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.     

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.     

Hemisection for treatment of an advanced endodontic-periodontal lesion: a case report

AIM: To emphasize the importance of primary endodontic treatment when dealing with endo-perio lesions and to demonstrate the considerable healing potential of the endodontic aspect. CASE REPORT: After several years of unsuccessful symptomatic periodontal treatment, an advanced endo-perio lesion on a right-mandibular first molar was successfully treated by root-canal treatment and hemisection after the re-evaluation of the lesion. This successful treatment appeared to have a positive effect on the patient's general well-being. KEY LEARNING POINTS: The origin of a combined endo-perio lesion is indicated by its clinical and radiographic appearance. The periodontal situation is often misinterpreted. The prognosis for the endodontic element of treatment is excellent. Local pathologic processes in the oral cavity may affect a patient's general health.     

Periodontal-endodontic interdisciplinary treatment--a case report

Periodontal-endodontic lesions pose a difficult diagnostic and therapeutic challenge to the dental practitioner. A careful diagnostic examination consisting of a thorough patient and dental history, comprehensive clinical examination, and use of appropriate dental radiographs is necessary to arrive at a proper diagnosis of the periodontal-endodontic lesion. Despite these measures, it is not always possible to make an accurate diagnosis, which is imperative to provide the proper therapy in the correct treatment sequence. In some instances, endodontic or periodontal therapy alone may suffice; however, in other instances, a combination of endodontic and periodontal therapy may be required to successfully treat the case. In this article, classifications of periodontal-endodontic lesions are discussed, including the appropriate treatment and correct treatment sequence for each classification. Prognosis of periodontal-endodontic lesions depends on the diagnosis, treatment, and chronicity of the lesion, as well as the duration of periodontal involvement. A clinical case is presented in which a periodontal endodontic lesion has been successfully treated with a combination of conventional endodontic therapy and regenerative periodontal surgery.     

Endodontic, surgical and periodontal treatment of dens invaginatus. Case report

The aim of this paper is to propose a single stage global treatment of endodontic, periapical and periodontal lesions in a lateral maxillary incisor with dens invaginatus. A 24 year-old woman presenting a lateral maxillary incisor with dens invaginatus in association with periapica1 and periodontal lesions underwent simultaneous surgical, endodontic and periodontal regenerative procedures. At 2, 6, 12, 18 months follow-up the radiographic healing appeared to be improved and the periapical lesion healed completely 1 year after surgical intervention. Surgery in association with endodontic and periodontal procedures represents the treatment of choice to maximize long term prognosis in cases of dens invaginatus with chronic periapical and periodontal lesions.     

牙周牙髓病损预后的临床分析

目的 通过临床病例回顾分析牙周牙髓病损原发病因的诊断，治疗方案的选择对患牙预后的重要性。方法 选择31颗牙周牙髓病损患牙，临床详细检查，根据患牙的分类选择相应牙周，牙髓治疗方法，6－24个月评价临床愈合。结果 源于牙髓感染的牙周病损，牙周治疗需要量小，预后最好；源于牙周感染的牙髓病损，患牙预后取决于牙周病变程度，牙髓治疗未显著提高骨缺损的修复。评估牙周牙髓联合病变的预后，需监测阶段性治疗效果，牙周治疗需要量大。结论 牙周牙髓病损的临床需详细分析原发病因，选择优化治疗方案，监测阶段性治疗效果。     

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牙髓牙周联合病变是发生于牙髓及牙周组织的细菌感染性疾病,当病情发展到一定程度,细菌、毒素和组织炎性产物可通过根尖孔、侧枝根管、牙本质小管等途径在牙髓与牙周组织中相互渗透、相互影响,导致联合病变的发生。近年来,牙周和牙髓的内在关联及其发病机制一直为学者们所关注。为此,本文主要就牙周和牙髓组织间相互通路及细菌感染的相互影响做一综述。     

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.     

