牙髓病与牙周病的内在联系

牙髓病与牙周病的鉴别诊断通常不是简单明了的,患牙同时罹患牙髓病损和牙周病损无疑大大增加疾病的诊断难度,需要通过诊断性检查收集大量临床数据来获得正确的诊断。当检查和治疗牙周牙髓联合病变或单个病变时,必须牢记成功的治疗基于正确的诊断。     

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??The simultaneous existence of pulpal problems and inflammatory periodontal disease can complicate diagnosis and treatment planning. Endodontic and periodontal lesions result from the close interrelationship of pulp tissue and the periodontium. The major pathways of communication between the two types of tissue are the apical foramina??lateral and accessory canals??and dentinal tubules. The differential diagnosis of endodontic and periodontal lesions is not always straightforward and requires clinical data accumulation from a number of diagnostic tests to obtain a correct diagnosis. When examining and treating the combined or individual lesion in endodontics and periodontics??the clinician must bear in mind that successful treatment depends on a correct diagnosis. Lesions with combined causes will require both endodontic and periodontal therapy??and endodontic therapy should usually be completed first.     

Comparison of profiles of key periodontal pathogens in periodontium and endodontium

Abstract – Despite the established anatomical relationship between the periodontal and pulpal tissues, bacterial migration between endodontium and periodontium is still under discussion. The objective of this study was an investigation of profiles of periodontal pathogens in pulpal and periodontal diseases affecting the same tooth by means of 16S rRNA gene directed polymerase chain reaction (PCR). 31 intact teeth with both pulp and marginal infections were investigated. The diagnosis was based on clinical and radiological examination. Samples were taken from the gingival sulcus or periodontal pocket, respectively, with sterile paper points before trepanation of the teeth. After trepanation sterile paper points and Hedstroem files were used for taking samples from the root canal. Specific PCR methods were used to detect the presence of the following pathogens: Actinobacillus actinomycetemcomitans, Bacteroides forsythus, Eikenella corrodens, Fusobacterium nucleatum, Porphyromonas gingivalis, Prevotella intermedia and Treponema denticola. In addition, quantitative competitive PCR was used to determine the total bacterial count of the samples. The investigated pathogens were proven to be present in the endondontium in all disease categories. Particularly in endodontic samples of "chronic apical periodontitis" and "chronic adult periodontitis" profiles of the periodontal pathogens were found. The results confirmed that periodontal pathogens often accompany endodontic infections and supported the idea that the periodontic-endodontic interrelationships should be considered as critical pathways which might contribute to refractory courses of endodontic or periodontal diseases.     

Comparison of profiles of key periodontal pathogens in periodontium and endodontium

Despite the established anatomical relationship between the periodontal and pulpal tissues, bacterial migration between endodontium and periodontium is still under discussion. The objective of this study was an investigation of profiles of periodontal pathogens in pulpal and periodontal diseases affecting the same tooth by means of 16S rRNA gene directed polymerase chain reaction (PCR). 31 intact teeth with both pulp and marginal infections were investigated. The diagnosis was based on clinical and radiological examination. Samples were taken from the gingival sulcus or periodontal pocket, respectively, with sterile paper points before trepanation of the teeth. After trepanation sterile paper points and Hedstroem files were used for taking samples from the root canal. Specific PCR methods were used to detect the presence of the following pathogens: Actinobacillus actinomycetemcomitans, Bacteroides forsythus, Eikenella corrodens, Fusobacterium nucleatum, Porphyromonas gingivalis, Prevotella intermedia and Treponema denticola. In addition, quantitative competitive PCR was used to determine the total bacterial count of the samples. The investigated pathogens were proven to be present in the endondontium in all disease categories. Particularly in endodontic samples of "chronic apical periodontitis" and "chronic adult periodontitis" profiles of the periodontal pathogens were found. The results confirmed that periodontal pathogens often accompany endodontic infections and supported the idea that the periodontic-endodontic interrelationships should be considered as critical pathways which might contribute to refractory courses of endodontic or periodontal diseases.     

