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Summary. The relationship hetween periodotital hand, endodontists fi-equentiy have a lack of
disease and pulpal disease is reviewed byfirstconsi- understanding concerning the treatment of the
dering their pathogenesis and differetitial diagnosis. diseased periodontal tissues.
The author then proposes a classification of lesions
Therefore, it is important to correlate these
based mainly on their aetiolog}'; this is primary
endodontic lesion, primary periodontal lesion and two entities, as confusion exists with regard
combined lesion. The treatment of the various types to aetiology, diagnosis and therapy (Sinai &
is described in detail. Soltanoff 1973).
Introduction Pathogenesis
It Is well known that the dental pulp and the The effect of periodontal lesions on pttlp tissue
periodontal tissues have a close interrelation- Investigations on teeth in man and animals
ship, both anatomically and functionally (Hiatt (rat, dog and monkey) have shown that the
1959, 1964, 1977, Schilder 1963, Seltzer «ai. pulp may react in a variety of ways in the pres-
1963, Simon & Jacobs 1969, Seltzer 1971, Ross ence of periodontal disease (Mazur & Massler
1972, Blair 1972, Cliacker 1974, Guldener 1964, Seltzer et al. 1967, Bender & Seltzer
1975, Simon 1980). The apical foramen is the 1972, Langeland tfa/. 1974, Seltzer & Bender
most itnportant but by no means the only 1975). The pulpal reaction may be infiuenced
location where these tissues meet. Lateral and not only by the stage of periodontal disease,
accessory canals, mainly in the apical area and but also by the type of periodontal treatment,
in the furcation of molars, also connect the such as scaling, root planitig and admitiis-
detital pulp with the periodontal ligament. In tratlon of medicaments (Stallard 1967). The
addition, a great nuniiber of dentinal tubules size, number and location of accessory canals,
extend from the pulp to the cementum on tbe the area of exposed root and the amount of
root surface. If the cementum is removed, e.g. toxic substrates being transmitted into the
scraped away by root planing, toxic substances pulp may also be important in the consequent
can be transmitted from the pulp to the severity of puipal damage (Sinai & Soltanoff
periodontal ligament or vice versa. 1973, Bergenholtz & Lindhe 1975). Pulpal
Many dentists consider endodontic and changes due n periodontal disease may occur
periodontal lesions as separate entities. Obvi- in teeth with or without caries or restorations
ously, because periodontal disease and pulpal (Seltzer et al. 1%3). The predominant pulpal
infections are treated diflFerently, naany den- changes due to toxic agents and medicaments
tists in the last 40 years have specialized which penetrate into the pulp via lateral catials
in ]}eHodontics or endodontics. Combined or dentinal tubules are degenerative in nature
periodontal-endodontic lesions require both (secondary dentine formation, internal resorp-
root canal therapy and periodontal treatment tion, fitHosis) (Rubach & Mitchdl 1965a).
to save the tooth involvwl. Inflammatory lesions of varying severity and
Pertodonttsts, being mainly concerned with necrotic pulp tissue are usually found in teeth
treating gin^val and periodontal disease, with large canats or in cases where the
have little specialized knowledge about the periodonol breakdown has extended to the
problems of the diseased pulp. On the other apex (Stahl 1966). In these inst^ces, apical
granulomata, necrotic putp tissue in the
apical region and enemal root resorpticHi
Correspondence: P. H. A. Guldener, Helvetia-
strasse 9, 3005 Berne, Switzerland. can be diagnosed (Simring & GtJdberg 1964,
4i
42 P. H. A. Guldener
Langeland et til. 1974). In about 40 per cent granuloma, radicular cyst, and chronic alveolar
of cases the pulp remains normal (Mandi abscess.
