1 Diagnosis and treatment planning for Endo-Perio Lesions. ‘Shab. Introduction Tissues of dental pulp and periodontium are inter-linked from the embryonic stage. The dental papilla (precursor of dental pulp) and the dental sac (precursor of periodontal- ligament)are of a common mesodermal origin. At the late bell stage, epithelial root sheath seperates the dental papilla and dental follicle = precursor of dental pulp and periodontal structures respectively except at the base, the future apical foremen. Therefore, it is natural to expect that any part of periodontium can get affected by pulpal inflammation and vice- versa. Effect of periodiontal tissue disease on pulp was first described in 1918 by Turner and Drew.' They demonstrated that pyorrheoa, i.e. suppurative periodontitis, induced changes in the pulp such as fibrosis, calcification and cystic degeneration. In a study on 85 periodontally involved extracted teeth, Seltzer et al? found 94% of the teeth had some degree of pulpal involvement in the form of inflamma- tion, atrophy or complete nacrosis. Similar findings were reported by Sinnai and Soltanof* and Sharp* However, there were others © ® 7 who believed that disease of periodontal structures have no or minimal influence on the status of Pulp. They argued that even in severe peri- odontal destruction, the pulp of the involved ‘éional Professor Department of Dental Sugary AIMS New Deli 110029, study on 75 white rats documented this. fact. They also found that effect of pulp disease always resulted in inflammation of periodontal structures but changes in the pulp due to Periodontal disease was either proliferation or resorption, very rarely was inflammation and nacrosis observed. Langeland et all, in their experimental study on extracted periodontally involved human teeth, observed that calcification in the Pulp was more prevalent than any conspicu- ous inflammation. It was also seen that as long as the main canal - the major pathway of circulation - is not seriously involved, the entire pulp does not succumb. EFFECT OF PULP ON PERIODONTAL TISSUES : Pulp communicates with periodontal ligament Via the apical foramen, auxillary and furcation canals and dentinal tubules. (Diagram-|). In addition, certain pathological conditions cre- ate abnormal communications between the pulp and periodontal ligament structures like dental caries, attrition, abrasion and erosion, fracture of crown or root, internal and external Toot resorptions and iatrogenic perforations. (Diagram-I!). The first indication of periodontal involvement as a sequelae to a pulp involved, generally a non-vital tooth, is the thickening of Periodontal ligament space at the apical end Toxins, liberated by dead puilpal tissue and bacteria cause inflammation in the apical12 Anatomic Relationship Bstwocn Pulp & Periodontal Ligament. + Denina Tubues, Apical Foramen Diagram + periodontal ligament and microscopic resorp- tion of adjucent alveolar bone and apical cementum. If the irtanat, i.e., the toxic ma- terial is not removed from the pulp space, a definite peri-apical radioluscency is seen due to formation of either abscess, granuloma or a cyst. In acute condition, the acute inflamma- tion in periodontal ligament space in the apical region causes extrusion of tooth in its socket and severe tenderness to purcussion and mobility of the tooth, Sometimes even before the apical luscency, furcation luscency is seen in mutti-rooted pulp involved tooth (Fig. 1). This is due to the presence of accessory canals in furcation area. The inflammation progressing from coronal to apical end, it volves the furcal area much before the apical area. Furcal bone being thinner than: the apical bone resorbs faster. Incidence of furcal canals is reported by different workers rang- ing from 2% to 59% "**, Thus, combined lesions involving both the periodontal and pulpal organs are found much more frequently in posterior teeth than in anterior teeth.'? Furcation luscency is typically found in pulp involved deciduous molars due to presence of large number of furcation canals. Even if Diagram 2 Fig 1: Pulp death under large restoration has resulted in furcal and apical bone loss. Furcal radioluscency is one of the intial signs of pulp disease andresults due to presence of accessory canals/ permeability of the dentin in the floor of the pulp chamber. auxillary canals were not present, the in- creased permeability of the floor of the pulp chember in an infected molar leads to free passage of toxic material from the pulp to the adjucent furcal bone."* eee eases nE run oy ness nner nlrsEN Jen eee abs Sep entey eee ees renee |EFFECT OF PERIODONTAL TISSUES ON PULP: It is a common observation that teeth become hypersensitive after periodontal proceedures like flap operation, gingivectomy, curettage or even after deep scaling. Another common observation is that with gingival recession and lengthening of clinical crowns, due to ageing or otherwise, teeth also become hypersensi- tive. These phenomenons explain the influ- ence of periodontal diseases on the status of pulp. When periodontal disease extends apicallly the cementum is nacrosed or during periodontal procedures the cementum is re- moved, the dentin or an incidental lateral canal may be exposed. Dentin itself, with its open dentinal tubules can provide multiple channels of communications and can irritate the pulp. If less than 2 mm. of dentin remains, after scaling or root planing, as might occure ‘on mesiodistal aspect of mandibular anteriors, pulpal changes would occure. Thus, frequent Periodontal procedures of long duration can “cause pulpal pain. Certain drugs, - specially caustic agents used for chemical cautery of inflammed gingival tissue can also cause pulp damage via the dentinal tubules, If the lateral canal is exposed, it may provide pathway between the oral fluids and pulp. In addition, laceration or severing of lateral blood vessels can cause focal areas of coagulation nacrosis in the pulp. Another pathway for periodontal inflamma- tion to reach the pulp are the furcation canals. Ribach and Mitchell’® have shown that imflammation of periodontal ligament can af- fect the dental pulp via lateral canals. Re- cently, a condition termed as burrowing cer- vical resorption has been attributed to chronic periodontal inflammation’. The resorption occures in the cervical area of the root involv- ing root dentin but resisted by predentin and odontoblasts lining the pulp space. (Fig. 2), Treatment of such lesions requires good 13 Fig. 2 : Burrowing cervical resorption - the case shows a large area ofthe resorption in the cervical ha of the roct. Note the intact walls ofthe root canal passing through the resorption defect. endodontic treatment, followed by surgical exposure of the resporption defect, its’ cau- terization with trichlor acetic acid and eventual obturation with glass-ionomer cement.” DIAGNOSIS Pulpal and periodontal diseases have many common clinical symptoms like swelling of gingiva, pus discharge, pocket formation, fistu- lous tract, tenderness to purcussion and tooth mobility. Radiographically also, itis sometimes ifficult to diagnose the exact etiology of the pathological condition. However, certain clini- calfeatures help to distinguish between lesions of endodontic and periodontal origin. (Table I) Trope et al"* found greater percentage of spirochetes in discharge from the draining sinus in lesions of periodontal origin com- pared to the lesions of endodontic origin. This fact can be used to diagnose lesions of periodontal origin from that of endodontic origin by using dark field microscopy which is easy, fast, economical and reliable.