Key points on diagnosis in periodontology

It is a challenge to identify endodontic involvement while forming a periodontal diagnosis. For a successful treatment it is essential to identify pathologies involvement especially endodontic involvement.

Questions to be asked while forming a diagnosis-

1.    What are the etiological factors?

2.    Are there any co-morbidity?

3.    Is it a periodontal disease?

·       The knowledge of the etiology of the disease is highly important, since the success of the treatment depends on the rapidity of its onset.

·       Perio-endo lesions depict a close relationship between pulp & periodontium through the apical foramen, accessory canals & dentinal tubules of the root.

·       Diagnosis: Radiographic interpretations are more reliable. The presence of bone loss, deep restorations & Endodontic Treatments can be evaluated, which eventually helps to diagnose the origin of the lesion i.e. whether the lesion is of periodontal or endodontic origin.

·       Among the criteria for the diagnosis, the clinical history of the patient is of great significance. History of trauma, caries, abrasions, defective restorations can develop into pulp necrosis which indicates the lesion to be of endodontic origin. Whereas, in cases of presence of calculus, plaque, gingival inflammation & periodontitis, there is the probability of the lesion to be of periodontal origin.

·       Often the lesion of endodontic origin drains by the mucosa, gingiva or gingival sulcus; when the lesion is of periodontal origin, the drainage is through the periodontal pocket. Thus the path of fistula should be tracked to determine the lesion origin.

·       Single-rooted teeth have less favourable prognosis than multirooted teeth, since multirooted teeth can undergo root resection as an alternative treatment.

·       Treatment protocol:

§  Exclusively endodontic lesion- Root canal treatment is performed with intracanal medications like calcium hydroxide because of its mineralizing & antimicrobial action.

§  Lesion involving only periodontium- The periodontal therapy is performed comprising of scaling & root planing. 0.12% chlorhexidine solution is used as an antimicrobial agent during the treatment to control periodontal infections.

§  Perio-endo lesions- If two diseases are combined, the primary treatment recommended is the treatment of endodontic lesion, followed by Non-Surgical Periodontal Therapy.

In cases with no improvement in periodontal conditions, scaling & root planing is performed, guided tissue regeneration can be used to prevent migration of epithelial cells towards the defect during the healing process.

Is it a periodontal disease or other condition?

·       There are vast majority of conditions that may mimic periodontitis.

·       Gingivitis- Lichen planus, pemphigus/pemphigoid, herpes, leukemia etc.

Bone loss- Squamous cell carcinoma, giant cell granuloma, hyperparathyroidism, neutropenic conditions etc.

·       Factors one should consider- asymptomatic, intraoral lesion, vital tooth within a destructive lesion, change in general health, rapid change in lesions, not localised to gingival margin, isolated lesions in periodontally healthy patient & no response to the periodontal treatment.

It is extremely important to know how to differentiate between the origins of the lesions. This gives a direct conclusion to the correct diagnosis & adequate treatment resulting in successful treatment of the periodontal-endodontic lesions.