1972). Acute pulpitis is detected by clinical signs
and symptoms (pain), including thermal and
The effect of pulpal lesions on periodontal tissue electrical pulp tests. Radiographs are important
Obviously, an infected or necrotic pulp may for the detection of caries.
cause a periodontai lesion (Bergenholtz 1977, Clinically, pulp degeneration is not an im-
Sinai & Soltanoff" 1973). Endodontically- portant lesion under ordinary circumstances.
induced periodontal changes are referred to as Pain is generally absent when degeneration is
periradicular lesions (periapical, lateral, furca- limited to puipal tissue. Degenerative changes
tional). The periodontal response is always such as reactionary dentine formation and
inflammatory in nature, either acute (alveolar intertia! resorption can be detected radio-
abscess, apical periodontitis) or chronic (granu- graphically. However, hyalinization, atrophy
loma, cyst) (Stahl 1966). The lesion can. be and fibrosis are degenerative changes which
localized at the root apex or at the orifice of cannot be detected on radiographs since they
a lateral canal within the periodontal ligament. are radiolucent.
In addition, a sinus tract can develop which Histopathologically, the various stages of
may extend from the apex to the furcation area acute and chronic pulpitis or degenerative
or even to the gingival sulcus. Such a sinus changes do not affect the treatment plan; in al!
tract must be distiogaished from a periodontal these situations pulpectomy is indicated.
pocket. Endodontic treatment alone will cause
the resolution of the sinus tract and healing of
the damaged periodontal tissue. Classification
The classification of teeth with pulpo-
Combined periodontal and endodontic lesions periodonrai changes suggested by the author is
First one has to distinguish separate periodon- based mainly on the aetiology of the disease
tal and endodontic lesions which may occur (Guldener 1975, Hiatt 1977,""Simoo 1980).
independently on a tooth from those endodon-
tic and pedodontic lesions which join {Rubach Class I: primary endodsntic lesion
& Mitchell 1965b, Simon & Jacobs 1969). At Class l(al. Accidental perforations (intra-
the latter stage both lesions are indistinguish- alveolar) or resorptive perforations (internal
able froHi each other and it is not possible to resorption).
tell whether the primary lesion was endodontic
or periodontal. Class 1(B). Chronic periradicular lesion
(granuloma or cyst) or acute periradicular
lesion (alveolar absce.ss).
Diagnosis
Diagnosis of periodontal lesions Class 11: primary periodatmJ lesions
Periodontitis is detected by clinical examin- Class n(A). Advanced periodontal disease
ation (tissue colour and texture, pocket depth, with or without extension to the apicai area
bleeding tests), by radiographic interpretation {pulp vital).
and by histological findings. Tooth mobility is
a frequent observation of moderate and ad- Class 11(B). Secondary' endodontic involve-
vaeced periodontitis, frequently in combination ment. Infection through lateral canals or
with occiusal trauma. dentinal tubules. Pulpal necrosis with or with-
out secondary periapicai Involvement {pulp
Diagnosis of endodontic lesions non-vital).
Clinically, the condition of the pulp can be
classified as a normal puip, reversible pulpitis, Class HI: combined lesion
irreversible pulpitis or pulpal necrosis. Peri- True combined lesion (coalescence between
apical lesions of pulpal origin can be clas.iiified periodontal and endodontic lesion) or vertical
as apical periodontitis, acute alveolar abscess. crown-root fracture with pulpal iavolvement.
Rdatwmhip betmeen periodontai and pulpal disease 43
Fig. 1. (a) l.iwcr first premolar with periapical radiolucency. (b) Two years after root canal treatment
of the alveolar hone mav be noted.
