Interaction between endodontics and periodontics

Endodontic–periodontal lesions present challenges to the clinician regarding diagnosis, treatment planning and prognosis. Etiologic factors, such as bacteria and viruses, as well as contributing factors, such as trauma, root resorptions, perforations, cracks and dental malformations, play an important role in the development and progression of such lesions. Treatment and prognosis of endodontic–periodontal lesions vary, depending on the etiology, pathogenesis and correct diagnosis of each specific condition. This chapter will appraise the interrelationship between endodontic and periodontal lesions and provide biological and clinical evidence for diagnosis, prognosis and decision‐making in the treatment of these conditions.     

影响牙周-牙髓联合病变预后的相关因素研究进展

牙周-牙髓联合病变是牙周炎的伴发病变之一,因其治疗方法复杂,疗程相对较长,预后难以确定,给口腔科医生的临床诊治带来了巨大的挑战。该文对影响牙周-牙髓联合病变预后的相关因素研究进展作一综述。     

The endo-perio problem in dental practice: diagnosis and prognosis

The relationships between endodontics and periodontics are explored. Diagnosis, prognosis, and treatment planning are discussed for the primary endodontic lesion and the primary endodontic lesion with secondary periodontal involvement. These endodontic lesions are compared with primary periodontal lesions and primary periodontal lesions with secondary endodontic participation. The "true" combined lesion is also reviewed. Clinical photographs and radiographs are used to illustrate specific aspects.     

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.     

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.     

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.     

Clinical Judgement And Decision Making In Endodontics

Clinical judgement in endodontics consists of much more than diagnosis and treatment planning for the affected tooth. The issues involved in clinical judgement and decision making can be summarised by three questions:

• 1 Is endodontic treatment appropriate for the patient? Endodontic treatment should be undertaken only as part of an agreed, comprehensive treatment plan that takes into account patient concerns as well as objective clinical findings.
• 2 How difficult is the endodontic treatment? The difficulty of the case should be balanced with the skill and experience of the dentist, in deciding whether to manage the case in general practice or to refer the patient to an endodontist. The use of a standard form for assessing the difficulty of each endodontic case will aid in consistent, systematic assessment of patients. An example of such a form is provided.
• 3 What is the prognosis for the tooth? The outcome of endodontic treatment depends not only on the endodontic treatment but on other factors such as restorability and periodontal status. The prognosis will be compromised by procedural problems and by restorative and periodontal factors.

In all but routine cases, the steps involved in decision making may be more complex and less easily resolved than the practical clinical aspects of endodontic therapy.     

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。     

���財�����ܲ���������ϵ

??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.     

Influence of pulpal treatments on cell and tissue reactions in the marginal periodontium

The effects of pulpal infection and intrapulpal application of calcium hydroxide and antibiotics were evaluated with special reference to cell and tissue reactions in the marginal hard/soft tissue interface in monkeys. Results indicate the pulpal conditions and endodontic dressings influence marginal healing and repair, provided an endodontic-periodontic pathway such as patent dentin tubules is present. These results suggest that permanent endodontic treatment, with an inert material, should be performed before the protective cementum layer is removed. Pulpally aggravated periodontal lesions should therefore not be overlooked in periodontal diagnosis and treatment.     

���ܺ�������֯��ϸ����Ⱦ���໥Ӱ��

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。     

Salvaging a tooth with a deep palatogingival groove: an endo-perio treatment--a case report

AIM: To describe the diagnosis and management of tooth 22 with a necrotic pulp and severe periodontal destruction associated with a deep palatogingival groove extending to the root apex. SUMMARY: Palatogingival grooves are uncommon in maxillary lateral incisors, but when present may contribute to the pathogenesis of periodontal and endodontic lesions. In the present case, the prognosis was considered poor, as the patient presented with a deep probing defect, advanced bone loss and grade III mobility of tooth 22. Root canal treatment was performed, followed by periodontal surgery, during which the groove was conditioned and sealed with conventional glass-ionomer cement and the osseous defect filled with indigenously prepared hydroxyapatite. The 18 month post-operative follow up showed substantial resolution of the osseous defect with gain in attachment and decreased tooth mobility. KEY LEARNING POINTS: Teeth with deep palatogingival grooves may be significantly compromised with severe periodontal and periapical bone loss. Following thorough evaluation, the careful application of endodontic and periodontal surgical procedures may restore satisfactory function.     