Cone-beam Computed Tomographic Analysis to Detect the Association between Primary and Secondary Endodontic Infections and Mucosal Thickness of Maxillary Sinus

IntroductionThis retrospective study used cone-beam computed tomographic (CBCT) imaging to evaluate the differences in the mucosal thickness of the Schneiderian membrane in primary and secondary endodontic lesions.MethodsA total of 121 CBCT scans were analyzed. Clinical features such as sex, age, size and volume of the periapical lesion, dimension of the bone, morphology, and relationship between the roots and the mucosal thickness were recorded and analyzed in primary and secondary endodontic lesions in CBCT sagittal and coronal planes. Data were analyzed using the chi-square test, the Mann-Whitney U test, and multiple logistic regression (P < .05).ResultsStatistical analysis revealed no significant differences in membrane thickness between the primary and secondary lesions in the sagittal and coronal planes (P = .08 and .06). Differences between age groups were statistically significant in both groups (P < .05). The volume of the periapical lesions of the secondary endodontic lesions were statistically greater than that of the primary lesions (P < .05). Mucosal thickness prevalence increased when the volume of the lesion was greater, and the bone dimension was narrower in maxillary second premolars and first and second molars. Teeth with 2 or more affected roots were directly related to increased sinus mucosa thickening.ConclusionsCBCT images showed no differences in mucosal thickening between primary and secondary endodontic lesions.     

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.     

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.     

牙周牙髓联合病变伴畸形根面沟治疗的临床疗效研究

目的:评价显微根管外科手术联合牙周治疗牙周牙髓联合病变伴畸形根面沟的治疗效果。方法:选择畸形根面沟致牙周牙髓联合病变的患牙11例,经显微根管治疗后,采用显微根管外科手术联合牙周治疗,分别记录患牙术前、术后6个月及术后1年牙周探诊深度(PD)、龈沟出血指数(SBI)、牙齿松动度(TM),并进行统计分析。所有患牙术后6个月及1年复查,通过临床检查和X线片评定根尖周病损愈合结果。结果:术后6月及术后1年分别与术前相比,PD、SBI及TM均明显降低(P<0.05);术后6月成功率为81.82%;术后1年成功率为90.91%。结论:显微根管外科手术联合牙周治疗是畸形根面沟致牙周牙髓联合病变的可行治疗方法。     

Failure of endodontic treatment due to a palatal gingival groove in a maxillary lateral incisor with talon cusp and two root canals

A case is presented in which endodontic treatment of a maxillary lateral incisor with a talon cusp and two root canals failed following a mistaken diagnosis. What was first diagnosed as an endodontic lesion was, in all probability, a primary periodontal lesion caused by the advance of bacteria from the gingival crevice to the apex along the radicular groove between the main tooth and the talon cusp.     

Endodontic infection caused by localized aggressive periodontitis: a case report and bacteriologic evaluation

A rare case of a periodontally induced endodontic lesion in a systemically healthy subject of 28 years is described. The patient, having presented with severe attachment loss on the palatal and distal aspects of his maxillary right second premolar, was diagnosed with localized aggressive periodontitis. He had never received periodontal treatment. The tooth was nonvital and showed all signs of symptomatic apical periodontitis. It was also free of any restoration. All clinical findings clearly suggested that the endodontic problem was caused by the aggressive periodontal disease. Bacteriologic screening of the pocket and the root canal, by using "checkerboard" DNA-DNA hybridization analysis, revealed diverse flora in the periodontal lesion. The sample obtained from the root canal exhibited DNA from a limited number of species, including black-pigmented anaerobic rods. No bacterial DNA was found in the root canal that was not also recovered from the periodontal pocket.     

重度牙周炎患牙的保存治疗

重度牙周炎患牙,尤其是被判断为“预后无望”的患牙,其保存与否是困扰口腔医师的常见且重要的问题。针对这类患牙,临床医生不应轻易做出拔牙的决策,而应仔细检查病情,充分与患者沟通,找到正确的病因,根据患者的具体情况分析保存患牙的有利因素和不利因素,结合患者的意愿、依从性、经济能力等,综合考虑有无保存的可能。本文以单纯重度牙周炎、牙周来源的牙周牙髓联合病变和“真正的牙周牙髓联合病变”3种不同类型的重度牙周炎患牙为例,列举了重度牙周炎患牙的试保存治疗的过程,以期为重度牙周炎患牙的保存和拔牙决策提供参考。     