The influence of endodontic treatment upon periodontal wound healing

Abstract The interrelationship between periodontal and endodontic disease has aroused much speculation, confusion, and controversy. Pulpal and periodontal problems are responsible for more than 50% of tooth mortality today. Diagnosis is often difficult since these diseases have been studied primarily as separate entities. The toxic substances of the pulp may initiate periodontal defects through canal ramifications and patent dentinal tubules, thus impairing wound healing in regenerative procedures. Although no studies exist addressing the direct effect of pulpal infection on the outcome of guided tissue regeneration (GTR) procedures, several studies do indicate that pulpal status may play a significant role toward the end results of GTR. This review article discusses the potential influence of endodontic treatment on the long-term outcomes of GTR. Potential pathways between the pulp and periodontal ligament, which may be responsible for the failure of the regeneration of new periodontal attachment apparatus, are explored. Examination and review of the clinical and research findings in the literature relating to perio-endo lesions are made to demonstrate that a negative influence may exist between GTR outcomes and the status of the pulp.     

Management of periodontitis associated with endodontically involved teeth: a case series

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.     

Periodontal healing in teeth with periapical lesions

Abstract The purpose of the present investigation was to compare clinical periodontal healing in periodontally involved teeth with and without pulpal pathosis. The investigation was conducted as a retrospective study on a consecutive referral population. The periapical conditions in endodontically involved single-rooted teeth from a selected patient sample were evaluated and correlated with their periodontal healing pattern. Multiple regression analysis of the registered variables showed that initial mean pocket depth and time elapsed after treatment significantly influenced change in pocket-depth. Non-surgical treatment of periodontal pockets exceeding 2.5 mm in teeth with horizontal marginal defects, over the observation period, showed significantly reduced mean pocket depth reduction in teeth with periapical pathology compared to teeth without periapical pathology. It was, furthermore, evident that proximal restorations, abutments for fixed bridges and root fillings with and without dowels did not significantly influence pocket depth reduction in the present material. It was concluded, based on the present results, that a root-canal infection, evident as a periapical radiolucency, if left untreated may in the long term perspective result in retarded or impaired periodontal healing following periodontal therapy and, consequently, should be given appropriate consideration when coordinating endodontic therapy and periodontal treatment.     

Endodontic or dental implant therapy: the factors affecting treatment planning

BACKGROUND: Clinicians are confronted with difficult choices regarding whether a tooth with pulpal and/or periapical disease should be saved through endodontic treatment or be extracted and replaced with an implant. METHODS: The authors examined publications (research, literature reviews and systematic reviews) related to the factors affecting decision making for patients who have oral diseases or traumatic injuries. RESULTS: The factors to be considered included patient-related issues (systemic and oral health, as well as comfort and treatment perceptions), tooth- and periodontium-related factors (pulpal and periodontal conditions, color characteristics of the teeth, quantity and quality of bone, and soft-tissue anatomy) and treatment-related factors (the potential for procedural complications, required adjunctive procedures and treatment outcomes). CONCLUSIONS: On the basis of survival rates, it appears that more than 95 percent of dental implants and teeth that have undergone endodontic treatment remain functional over time. CLINICAL IMPLICATIONS: Clinicians need to consider carefully several factors before choosing whether to perform endodontic therapy or extract a tooth and place an implant. The result should be high levels of comfort, function, longevity and esthetics for patients.     

Pathologic interactions in pulpal and periodontal tissues

Both endodontic and periodontal disease are caused by a mixed anaerobic infection. The pathways for the spread of bacteria between pulpal and periodontal tissues have been discussed with controversy. This article is an attempt to provide a rational approach to the perio-endo/endo-perio question based on a review of the relevant literature. In the light of evidence, clinical concepts for the diagnosis and treatment of lesions involving both periodontal and pulpal tissues are discussed.     

Endodontic pathogens in periodontal disease augmentation

Abstract. Periapical pathology indicating endodontic infection, when present in periodontitis-affected teeth, has recently been shown to be correlated to marginal periodontal breakdown. This has been associated with patency of dentinal tubules in the tooth cervix, an area normally devoid of cementum following periodontal therapy. These studies are, however hampered by that only circumstantial evidence such as presence of periapical destruction have been applied as criteria of endodontic infection. The aim of the present investigation was to assess the effects of endodontic pathogens on marginal periodontal wound healing on root surfaces devoid of cementum but surrounded by healthy periodontal membrane. Significant differences between infected and non-infected teeth were found with respect to pathological pocket and connective tissue: The experimental defects were covered by approximately 20% more pocket epithelium in infected teeth while defects in non-Infected teeth showed approximately 10% more connective tissue coverage. It was concluded, that an intra-canal infection of endodontic pathogens stimulates epitelial downgrowth along denuded dentin surfaces with marginal communication. Extrapolated to the clinical situation, endodontic infections in periodontitis-prone patients may augment periodontitis propagation.     

