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Internal relation between pulp disease and periodontal disease









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发表于 2018-9-16 15:16:27 | 显示全部楼层 |阅读模式
Due to the close anatomical relationship between the pulp and periodontal tissue, there must be a certain relationship between the periodontal disease and the pulp disease. Periodontal disease may cause pulp disease and periodontal disease may also cause periodontal disease loss, but its manifestations are quite different from those of chronic periodontal disease. This paper mainly discusses the intercommunication between dental pulp and periodontal tissue, the effect of dental pulp lesions on periodontal tissue, the effect of periodontal inflammation on dental pulp tissue, the classification of periodontal pulp lesions and the differential diagnosis.
1. Intercommunication between the pulp and periodontal tissue
There are several possible pathways between the pulp and periodontal tissue that allow disease to interact between the two tissues. These channels mainly include neural traffic branch, lateral accessory root canal, dentinal tubule, malformed lateral sublingual groove, periodontal membrane, alveolar bone, apical foramen and the common vascular lymphatic drainage pathway of periodontal pulp. The vascular system is the most closely related part of periodontal and dental pulp tissue, which may become the pathway of inflammatory material interaction.
1.1 apical orifice and lateral accessory orifice
Apical foramen is the most direct path between the dental pulp and periodontal tissue. The lateral accessory root canal located in the apical area and the bifurcation area of the molar root also connects the dental pulp and periodontal tissue.
1.2 dentinal tubules
The dentinal tubule is considered to be another pathway between the periodontal membrane and the dental pulp tissue. The medullary cavity can be transported through the dentinal tubule and the outer surface of the root, especially in the case of loss of cementum.
1.3 root malformation
The root deformities mainly include the malformed lateral lingual groove and the internal cavity. Deformed lateral lingual groove is the developmental abnormality of maxillary incisors, and lateral incisors are more common than middle incisors. These communication often starts from the central fossa through the glossal protuberance to different depths of the root surface, and the incidence of deformed lateral lingual groove is 1.9%~8.5%. Jansson et al. showed that 0.5% of the deformed lateral lingual groove can extend to the root tip and thus cause the pathological state of the pulp. According to the degree of the tooth to the root square, the tooth is divided into the following three types. Ⅰ type: enamel invagination of bone world but not more than glaze; Ⅱ type: enamel invagination, into the root of bone world over glaze, but did not reach the periapical tissue, and the periodontal ligament is not mutually; Ⅲ type A: enamel invagination, throughout the entire root in root side hole formed new root and periodontal membrane are interlinked; Ⅲ type B: enamel invagination extends to the apex, while in the hole formed new root apex and periodontal membrane are interlinked. Malformed root fissures and dental invaginations can sometimes be connected to the medullary cavity, and sometimes cannot.
1.4 root canal lateral perforation
Root canal treatment of internal and external absorption of root canal preparation, root and drag in the bottom of the pulp chamber of root caries loss caused by the lateral wall wear or medullary perforation can provide transportation for root canal system and the periodontal ligament, the prognosis of root tube wall side wear mainly depends on the position of the perforation, perforation of the time, perforation can be closed, establishing new adhesion ability and residual root canal can pass.
1.5 the root line
The fracture line provides access to the root canal system and periodontal tissue. Lateral root fracture can lead to progressive destruction of periodontal tissue that has been successfully treated by root canal, and the periodontal condition is stable at other points in the whole mouth.
2. Effects of pulp lesions on periodontal tissues
Untreated pulp infection is considered a local risk factor for the development of periodontitis. Untreated periapical infection can provide an environment for the growth of pathogens, and the products of infection can reach periodontal tissues through apical orifices and lateral accessory endodontic orifices, which will aggravate the formation of periodontal pockets and bone loss, and weaken tissue healing to aggravate further periodontal damage. In addition, high concentrations of drugs (such as calcium hydroxide, steroid hormones, and antibiotics) in root canal therapy can stimulate periodontal support tissues. The type and extent of periodontal destruction depends on several factors, including the virulence (such as bacteria, drugs, and foreign antigens) of the stimuli present in the root canal system, the course of disease, and the host's defense mechanisms. Although there is a high correlation between dental pulp infection and the root bifurcation lesions of deep periodontal pocket and mandibular molar, the causal relationship between the two diseases has not been determined. It is generally recommended that root canal therapy should be completed before root bifurcation to ensure better results. Although there is insufficient evidence, the treatment of periodontal disease from pulp sources through improved root canal therapy has been widely recognized. Whether pulp infection has significant effects on periodontal tissue health remains to be demonstrated.
3. Effect of periodontal inflammation on pulp tissue
Clinically, progressive periodontitis is often found with pulp necrosis when it spreads to apical foramen. The infection inside periodontal pocket can also infect the pulp tissue through the lateral accessory root canal, which is usually found in the bifurcation area and the proximal apical area. Bacteria products and toxins can also infect dental pulp tissue through exposed dentinal tubules. The pulp response is affected not only by the progression of periodontitis, but also by the type of periodontal treatment such as curettage, root flattening and the use of drugs.
