margin, leading to an **affected root canal system** and distal bone loss.== - **Gender:** Female - **Occupation:** Secretary - **Age:** 35 yrs - **Medical History:** Nil Medically #### **Treatment Progression** - ==Following the protocol, significant bone repair was already visible just 3 months after commencing **root canal treatment**. The result remained stable for years.== - **Pre-op.** - **9 mths - RCF** - **WL** - ==The bridge was removed, and the protocol was followed. The final result showed excellent bone repair both periapically and on the distal aspect where the periodontal defect was.== # Managing Concurrent Endodontic and Periodontal Diseases W/Prof. Paul V. Abbott AO 2nd Year DMD - 2020 Page 45 ## Prognosis of Teeth with Concurrent Endodontic and Periodontal Diseases - **Wait and reassess** - But how long do you wait after 1° treatment? - **Outcome will depend largely on the periodontal response and prognosis** - **Essential to keep monitoring all aspects:** - → Periodontal - → Endodontic - → Restorative - → And any other aspects ## Alternative Treatments for Teeth with Concurrent Endodontic and Periodontal Diseases - **Root resection** - **Hemisection** - With root removal - Without root removal - **Extraction** - Or other prosthesis # **Prognosis and Alternative Treatments** ## **Prognosis of Teeth with Concurrent Endodontic and Periodontal Diseases** - ==The overall prognosis depends **mainly on the periodontal prognosis.**== - ==Disinfecting the **root canal system** is relatively predictable.== - ==Achieving ideal periodontal healing is more challenging due to factors like complex root anatomy and patient oral hygiene.== - **Wait and reassess** - But how long do you wait after 1° treatment? - **Outcome will depend largely on the periodontal response and prognosis** - **Essential to keep monitoring all aspects:** - → Periodontal - → Endodontic - → Restorative - → And any other aspects ## **Alternative Treatments for Teeth with Concurrent Endodontic and Periodontal Diseases** - **Root resection** - **Hemisection** - ==Involves sectioning a lower molar through the furcation and removing one half, or separating the roots to be restored as two individual premolars.== - With root removal - Without root removal - **Extraction** - ==Sometimes extraction is the only option.== - ==Replacement with an implant may be complicated. These sites often have significant bone loss, and patients with generalized **periodontal disease** may be poor candidates for implants.== - Or other prosthesis **Managing Concurrent Endodontic and Periodontal Diseases** **W/Prof. Paul V. Abbott AO** **2nd Year DMD - 2020** **Page 46** --- **Root Resections** *Lander et al J Perio 1981; 52: 719-22* **Molars lost after 10 yrs** <table> <thead> <tr> <th>Reason for loss</th> <th>Max.</th> <th>Mand.</th> <th>Total</th> </tr> </thead> <tbody> <tr> <td>Periodontal</td> <td>7 %</td> <td>3 %</td> <td>10 %</td> </tr> <tr> <td>Endodontic</td> <td>3 %</td> <td>4 %</td> <td>7 %</td> </tr> <tr> <td>Root fracture</td> <td>3 %</td> <td>15 %</td> <td>18 %</td> </tr> <tr> <td>Other</td> <td>0</td> <td>3 %</td> <td>3 %</td> </tr> <tr> <td>TOTAL</td> <td>13 %</td> <td>25 %</td> <td>38 %</td> </tr> </tbody> </table> --- **SUMMARY** - **Concurrent Endodontic & Periodontal Diseases** - Infected root canal system + a periapical condition - **PLUS** periodontal disease - **Diagnosis** - essential and must be accurate! - **Management** can influence outcome - **Prognosis** - depends mainly on Periodontal aspects - Do not confuse with other conditions that have both Endodontic and Periodontal implications --- **91** **92** ### **Root Resections** - ==Involves removing one root of a multi-rooted tooth (e.g., mesiobuccal root of an upper molar).== *Lander et al J Perio 1981; 52: 719-22* - ==A 1981 study following resected molars for 10 years found a survival rate of 62%, indicating it is a viable long-term procedure. Modern techniques may yield even better results.== **Molars lost after 10 yrs** <table> <thead> <tr> <th>Reason for loss</th> <th>Max.</th> <th>Mand.