Guided tissue regeneration in the management of severe periodontal-endodontic lesions

Diagnosis of combined periodontal-endodontic lesions can prove difficult and frustrating. They are often characterised by extensive loss of periodontal attachment and alveolar bone, and their successful management depends on careful clinical evaluation, accurate diagnosis, and a structured approach to treatment planning for both the periodontic and endodontic components. Recent advances in regenerative periodontics have led to improved management of periodontal-endodontic lesions. This paper reviews the management of such lesions in light of these recent advances and illustrates this through reports of two patients who had severe periodontal involvement.     

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.     

Failing before starting: when not to do endodontics

It's a fact: Perfect endodontic treatment can be unsuccessful. Unfortunately, endodontic failure often can result from an inadequate preliminary diagnosis or prognosis assessment. Many variables should be considered before endodontic treatment begins, including assessing the endodontic case, addressing periodontal concerns, determining restorative issues, and detecting root fractures. If these parameters are not evaluated carefully, then short- or long-term endodontic failure will result. Unfortunately, an endodontic prognosis assessment is often subjective. Although dentists must rely on evidence-based research to determine the best modality of treatment, good clinical judgment and experience may override the most objective findings. This article discusses the objective and subjective nuances involved in evaluating the potential prognosis of endodontic treatment.     

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.     

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.     

Conventional and Surgical Retreatment of Complex Periradicular Lesions With Periodontal Involvement

A periradicular pathosis with an associated periodontal breakdown creates a complex problem during endodontic therapy. In cases in which nonsurgical retreatment does not have a successful outcome, a surgical retreatment has to be taken into consideration. With the introduction of microsurgical techniques in endodontics, surgical treatment success has improved considerably. The surgical treatment of combined lesions, however, is still considered to have a less favorable prognosis. The presented cases illustrate successful treatments in which a periodontal breakdown and an endodontic breakdown were present.     

The effect of diabetes mellitus on endodontic treatment outcome: data from an electronic patient record

BACKGROUND: The authors used a custom-built electronic record system to investigate endodontic diagnostic and treatment outcome data in patients with and without diabetes. METHODS: The medical histories and endodontic treatment data for nonsurgical endodontic patients treated in predoctoral and postgraduate specialty clinics were entered into an electronic record system. A total of 5,494 cases (including 284 cases in patients with diabetes) were treated, and 540 cases (including 73 cases in patients with diabetes) had follow-up data two years or more postoperatively. The authors performed univariate and multivariate analyses to determine important factors affecting endodontic diagnosis and treatment outcome. RESULTS: Patients with diabetes had increased periodontal disease of teeth with endodontic involvment compared with patients who did not have diabetes. There was a trend toward increased symptomatic periradicular disease in patients with diabetes who received insulin, as well as flareups in all patients with diabetes. Two years or longer postoperatively, 68 percent of cases followed were successful. Older age, the absence of preoperative lesions, the presence of permanent restorations and longer postoperative evaluation periods all were associated with a successful outcome. A multivariate analysis showed that in cases with preoperative periradicular lesions, a history of diabetes was associated with a significantly reduced successful outcome. CONCLUSIONS: Patients with diabetes have increased periodontal disease in teeth involved endodontically and have a reduced likelihood of success of endodontic treatment in cases with preoperative periradicular lesions. CLINICAL IMPLICATIONS: Patients with diabetes who are treated endodontically should be assessed carefully and be treated with effective antimicrobial root canal regimens, particularly in cases with preoperative lesions.