Periosteal grafts as barriers in periradicular surgery: report of two cases

AIM: To describe the usefulness of periosteal grafts as barriers for bone regeneration in periradicular surgery when advanced periodontal breakdown occurs. SUMMARY: The treatment of advanced periodontal breakdown as a result of an associated endodontic lesion constitutes a multifaceted challenge to the clinician. If the source of the irritation cannot be removed by orthograde endodontic treatment, nonsurgical and surgical endodontic/periodontal intervention may be required. Two cases with suppurative chronic apical periodontitis with apicomarginal communication are described. Clinical and radiological evaluations were completed immediately prior to surgery, a week later and every 2 months after surgery for 10 months. Both patients were treated using split-thickness flaps and lateral displacement of the periosteum prior to suturing, in order to close the communication between the oral and the periapical surroundings. A remission of the clinical signs and symptoms, and successful healing in the short-term were achieved in these cases. KEY LEARNING POINTS: Periapical and periodontal lesions are closely related through pathways of communication. Disruption of the cortical plate and the presence of dentoalveolar sinus tracts can have a deleterious effect on the regeneration process after periradicular surgery. The adoption of supplementary periodontal surgical techniques may help to solve some of the difficulties in the healing process in periradicular surgery. Periosteal grafts have been shown to have the potential to stimulate bone formation when used as a graft material.     

牙髓卟啉单胞菌在原发性感染和再感染根管内的定植

目的 采用16s rDNA PCR和实时荧光定量聚合酶链反应（RTFQ-PCR）分析和比较牙髓卟啉单胞菌（P. endodontalis）endodontalis）在原发性感染和再感染根管中的定植情况。方法 将120例慢性根尖周炎患者的120颗单根管患牙按原发性感染和再感染分为2组,每组60颗。采用16s rDNA PCR分析P. endodontalis在两种感染根管内的检出率,对于P. endodontalis endodontalis检出阳性者用RTFQ-PCR比较P. endodontalis在两种感染根管内的DNA相对表达量。结果 P. endodontalis在原发性感染根管内的检出率明显高于再感染根管的检出率（P=0.001）。RTFQ-PCR检测结果表明P. endodontalis在原发性感染根管内的DNA表达量和再感染根管内DNA表达量差异无统计学意义（P=0.303）。结论 P. endodontalis在原发性感染和再感染根管内均有定植,但与原发性感染根管关系更为密切。     

Diabetes mellitus as a modulating factor of endodontic infections

Diabetes mellitus is a chronic disease with serious health consequences. The association between diabetes and periodontal disease is well documented. However, the progression and healing of endodontic infections in diabetic patients has not been adequately studied. In this review, diabetes mellitus is explored as a potential modulating factor of endodontic pathosis. Recent data on the relationship between the clinical presentation of pulpal and periradicular disease, as well as the outcome of endodontic treatment in diabetic and nondiabetic patients, are presented. Diabetics who present for endodontic treatment, particularly those with periradicular pathosis, may have increased perioperative symptoms. Cases with preoperative periradicular lesions are less likely to be determined successful two years or longer postoperatively if the patient reports a history of diabetes. Studies examining the pathogenesis of periradicular lesions in mouse models with uncontrolled type 1 diabetes suggest that the lesion size may be increased and the animals have increased serious sequelae. Preliminary findings suggest that some bacterial species may be more prevalent in necrotic pulp of diabetic than nondiabetic patients. More studies are needed to further explore the microbiology of endodontic infections and to determine effective treatment strategies in both diabetic and nondiabetic patients.     

Long-term evaluation of endodontic and periodontal treatment

One hundred and ninety-five teeth in 35 patients with periodontitis who had received both endodontic and periodontal treatment were evaluated 9 years after endodontic treatment and 8 years after periodntal treatment. Some 91.4% of cases were well maintained and 8.6% showed a deterioration in their periodontal condition. Twelve of the 195 teeth with endodontic treatment were lost, eight for periodontal codition. Twelve of the 195 teeth with endodontic treatment were lost, eight for periodontal reasons, three as a result of fracture and one because of caries, and the periodontal condition of 10 teeth had worsened. An apical lesion formed on one tooth. The results indicate that the risk of endodontic failure in this group of 195 teeth is very low, and that there is little risk of tooth loss for periodontal reasons, provided that the patients receive suppportive periodontal treatment.