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The Perio-Endo lesion
From: Mike Rethman
To: periotherapist group
Sent: Wednesday, March 28, 2007 2:32 AM
Subject: [periotherapist] "The Perio-Endo lesion"
Re: "From Paul Keyes,
I have recovered spirochetes from necrotic pulp canals in intact
teeth with perio-endo lesions."
M. Rethman: Indeed, you and others have isolated bugs considered
"periodontal" from necrotic pulpal tissue remains.
However, the questions remain:
1. How did they get there (post-necrosis perhaps?) Anachoresis? Thru
dentinal tubules prior or post pulpal necrosis?
2. If it's a true perio-endo lesion, did these periodontal bugs have
etiologic role(s) in pulpal death?
You'll never get me to say "no way" but despite ample endo experience,
I've never seen an endo case that I could confidently attribute to a
periodontal etiology (#3 above). Therefore the "threat" that
periodontitis or periodontal therapy presents to pulpal health is,
IMHO, a red herring. At best, it appears to be an extremely rare
phenomena, if it happens at all.
From Paul Keyes,
This is a late reply. I speculate that as the epithelial cells migrate
apically they and other cells destroy the attachment tissues and any
blood vessels, etc., that enter lateral canals. This leads to
infection and eventual pulpal necrosis. Spirochetes, etc then enter
the pulp chamber thru lateral canals. This is what I believe happens.
Mike Rethman:
Paul's description seems reasonable, but it's my impression that the
so-called "perio-endo" lesion rarely, if ever, actually happens.
1500 or so endo teeth treated (referred to me) and many years of
practicing perio and I never saw a "perio-endo" lesion that I felt
wasn't really an "endo-perio" lesion. (Some of these could have been
either, but in each case there was at least some evidence that the
initial lesion was pulpal.) Also, I see no reason why periodontal
bacteria couldn't "move" thru exposed dentinal canals (or lateral
canals -- that tend to be mostly near the apex of single-rooted
teeth but can penetrate from the interprox. bone into the pulp in
furcations) into an already-dead pulp. Indeed I suspect that this
process would be easier than bacteria successfully attacking and
killing live tissue in the tubules.
From Paul Keyes,
Such lesions are rare. When radiographs showed a periodontal lesion
with total loss of bone around the apex of a tooth, I tested the pulp.
If it were non-vital, one of my colleagues treated the tooth
endodontically and I treated it periodontically. We had some success
saving teeth with this type of involvement.
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