44 P. H. A. GuMener
•'1
Fig. 2. (a) Perforation in the middle third of the riiot ol J. (.cment t..n :H .icitUL-.l .uii.Kfi;- M ihc pcrlur-
atioo (bi THo-and-a-hail~}ears after surfncal treatmcar o! the perlfirarion with silver amaR^am. Nutc alsn
tht root canai liiiinK was redone.
on a maxillary lateral incisor with two roots, surgical, depending on the size and location of
in which only one root canal had been filled. the perforation. If the perforation was created
with a root canal instrument, it is usualh"
2. Therapy of acciderMiperforations small. The perforation canal is then treated
Accidental perforations are treated surgically like an additional root canal. Care has to be
or non-surgically, depending on their size and taken not to overfill this artificial canal into the
location (Seltzer et al. 1970). They can be periodoMa! ligatnent space. If, on the other
classified into four groups: hand, the perforation is made with z bur during
preparation for a post hole, the perforation
should he sealed from the outside with zinc-
Class 1: Cromi or root perforations coronal to
free silver amalgam (Fig. 2).
the epithelial attachment. If the perforation
occurs corona! to the gingiVal tissue, it is
Class US: Perforations in the apical third of the
visible and can easily be sealed from the out-
root. Class III perforations are the most fre-
side using composite resin. This is the only
quent type, often due to the 'zipping effecf
perforation which does not damage the perio-
dontal tissue. If the perforation is located with- described by Weine et al. (1976). In many
in a periodontal pocket, a small flap is raised instances, the perforation can be sealed con-
to allow the perforation to be treated in a servatively. If the perforated canal is slightly
similar manner. overfilled and the symptom-free periapical
lesion heals uneventfully, no further treatment
is indicated. But, if clinical symptoms occur
Class II: Perforations in the middle third of the or an area can be detected radiographically,
root. The treatment is either surgical or non- endodontic surgery is indicated (Fig. 3).
Relationship hetmem periodonlal and pulpa! disease 45
Ciasi IV: Perforatiims in the interradicular hydroxide is replaced by the definitive root
space of multirooted teeth. The rype of treatment canal filling: gutta-percha and sealer. The
iodicated depends on the size of the perfor- surgical treatment consists of reflecting a flap
ation and also on the health of the periodontal and sealing the perforation from the outside
tissue. Perforations of small diameter are with silver amalgatn (Fig. 4).
treated non-surgically. The perforation may be External resorptions which are caused by
sealed with stiver atnalgam, gold foil or gutta- pulp infection, in many instances can be
percha and root canal sealer. If, however, the successfully treated by root canal therapy.
perforation is large ( > 2 mtn) root separation The resorptive lesion will cease to progress.
or hemisection is the treatment of choice. External resorptions caused by trauma require
surgical intervention (Fig. S).
i. Therapy of resorptive perforations
Internal resorptions that have perforated 4. Incision for drainage
into the pedodonta! ligament space mtist be In the presence of an acute alveolar ahscess,
distinguished from e.xternal resorptions that periodontal tissue is destroyed because of
perforate into the pulp. pulpal infection. If the abscess has perforated
Perforated internal resorptions can be through the periosteum, there will be a fluc-
treated non-surgically, but more frequently tuaot STvelling of pus which can be displaced
require surgical therapy. The conservative by palpation. To establish drainage, a sharp
approach, suggested by Frank (1967), consists incision with a scalpel is tnade through the
of filling the entire root canal with calcium alveolar inucosa to bone. A drain (gauze strip
hydroxide, after the root canal systetn has been or T-shape rubber dam) is placed into the
thoroughly cleaned and shaped, to induce wound to provide a channel for discharge of
cememogenesis. .4fter 2—3 months, calcium pus and blood.
46 P. H. A. Guldener
"b
Fig. 4. (a) Internal resorption affecting 1/, labial perforation of the internal resorption cannot be seen on
the radiograph, (b) The defect was filled with silver amalgam, and an apicectomy was nho performed,
(c) Radiograph several weeks after surgery.
Relationship helween periodontal and pulpal disease 47
Treatment
4- —Treatment indicated.
—^=:Treatment not indicated.
^The tooth mav l>e treated sureicaMv instead ofbv root canal treatmeot.
48 P. H. A. Guldmer
• •
< - • , • ••
Fi^;. 0. l;ii !loot canal filling with hot gutta-percha and vertical condensation (Schilder). Two lateral canals
wert rilk-d near the apex; overextended root canal filling material is present within the periapica! lesion,
(b) Periapical healing U years after periapical curettage.