Rationale for the application of the GTR principle using a barrier membrane in endodontic surgery: a proposal of classification and literature review

Periradicular surgery has become an established treatment option in endodontic surgery. The major objective of this surgery is to obtain periradicular tissue regeneration, including the formation of a new attachment apparatus, by exclusion of any potentially noxious agent within the physical confines of the affected root. However, in a substantial number of cases, the endodontic lesion has a concomitant marginal periodontal lesion that may complicate the healing success. In periodontology, the guided tissue regeneration (GTR) principle using a barrier membrane has been extensively studied and successfully used, and thus may become an adjunct in endodontic surgery. This article presents a classification system of endodontic and periodontal lesions with respect to the application of the membrane technique and reviews the pertinent literature based upon this classification system.     

Pulpal pathosis and severe alveolar lesions: a clinical study

Abstract Gingivitis is widely believed to be the precursor of crestal alveolar bone destruction (periodontitis) in some individuals. However, there is no correlation between gingivitis and severe localized lesions of alveolar bone. Specific ‘periodontopathogens’ of the indigenous oral flora are hypothesized to be the cause of localized lesions but the evidence to date is one of association only. Acute and chronic pulpal inflammation are known causes of irritation to the periodontal ligament and alveolar bone; retrograde pockets may subsequently form. Contamination by indigenous organisms best adapted to the special environment of the deep pocket could be expected to follow the establishment of the new conditions. This study was undertaken to examine the clinical and histological status of the pulps of teeth affected by severe localized alveolar lesions. A total of 153 teeth in 90 subjects were studied; full periodontic and endodontic assessments were made. Seventy-seven teeth responded in the normal range to pulp testing, but 52% of these had no recoverable tissue from their root canal systems on endodontic opening. The findings indicated that pulpal pathosis was not clinically detectable in the majority of teeth studied when conventional endodontic diagnostic tests were applied. Rather, the presence of localized severe alveolar defects was a more accurate predictor of pulpal pathosis. The strong association between pulpal pathosis and localized, severe alveolar defects and the appearance of similar lesions in dry skulls indicates that the alveolar lesions were of pulpal origin with spread to localized periodontal sites.     

Regenerative therapy: a periodontal-endodontic perspective

Periodontal and endodontic diseases are inflammatory responses leading to periodontal and pulpal tissue loss. Regenerative therapies aim to restore the lost structures to vitality and function. Various materials and treatments methods have been used such as bone grafts, guided tissue regeneration, enamel matrix derivatives, growth and differentiation factors, and stem cells. Although the current materials and methods demonstrated adequate clinical results, true and complete biological tissue regeneration is not yet attainable. The current article reviews chronologically the materials and methods used in periodontal and endodontic regeneration highlighting their clinical success and shortcomings, and discussing future directions in regenerative therapy.     

Extraoral endodontic treatment, odontotomy and intentional replantation of a double maxillary lateral permanent incisor: case report and 6-year follow-up

AIM: To describe combined endodontic, surgical and orthodontic treatment of a maxillary lateral incisor fused with a supernumerary. SUMMARY: Double tooth is a dental irregularity consequent to fusion of two or more teeth or dental gemination. The teeth most commonly involved are deciduous, but in 0.1% of cases permanent teeth are affected, in which case aesthetic, functional and periodontal problems can result. This paper reports a clinical case of a double tooth in the position of the maxillary right lateral permanent incisor. Combined orthodontic, endodontic and surgical treatment (intentional replantation) allowed the tooth to be retained without periodontal compromise and with a positive orthodontic result both immediately and 6 years following intervention. *A conservative approach that addresses periodontal, pulpal and tooth tissues, can result in the retention of a double tooth. *Maintenance of the root and alveolar bone in young adults at least until full skeletal maturation should be the main treatment objective.     

Cellular reactions in pulpal and periodontal tissues after periodontal wound debridement

Periodontal wounds in monkeys were prepared with a bur followed by the application of microbially contaminated cotton pellets. 3 weeks later, the wounds were debrided by scaling followed by etching with citric acid or by treatment with carbonate/peroxidate. The cellular reactions in the periodontal tissues and in the pulp 4, 11, 25, 39 and 53 days after treatment were followed with light microscopy. The marginal periodontium showed heavy inflammatory reactions immediately after treatment, regardless of the debridement procedure. 25 days after debridement, a long epithelial junction had been formed. The apical part of the epithelium deviated from the root surface into the connective tissue, delineating a heavily inflamed part of the connective tissue. After 39 to 53 days, most of the experimental wounds were covered by an epithelial lining. The pulpal reactions were generally limited to a production of irregular dentin on the pulpal wall facing the periodontal wound. It was concluded that the marginal healing pattern following various chemical treatments to the root surface followed, in all essential aspects, conventional treatment with scaling and root planing.     

