Periodontal Disease with Posterior Endodontic Involvement
Subjective information is that the patient does not report spontaneous pain episodes. Objective information includes an intact tooth with gingival
inflammation, bad buccal hygiene, but no fistula.
Clinical tests include a pulp test (negative) and periodontal probing: wide probing in several teeth. Radiological evaluation reveals angular bone lesions at the cervical part of several teeth.
Initial periodontal lesions that can, afterwards, affect the pulp are adamantine pearls and development grooves.
These are extensions of the enamel on the furca of the multiradicular teeth. Their origin seems to be related to the sporadic presence of starred reticle and intermediate stratum between the two epithelial layers of the epithelial radicular sheath of Hertwig. Their frequency ranges from 18% to 45%, and they are found at routine check-ups.
These are developmental anomalies on the palatal side of maxillary incisors. Their incidence has been reported as 1.9-8.5%, with a higher incidence laterally (4.4%) than centrally (0.28%). Development grooves may be asymptomatic, or periodontically symptomatic (either acute or chronic). When they are discovered in a clinical and radiological exam they already have a necrotic pulp, and canal treatment will regenerate only the endodontic part of the lesion. A periodontal lesion can be regenerated through surgery that removes root invaginations and calculus, and grafts the lesion in order to get a stable long-term clinical situation.
The True Endo-Perio Lesion
A mixture of the diagnosis data of the lesions described above can be found here. Since many of the various pathological processes have the same symptomatology, and the most important test, the pulp test, produces many false positives and false negatives, the clinician has to balance the higher number of clinical symptoms and diagnostic tests, in the most objective way, to reach the best diagnosis and treatment.
The dental history is crucial to get valuable information on the initial characteristics of the lesion, which is the result of a dynamic process. The symptoms could be well defined on one side at the very beginning, but when the clinician comes to evaluating the lesion the symptoms may have changed and are on both sides.
A healthy mouth that does not have periodontal attachment loss and with abundant reconstructions and accurate probing is an endodontic scenario. A mouth that is not that hygienic and shows periodontal attachment loss in many teeth, without reconstructions but with generalized probing points, is a periodontal scenario.
Even though it is impossible to determine the histological condition of the pulp through the described clinical exams, the pulp test is very helpful in a tooth without root canal treatment.
The periodontal treatment will be applied only if the tooth responds within the normal limits to a pulp vitality exam and there are no signs to make the clinician doubt the validity of the pulp test response.
Prognosis of the periodontic lesion is related to the amount of bone destruction and attachment loss. When no periodontal contamination exists, prognosis of an endodontic lesion is related to the size of bone lesion or attachment loss. The prognosis of an endo-perio lesion is related to the prognosis of the periodontic lesion.