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June 2009 | DentalProductsReport.com
Clinical 360°: periodontics When doing endo, don’t forget to think perio Complications from endodontically treated teeth in relation to periodontal therapy. The set-up “Periodontal disease is a multifactorial process. In this excellent review, Endodontic therapy has provided a valued means of preventing tooth loss along with improved prognosis for thousands of otherwise hopeless conditions. Success rates for teeth treated with endodontic therapy are greater than 90 percent (Imura 2007). But it’s important to note endodontically treated teeth exhibit anatomical changes both internally and externally because of the loss of vitality. As a result of the permanent changes that occur pulpally, the calcified structure has the potential to become brittle from a diminished flow of fluids and moisture traversing the dental tubules. This reduced fluid flow apparently has no adverse effects on the tooth or the periodontium in the short term, but because of the lack of vitality, the hard tooth structure has the potential to become brittle and more susceptible to cracking and fractures in the long term. A significant number of tooth losses are the result of fracture or cracks, not the failure of the root canal itself (Cvek 2008). How pulpal tissue health plays a role Before proper diagnosis and treatment of endodontically treated teeth, pulpally involved teeth can have a detrimental effect on the periodontium. Changes in the health of the pulpal tissue can alter the periodontal ligament (PDL), the apical area of the tooth, as well as the bifurcation or trifurcation areas. The necrotic or inflamed pulpal tissues in the furcal areas anatomically can exhibit accessory canals (haznedaroglu 2003) (16 to 24%). These accessory canals can have necrotic debris, bacterial contaminated tissue or other toxins leaching into the periodontal ligament spaces, resulting in temporary or permanent destruction of the PDL and bone. If there is concurrent periodontal involvement, the reaction becomes more complicated and increases the percentage of permanent attachment loss. The path of least resistance There are also instances where the path of least resistance is coronally and the inflammatory process progresses coronally, affecting PDL and bone with subsequent loss of attachment—especially if the lesion progresses into the sulcus and ultimately communicates with the oral cavity. In some of the teeth exhibiting combination lesions, treatment of both the endodontic portion as well as the periodontic portion can enhance retention of the tooth. However, some of these changes are irreversible and result in the loss of a tooth. Apical changes can lead to tooth loss If the irritant from an endodontically involved tooth is of a short duration, the changes that occur at the apical end usually are reversible. If, however, the irritants exist for longer periods of time, the apical changes can be more persistent and even remain after resolution of the endodontic condition. Chronic apical changes can result in cyst formation, soft- or hard-tissue scarring, or a chronic osteomyelitis condition. These conditions can remain dormant for long periods of time; however, they can, at any point, enter into an acute phase that can produce acute symptoms. In the most severe cases, they can result in tooth loss. What the radiographs tell you Radiographic or clinical signs of chronic low-grade reactive lesions are minimal if evident at all. Radiographic changes seen with chronic lesions are evident by either radioleucencies related to granulomatous or cystic reactions, as well as soft tissue scar formation, or radio opaque lesions that are related to hard tissue scar formation or even chronic osteomyelitis reactions (chronic focal sclerosing osteomyelitis). The body’s reaction to lesions The typical reaction to the presence of long standing inflammatory lesions is isolation and confinement. This reaction is the body’s attempt to prevent potential catastrophic systemic reactions. A soft-tissue cyst is an attempt to isolate an irritant and confine it. The hard tissue reaction is similar only differing in type of response with deposition of highly dense bone that exhibits minimal cancellous characteristics, with a similar goal of isolation and confinement. Nair (1990 and 1999) reported the range of chronic residual periapical lesions associated with endodontically treated teeth as 26 to 47 percent. These changes may not affect the tooth but when an endodontic tooth is extracted, these lesions can affect the placement, along with the short- and long-term prognosis of osseous integrated implant fixtures. The tooth is retained in most cases. No treatment is necessary to correct these chronic lesions, although it may be indicated if there is a compromised systemic condition. As we become more aware of potential systemic implications of periodontal conditions related to heart disease, low birth weight babies and other serious conditions, is it possible any of these chronic endodontic conditions can affect the patient systemically? Toxins and tooth loss If the areas of involvement are isolated and encompass a lower percentage of the root surfaces, the tooth’s prognosis will be favorable. But if a higher percentage is encountered, the long-term prognosis is questionable. Once the attachment apparatus is destroyed by the contaminants, no treatment will reverse the effects. It can be controlled
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