Periodontally derived pulpal lesions

Abstract Concurrent pulpal and periodontal disease has been described as the outcome of the pathogenetic interactions between the pulp and the periodontium. Although the existence of primary endodontic lesions with secondary periodontal involvement, as well as that of “true” combined ones has been undoubtedly justified, some controversy and confusion still exist over primary periodontal lesions with secondary endodontic involvement. In this article, theoretical communicable pathways between pulp and periodontal ligament, which can be responsible for the extension of the primary periodontal inflammatory lesion in the pulp, are described. Furthermore, a re-evaluation of the pulpal invasion phenomenon is presented, based on recent research and clinical findings that demonstrate that no constant relationship between the depth of the periodontal pocket and the status of the pulp has ever been found.     

Therapeutic solution for a combined endo-periodontal lesion. Case report

The endo-periodontal lesion may lead to diagnostic and therapeutic difficulties in general dental practice. In the present case endo-periodontal inflammation of the lower left first molar caused the patient's complaints. The inflammation of periodontal and pulpal origin was separated although they simultaneously were present in the same time. Endo-periodontal lesion can be treated by endodontic and periodontal care and sometimes complemented by surgery. Scaling and polishing, as well as root planing were performed following the endodontic treatment of distal root, then the tooth was dissected and the mesial root was removed. Finally the remained distal part of molar was used as a bridge abutment. Combined endo-periodontal lesion can be cured with appropriate treatment as root filling, periodontal treatment, supplemented with tooth dissection.     

The relationship between periodontal and pulpal disease

Summary. The relationship between periodontal disease and pulpal disease is reviewed by first considering their pathogenesis and differential diagnosis. The author then proposes a classification of lesions based mainly on their aetiology; this is primary endodontic lesion, primary periodontal lesion and combined lesion. The treatment of the various types is described in detail.     

Periodontic-endodontic lesions: diagnostic and therapeutic indications

The presence of connections between periodontium and endodontium can lead to the diffusion of an infection from one apparatus to another. The involvement of both periodontium and endodontium is defined as Combined Periodontic-Endodontic lesions. This definition is not based on the initial etiology of the lesion and either the endodontic or periodontal lesion may be the cause or the result of the other or both may develop independently. The lesions must be correctly diagnosed for the best therapeutic approach. The diagnosis is based on clinical symptoms and radiographic analysis; clinical signs must show the presence of periodontal probing and pulpal necrosis. Radiographic examination can confirm the involvement of both periodontium and endodontium only if the lesion is present on the mesial and distal part of the diseased tooth; in the case of a palatal/lingual or vestibular lesion such evidence will not be detectable. The therapeutic approach is always based on an initial endodontic treatment followed, if needed, by the proper periodontal treatment.     

Strategies for the endodontic management of concurrent endodontic and periodontal diseases

Endodontic and periodontal diseases can provide many diagnostic and management challenges to clinicians, particularly when they occur concurrently. As with all diseases, a thorough history combined with comprehensive clinical and radiographic examinations are all required so an accurate diagnosis can be made. This is essential since the diagnosis will determine the type and sequence of treatment required. This paper reviews the relevant literature and proposes a new classification for concurrent endodontic and periodontal diseases. This classification is a simple one that will help clinicians to formulate management plans for when these diseases occur concurrently. The key aspects are to determine whether both types of diseases are present, rather than just having manifestations of one disease in the alternate tissue. Once it is established that both diseases are present and that they are as a result of infections of each tissue, then the clinician must determine whether the two diseases communicate via the periodontal pocket so that appropriate management can be provided using the guidelines outlined. In general, if the root canal system is infected, endodontic treatment should be commenced prior to any periodontal therapy in order to remove the intracanal infection before any cementum is removed. This avoids several complications and provides a more favourable environment for periodontal repair. The endodontic treatment can be completed before periodontal treatment is provided when there is no communication between the disease processes. However, when there is communication between the two disease processes, then the root canals should be medicated until the periodontal treatment has been completed and the overall prognosis of the tooth has been reassessed as being favourable. The use of non-toxic intracanal therapeutic medicaments is essential to destroy bacteria and to help encourage tissue repair.