Fig. 7. (a) Incomplete root cana! filling of 6^-. The t^o huccal canals contain silver cones, the palatal canal
a post and gutta-percha filling. Note the periapical lesion around the apices of the mesiobuccai and palatal
roots, (h) Two years after apicectomy of both buccai roots. Goldfoil used as retrofilling. Palatailv. an
apicectomy and periapicaJ corettage without retrograde fillmg was performed.
3. Canal that cannot be dried because of If, however, the canal can be prepared to the
continuous exudate. apex, but cannot be dried, retrofilling is not
4. Periapical lesion that does not heal despite required (Fig. 9). The sequence of treatment
apparently correct root canal treatment in one visit is as follows:
having been performed. 1. Reflection of the flap.
5. Apical perforation with symptoms. 2. Location of the apex and surgical perfor-
6. Apical external resorption. ation of the alveolar bone.
In all cases in which the root canal cannot 3. Root resection.
he negotiated to the apex (Figs 7 and 8) the 4. Periapical curettage.
sequence of treatment is as follows: 5. Drj'ing of the root canal.
1. Reflection of the flap. 6. Root canal filling with overextension.
2. Location of the apex and surgical perfor- 7. Removal of excess filling material periapi-
ation of the alveolar bone. cally.
3. Root resection. 8. Suturing of the flap.
4. Periapical curettage. Endodontic apical surgerj' may be combined
5. Retrograde cavity preparation and retro- with periodontai surgery. In most instances,
grade filling, preferably with zinc-free a full thickness flap is made at the gingiv'al
silver amalgam or a high-copper silver margin, both on the lingual and buccal aspect.
amalgam and varnish (Tronstad et al.
1983). (iii) .Apical fistulation. This is the surgical
6. Suturing of the flap.-' creation of a hole through the alveolar mucosa
50 P. H. A. Guldener
Fig. 8. (a) Perforatioa in the apical third of the mesial root of 6/ which has a periapical lesion, (b) Ten
months after apicectomy and retrograde filling witli silver amalgam, the bony lesion has healed.
and cortical plate at the apex of a tooth with (Basaraba 1969, Abrams & Trachtenberg
acute sy'Hiptoms to relieve pain. The technique 1974). These procedures are indicated if
is dangerous if it is performed without raising periodontal disease or caries prevent other
a flap and first locating the apex. Anatomical surgical intervention and the remaining root
landmarks such as the maxillar}' sinus, the or roots are needed for reconstruction of the
mandibular canal or meotal nen'e in the neigh- dentition.
bourhood of root apices of posterior teeth There are several pathological conditions
should be identified. In addition, apical fistula- which require one of these procedures.
tion is never a definitive treatment, but only
for emergency use in very rare cases. The (a) Periodontal
author does not recommend this procedure. .Advanced vertical bone loss around one
root.
6. Diodentic implants Furcation involvement.
This rather rare procedure is occasionally per- Dehiscence extending to the apical third of
formed on a mobile lower anterior tooth with the root.
advanced periodontal disease (Frank 1967). Close proximity of adjacent roots with miss-
After normal preparation of the root canal, a ing interdental septum.
drill is used through the root canal to create
a space 6—8 mm into the alveolar bone. Dio- (b) Endodontic
dontic implants function primarily by improv- Obliterated canal with periapical lesion
ing the crown—root ratio, thereby stabilizing where surgerj- is not feasible.
the compromised tooth. Pocket elimination is Large perforation in the furcation (Class
performed when necessary, and healing should IV).
be complete prior to the implant procedure. Advanced external resorption of one root.
Where the puip of the tooth is non-vital, the
(c) Cronm—root fracture
implant should not be inserted at the first visit
of endodontic treatment. (d) Extensive root caries of one root
Before considering a hemisection or root
7. Hemisection, tooth separation and root amputation, it is advantageous to perform
amputation endodontic treatment of the remaining root
These techniques are performed on multi- canals first, otherwise the pulp will be exposed
rooted teeth, mainly on first and second molars during root resection.