The integrity of the cementum plays an important role in the protection of the toxins produced by the dental pulp against plaque. Studies have reported that the pulp of the teeth with long-term periodontitis may present fibrosis and varying degrees of mineralization, and the root canal of the teeth with periodontitis is thinner than that without periodontitis, which is considered to be a repair reaction rather than an inflammatory reaction. The effect of periodontal disease on pulp is controversial. In special cases, such as periodontitis resulting in the exposure of the root surface accessory root canal, the dental pulp of the adjacent exposed accessory root canal may undergo inflammatory changes or even local necrosis. However, further studies cannot prove a direct relationship between periodontal disease and changes in dental pulp tissue. When periodontal disease leads to pathological changes in the pulp, as long as the main root canal is not involved, there will be no pulp degeneration, and the pulp tissue usually has the ability to resist the physiological damage caused by periodontal disease.
4. Classification of periodontal pulp lesions
There is no doubt that dental pulp disease and periodontal disease both increase the difficulty of diagnosis. To clarify the relationship between the two diseases or pathological changes of source, need full periodontal and dental pulp disease clinical data collection, including review of medication history, dental pulp vitality testing, clinical periodontal pocket and root bifurcation lesions and loose teeth, X-ray inspection results, clear damage to formation of the way and type, can get better treatment effect.
4.1 primary pulp lesions
Primary diseases are derived from dental pulp. Caries, repair and treatment, and occlusion injury are the most common factors causing pulpitis changes. Dead pulp teeth can cause apical and lateral bone resorption and damage adjacent periodontal attachment structures. Periodontal inflammation caused by infected root canals is not only confined to the apical region, but also occurs in the lateral root and the bifurcation area of multiple teeth. The clinical manifestations of periodontal inflammation caused by pulp disease include: pain, sensitivity to pressure and percussion, increased tooth mobility, gingival margin swelling and other similar periodontal abscess. Inflammatory progression can form the sinus tract, which is expelled through periodontal membranes or proprietary channels, including apical and lateral accessory root canal orifices. The opening of the sinus tract is often located within the gums or periodontal pockets, through which the root tip area can be easily explored, while other sites of the affected tooth cannot reach the deep periodontal pocket. In many tooth root, pus of antrum of periodontal membrane to the root furcation area, similar to periodontitis caused Ⅲ class through root bifurcation lesions. Clinically, the necrotic pulp can be found by the pulp vitality test, and at least the abnormal reaction indicating the degenerative changes of the pulp can be found in the multiple teeth. Since the primary disease is derived from the pulp of the tooth, and the lesions are only reflected through the periodontal membrane, the non-operative pulp treatment can achieve better results.
4.2 primary pulp lesions with secondary periodontal disease
Primary pulp disease has not been treated and lesions continue to progress, resulting in bone destruction in the apical region and invasion of the interroot region, resulting in destruction of surrounding soft and hard tissue. Due to continuous drainage of the gingival crevicular fissure, plaque and calculus accumulate continuously in the periodontal pocket of suppurative periodontal, which eventually leads to periodontal disease, causing periodontal support tissue to migrate to the root. When these conditions occur, not only is the diagnosis more difficult, but the treatment and prognosis are altered. In terms of diagnosis, periodontal examination and X-ray imaging confirmed the necrotic pulp and plaque accumulation of these lesions. The treatment of primary pulp disease and secondary periodontal disease depends on the treatment of these two diseases. Only part of the lesions can be cured by simple pulp treatment. If pulp treatment is complete, the prognosis depends on the severity of the root bifurcation and the effectiveness of periodontal treatment.
4.3 primary periodontal disease
Periodontal disease is an inflammation caused by plaque and tartar deposition and is characterized by progressive destruction. It starts from the gingival crevicular and moves to the root, and eventually causes the destruction of periodontal supporting tissue, leading to the loss of clinical attachment, and the formation of periodontal abscess in the acute phase. The process of bone defect formation in periodontitis and its X - ray representation in the lateral root and the bifurcation area have obvious characteristics. These lesions can be accompanied or not accompanied by trauma, which is the cause of single periodontal disease. Bone lesions caused by periodontal disease are often accompanied by loose teeth, and the dental pulp vitality test of the affected teeth is responsive. In addition, extensive periodontal pocket formation and aggregation of plaque and tartar are often found on periodontal examination. Periodontal bone disease is more extensive than pulp bone disease. The prognosis of primary periodontal disease is affected by the degree of periodontitis progression and periodontal destruction. Treatment depends on the degree of periodontitis and patient compliance (compliance with long-term treatment and ability to maintain treatment). Since primary periodontal disease is a disease of simple periodontal tissue, its prognosis depends only on the result of periodontal treatment.