</th> <th>Total</th> </tr> </thead> <tbody> <tr> <td>Periodontal</td> <td>7 %</td> <td>3 %</td> <td>10 %</td> </tr> <tr> <td>Endodontic</td> <td>3 %</td> <td>4 %</td> <td>7 %</td> </tr> <tr> <td>Root fracture</td> <td>3 %</td> <td>15 %</td> <td>18 %</td> </tr> <tr> <td>Other</td> <td>0</td> <td>3 %</td> <td>3 %</td> </tr> <tr> <td><strong>TOTAL</strong></td> <td><strong>13 %</strong></td> <td><strong>25 %</strong></td> <td><strong>38 %</strong></td> </tr> </tbody> </table> # **SUMMARY** 1. ==**Definition:** A tooth with a concurrent disease has both an **infected root canal system** (with a periapical condition) AND a co-existing **periodontal disease**.== 2. ==**Diagnosis:** Make separate, specific diagnoses for the endodontic and periodontal conditions. Do not confuse these true concurrent diseases with other conditions like root fractures or resorption.== 3. ==**Management:** The treatment sequence significantly influences the outcome.== - ==The **endodontic treatment** should always be initiated first to eliminate the infection that hinders periodontal healing.== - ==In cases **WITH communication**, the final **root canal filling** must be **delayed** until the periodontal condition is stable and healed to prevent bacterial cross-seeding and reinfection.== 4. ==**Prognosis:** The ultimate prognosis is primarily determined by the predictability of the **periodontal treatment** and the patient's ability to maintain oral hygiene.== 5. ==**Patience is Key:** These cases require patience and regular reassessment before proceeding to the final restorative phase.== - **Concurrent Endodontic & Periodontal Diseases** - Infected root canal system + a periapical condition - **PLUS** periodontal disease - **Diagnosis** - essential and must be accurate! - **Management** can influence outcome - **Prognosis** - depends mainly on Periodontal aspects - Do not confuse with other conditions that have both Endodontic and Periodontal implications [[O4 EndoPerio.pdf#page=1|O4 EndoPerio, p.1]] [[O4 EndoPerio.pdf#page=2|O4 EndoPerio, p.2]] [[O4 EndoPerio.pdf#page=3|O4 EndoPerio, p.3]] [[O4 EndoPerio.pdf#page=4|O4 EndoPerio, p.4]] [[O4 EndoPerio.pdf#page=5|O4 EndoPerio, p.5]] [[O4 EndoPerio.pdf#page=6|O4 EndoPerio, p.6]] [[O4 EndoPerio.pdf#page=7|O4 EndoPerio, p.7]] [[O4 EndoPerio.pdf#page=8|O4 EndoPerio, p.8]] [[O4 EndoPerio.pdf#page=9|O4 EndoPerio, p.9]] [[O4 EndoPerio.pdf#page=10|O4 EndoPerio, p.10]] [[O4 EndoPerio.pdf#page=11|O4 EndoPerio, p.11]] [[O4 EndoPerio.pdf#page=12|O4 EndoPerio, p.12]] [[O4 EndoPerio.pdf#page=13|O4 EndoPerio, p.13]] [[O4 EndoPerio.pdf#page=14|O4 EndoPerio, p.14]] [[O4 EndoPerio.pdf#page=15|O4 EndoPerio, p.15]] [[O4 EndoPerio.pdf#page=16|O4 EndoPerio, p.16]] [[O4 EndoPerio.pdf#page=17|O4 EndoPerio, p.17]] [[O4 EndoPerio.pdf#page=18|O4 EndoPerio, p.18]] [[O4 EndoPerio.pdf#page=19|O4 EndoPerio, p.19]] [[O4 EndoPerio.pdf#page=20|O4 EndoPerio, p.20]] [[O4 EndoPerio.pdf#page=21|O4 EndoPerio, p.21]] [[O4 EndoPerio.pdf#page=22|O4 EndoPerio, p.22]] [[O4 EndoPerio.pdf#page=23|O4 EndoPerio, p.23]] [[O4 EndoPerio.pdf#page=24|O4 EndoPerio, p.24]] [[O4 EndoPerio.pdf#page=25|O4 EndoPerio, p.25]] [[O4 EndoPerio.pdf#page=26|O4 EndoPerio, p.26]] [[O4 EndoPerio.pdf#page=27|O4 EndoPerio, p.27]] [[O4 EndoPerio.pdf#page=28|O4 EndoPerio, p.28]] [[O4 EndoPerio.pdf#page=29|O4 EndoPerio, p.29]] [[O4 EndoPerio.pdf#page=30|O4 EndoPerio, p.30]] [[O4 EndoPerio.pdf#page=31|O4 EndoPerio, p.31]] [[O4 EndoPerio.pdf#page=32|O4 EndoPerio, p.32]] [[O4 EndoPerio.pdf#page=33|O4 EndoPerio, p.33]] [[O4 EndoPerio.pdf#page=34|O4 EndoPerio, p.34]] [[O4 EndoPerio.pdf#page=35|O4 EndoPerio, p.35]] [[O4 EndoPerio.pdf#page=36|O4 EndoPerio, p.36]] [[O4 EndoPerio.pdf#page=37|O4 EndoPerio, p.37]] [[O4 EndoPerio.pdf#page=38|O4 EndoPerio, p.38]] [[O4 EndoPerio.pdf#page=39|O4 EndoPerio, p.39]] [[O4 EndoPerio.pdf#page=40|O4 EndoPerio, p.40]] [[O4 EndoPerio.pdf#page=41|O4 EndoPerio, p.41]] [[O4 EndoPerio.pdf#page=42|O4 EndoPerio, p.42]] [[O4 EndoPerio.pdf#page=43|O4 EndoPerio, p.43]] [[O4 EndoPerio.pdf#page=44|O4 EndoPerio, p.44]] [[O4 EndoPerio.pdf#page=45|O4 EndoPerio, p.45]] [[O4 EndoPerio.pdf#page=46|O4 EndoPerio, p.46]]