Relationship hetrpeen periodontai and pulpal disease 51
•>.' • k
v
Fig. 9. (a) Large penapical lesion and apical rooi lestirption of 3 . The root canal was treated for several
\isit.s bul could niit be dned (b) '\pical curettagt was performed. After the root canal was dry. it was
intentionallj o\trfi!led with gutta-percha which was removed, (c) Radiograph 3 months after surgery,
(d) Radiograph Hi months after surgery.
p. H. A. Guldmer
Fig. 10. (a) Periapicai lesion and radiolucency in the bifurcation of/S The mesial root canal is blocked
by a post. Second and third molars are missing, (b) Hemisection was carried out. After removinc; the mesial
root, a four unit bridge was made using the distal root as an abutment.
/ ' - •
' • ' ^ -
Fig. 11. (a) Periodontally involved upper right first and second molars with furcation involvement, (b) The
distal root of the second molar and the mesial root of the first molar were amputated, after endodontic
treatment of the remaining roots.
SCHILDER, H . & GBDSSMAN, L.I. (1978) Endodontal— bined periodontal-piJpal problem. Dental Clinics
periodontal therapy. In: Endodontic Practice (ed. of North America, 13,45—52.
L. I. Grossman), 9th edn, pp. 378-390. Lea & SiMRiNc, M. & GOLDBERG, M . (1964). The pulpal
Febiger, Philadelphia. pocket approach: retrograde periodontitis.
SELIZER, S . (1971) Endodontology. McGraw-Hill Journal of Periodontology. 35, 22—48.
Book Co, New York. SiNAi, I.H. & SoLTANOFF, W. (1973) T h e trans-
SELTZER, S . & BENDER, I . B . (1975) The Dental mission of pathologic changes between the pulp
Pulp. 2nd edn, pp. 270-299. J.P. Lippincott, and the periodontal structures. Oral Surgery, Oral
Philadelphia. Medicine and Oral Pathology, 36, 558-568.
SELTZER, S., BENDER, I.B., NAZIMOV, H . and SINAI, SMUKLER, H . & TAGGER, M . (1976) Vital root
\. (1%7) Puipitis induced interradicular perio- amputation. A clinical and histologic study.
dontal changes in experimental animals. Journal Journal of Periodontology, 47, 324-330.
of Periodontology, 38, 124-129. STAHL, S . S . (1966) Pathogenesis of inflammatorj-
SELTZES, S . , BENDER, I.B. & ZIONTZ, M . (1963) The lesions in pulp and periodontal tissues. Periodon-
interrelationship of pulp and periodontal disease. tics, 4, 190-196.
Ora! Surgery, Oral Medicine and Oral Pathology, STALLARD, R . E . (1967) Periodontal disease and its
16, 1474-1490. relationship to puipal patholog). American Insti-
SELTZER, S . , SINAI, I. & AUGUST, D . (1970) Perio- tute of Oral Biology, Annual Meeting, pp. 197-203.
dontai eiFects of rcxit perforations before and TRONSTAD, L., TROPE, M., DOERING, A. &
during endodontic procedures. Journal of Dental HASSELGREN, G . (1983) Sealing ability of dental
Research, 49, 332-339. amalgams as retrograde fillings in endodontic
SIMON, J . H . (1980) Periodontai-Endodontic treat- therapy. Journal of Endodontics, 9, 551-553.
ment. In: Pathways of the Pulp (eds S. Cohen and WEINE, F . , KELLY, R . F . & BRAY, K . E . (1976) Effect
R. C. Bums), 2nd edn pp. 465-492. C V . Mosby of preparation with endodontic handpieces on
Co, St Louis. original canal shape. Journal of Endodontics, 2,
SIMON, P. & JACOBS, D . (1969) The so-called com- 298-303.