4.4 primary periodontal disease with secondary pulp disease
As mentioned earlier, periodontal disease can affect the pulp through the dentinal tubule or the lateral accessory root canal. The difference between primary periodontal disease and primary periodontal disease is only the order of the disease process. The primary periodontal disease with secondary pulp damage is manifested as deep periodontal pocket, severe periodontitis or periodontal treatment history. The root progression of periodontal disease causes the exposure of lateral accessory root canal and dentinal tubule to the oral environment, resulting in dental pulp infection. Patients often report increased pain and clinical manifestations of dental pulp disease. On X-ray film, primary periodontal disease with secondary pulp damage and primary pulp disease with secondary periodontal damage are often indistinguishable. The prognosis depends on continued periodontal treatment and subsequent pulp treatment.
4.5 true associated lesions
Pulp and periodontal diseases may occur separately or simultaneously in and around the same tooth. Once pulp and periodontal diseases are combined, it is difficult to distinguish them clinically. Clinical presence of necrotic pulp or failure of root canal therapy, plaque, dental calculus and periodontitis. The prognosis of patients with polyodontal disease depends largely on the extent of periodontal disease.
4.6 coexistence of pulp and periodontal disease
Since the coexistence of two separate lesions is common in clinical practice, an additional classification is proposed, which is called the coexistence of periodontal disease. It refers to the coexistence of two diseases with different causes, and there is no clinical evidence that the two diseases affect each other, so it is usually difficult to diagnose clinically. Both diseases should be treated simultaneously, and their prognosis depends on the removal of their respective causes and the prevention of other influencing factors.
5. Differential diagnosis
5.1 root fracture
Root fracture, especially the longitudinal fracture, is very special in diagnosis. The symptoms and signs of longitudinal root fracture are diverse, which is difficult to distinguish from the tissue damage caused by periodontal pulp lesions. Root tips indicate that there are many types of longitudinal root fractures. For areas with rapid bone destruction, x-rays may sometimes be unable to be detected due to projection Angle, and multiple Angle projection is needed to confirm the diagnosis. Unless the fracture is clearly separated from the root surface, it is often difficult to find by clinical and imaging examination. As a result, the final diagnosis of some of the vertical root fractures requires exploration under direct vision by means of a valvular operation. Excessive lateral force filling of the root canal or the pressure of the root pile may lead to vertical root fracture. Clinical studies have shown that rhizotomy is more common in the overrepair of the affected teeth, the elderly and the mandibular posterior teeth. A single tooth with a root fracture usually needs to be pulled out. For multiple teeth, either a odontohemectomy or a root amputation can be selected.
5.2 bone laceration
The fracture of cementum is a special form of the longitudinal fracture of the tooth root. Some researchers have reported that the fracture of cementum or the separation of cementum from the root surface caused by trauma or aging changes can lead to periodontal destruction and pulp damage. It is often difficult to distinguish the lesions caused by the fracture of the dentin from those caused by the longitudinal fracture of the tooth, because it is generally impossible to tell whether the lesions are in the cementum layer on the two-dimensional X-ray. According to the location and degree of the fracture, conservative treatment is generally selected to remove only the fragments of the tear.
5.3 root malformation
Before CBCT, the diagnosis of root malformations was limited because root tips could not depict their anatomical morphology in all dimensions. Clinical examination of teeth is usually dynamic, so routine pulp vitality tests are difficult to diagnose. The increased palatal strength and depth in the anterior maxillary region can be used to detect the malformed root groove. Endodontic teeth involved in pulp may also show symptoms of pulpitis in the absence of deep caries and prostheses. In addition, although there is no direct connection with the pulp of teeth in the affected teeth, due to acute periodontal inflammation and infection, gingival swelling and other symptoms may occur, but the pulp vitality is normal. If such a condition is suspected, diagnosis with small field CBCT should be made to minimize pulp treatment.
The type and clinical characteristics of root deformities determine the treatment modality: if the pulp vitality of the tooth is normal and there are no obvious periodontal symptoms, the goal of treatment should be to prevent the colonization of the oral microflora to the site susceptible to infection. Studies have shown that surgical removal of rough tissue, combined with curettage and root face leveling, and then filling the root face groove with a composite resin can effectively prevent loss of attachment. For the internal cavity involving periodontal membrane, the closed wound after scaling can promote periodontal healing. If the malformed root canal and endodontic cavity involve the pulp of the tooth and have caused the pulp symptoms, the root canal treatment should be performed, and combined with surgery if necessary.
5.4 lateral cysts
The root and lateral cysts are usually asymptomatic in clinical manifestations and may present as labial gingival swelling, which may cause pain and gingival swelling. The imaging appearance is a circular or ovoid reflection, often surrounded by a membrane. Most lateral root cysts are less than 1 cm in diameter and lie somewhere between the tooth neck and the tip of the root. Lateral root cysts are most common in the mandibular cusp - bicuspid region, but a large number of cases have been reported in the anterior maxillary region.
6. Conclusion
Periodontal disease is caused by the close connection between the dental pulp tissue and periodontal tissue. The main transportation channels between the two kinds of tissues are apical orifice, lateral accessory endodontic canal and dentinal tubule. The differential diagnosis of dental pulp disease and periodontal disease is usually not simple and clear. When examining and treating periodontal combined lesions or individual lesions, it is important to keep in mind that successful treatment is based on correct diagnosis.

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