Periodontal Disease vs. Endodontic Disease in the Diagnostic Process

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1 Periodontal Disease vs. Endodontic Disease in the Diagnostic Process Travis Henry, DVM, DAVDC Author s address Midwest Equine Services, W3143 County Road D, Elkhorn, WI 53121; midwestequine@me.com. E I. ENDODONTIC DISEASE ndodontic disease affects the live pulp of the tooth and ultimately the vitality of the tooth. Clinical signs that can be noted with endodontic disease are poor mastication, pain, heat, swelling, discolored teeth, and with acute cases even pyrexia can be noted. The live pulp of the tooth is contained within the tooth in structures that are lined by dentin. These chambers are named according to the anatomy of specific teeth. Single rooted teeth have a pulp chamber and root canal. Multi rooted teeth have a root canal associated with each root, a common pulp chamber, and then pulp horns extending from the common chamber towards the occlusal surface. 1,2 II. PERIODONTAL DISEASE Periodontal disease is considered a common, painful condition in the equine oral cavity with clinical signs that may include quidding, weight loss, bitting problems, and halitosis. 3 The risk of a patient being affected by periodontal disease is directly related to the anatomy of the dental quadrants for instance if malpositioned teeth are present in the patient they are at a higher risk for periodontal disease. Therefore the more normal the anatomy of the dental quadrant, the less likely the patient will be affected by periodontal disease. Periodontal disease is an inflammatory process of the supporting structures of the dentition, and can be further broken down into gingivitis and periodontitis. 4 Gingivitis is the inflammatory process of the gingiva both free and attached at the gingival sulcus. Periodontitis is the inflammatory process related to the alveolar bone, cementum of the tooth and the periodontal ligament. In most species gingivitis is considered the reversible component of periodontal disease and periodontitis the irreversible component. Therefore if there is bone loss related to a periodontal lesion, the bone loss is often permanent. If there is gingivitis related to a periodontal lesion and the cause of the lesion can be identified and successfully treated, the gingivitis will resolve. Equine periodontal disease is often instigated by a pathologic diastema between teeth allowing food to impact. This initiates the inflammatory process leading to gingivitis and periodontitis. The diastemata are found to be in one of 3 types: 1. primary diastemata where the teeth in the quadrant lack the physiologic angulation that normally causes the teeth to pack together and function as one unit; 2. Secondary where teeth are displaced or in cases of supernumerary teeth; and 3. Senile where a pathologic space is created as the horse ages due to a tapering of the tooth towards the apex and or loss of angulation of teeth in the quadrant. Senile diastemata are often noted in the maxillary teeth between the 4th premolar and 1st molar, with the space wider at the palatal margin and narrowing toward the buccal margin of the quadrant. Diastemata are further classified by their shape from the occlussal surface to the gingiva 1. Closed or valve where the space between the teeth is closer at the occlusal surface and open at the gingival margin and 2. Open where the space is wider at the occlusal surface or it is similar in width throughout the entire diastema. Examples of variations in the dental quadrants that are known to promote periodontal disease are lingoverted teeth, buccoverted teeth, missing teeth and supernumerary teeth. 5 III. CLINICAL FINDINGS OF ENDODONTIC DISEASE AND PERIODONTAL DISEASE Endodontic Disease Loss of clinical crown and tooth fractures (Fig. 1) Exposed pulp horns or chamber (Fig. 2) Draining tracts and bony swelling (Fig. 3) Infundibular caries (Fig. 4) 28

2 Fig. 4. Photograph of caries of the mesial infundibulum of tooth 207. Fig. 1. Photograph of complicated crown root fracture of tooth 107. Radiographic Findings of Endodontic Disease Loss of crown/root integrity (Fig. 5) Failure to narrow the pulp horns or chambers (Fig. 6) Periapical lucency formation (Fig. 7) Inflammatory root resorption (Fig. 8) Fig. 2. Photograph of non-vital pulp exposure pulp horns 1 and 2 on tooth 309. Fig. 5. Radiographic image of a complicated crown root fracture of tooth 101. Fig. 3. Photograph of draining tract from tooth 108 with bony swelling. 29

3 Diastemata formation and periodontal pocketing (Fig. 11) Draining tracts and bony swellings (Fig. 12) Increased probing depth of the gingival sulcus (Fig. 13) Fig. 6. Radiographic image failure to narrow pulp chamber. Large diamond points in the diseased tooth demonstrating the pulp chamber is wider in the diseased tooth and narrower in the healthy tooth. Small diamond points in the normal tooth. Inflammatory root resorption tooth 101 (black arrows demonstrating the difference of the diseased 101 compared to the normal 201 tooth.) Fig. 9. Photograph of gingivitis of the maxillary incisor teeth. Fig. 7. Radiographic image. Periapical lucency tooth 406 (red arrow). Fig. 10. Photograph of gingival recession of all incisor teeth. Fig. 8. Radiogaphic image. External inflammatory root resorption (black arrows) and a crown root fracture of tooth 408. Clinical Finding of Periodontal Disease Gingivitis (Fig. 9) Gingival recession (Fig. 10) Fig. 11. Photograph of periodontal pocket lingual side of the interproximal space of teeth

4 Fig. 12. Photograph of bony swelling of the right body of the mandible. Fig. 14. Radiographic image of periodontal ligament widening tooth 101. Fig. 15. Radiographic image of horizontal bone loss. Fig. 13. Photograph of increased probing depth on the buccal aspect of the 208 tooth. Radiographic Finding of Periodontal disease Periodontal ligament widening (Fig. 14) Horizontal bone loss (Fig. 15) Vertical bone loss (Fig. 16) Periodontal endodontic lesions (Fig. 17) Fig. 16. Radiographic image of vertical bone loss depicted by black V affecting the mesial side of teeth 308, 309,

5 Fig. 17. Radiographic image of periodontal endodontic lesion of tooth 409 depicted by red arrows. Fig. 19. Radiographic image of stage 3 with horizontal bone loss of teeth 308, 309, 310. IV. TREATMENT PLANNING Periodontal Disease Understanding the diagnostic findings allows the practitioner the ability to properly formulate a treatment plan. Periodontal disease is a progressive condition that over time causes loss of tooth attachment, increased mobility, death of the tooth, and eventual loss of the tooth. Early identification and staging of lesions is important for treatment planning if premature loss of the tooth is to be avoided. Staging of periodontal disease is performed by a combination of clinical exam findings and the amount of attachment loss determined by the obtained radiographs. Staging the mobility of a tooth is a clinical impression related to the severity of the periodontal disease and attachment loss of the tooth. Complete explanation of periodontal staging is explained in the component based oral exam abstract. Stages of Periodontal Disease 3 Stage 0: Normal periodontia Stage 1: Gingivitis only Stage 2: Gingivitis with up to 25% attachment loss of the tooth (Fig. 18) Stage 3: Gingivitis with 25%-50% attachment loss of the tooth (Fig.19) Stage 4: Gingivitis with over 50% attachment loss of the tooth (Fig. 20) Fig. 18. Radiographic image of stage 2 with horizontal bone loss of tooth 307, 308. Fig. 20. Radiographic image of stage 4 with horizontal bone loss of teeth Mobility Scoring of the Teeth 3 Mobility Stage 0: Normal physiologic movement Mobility Stage 1: First detectable movement greater than physiologic movement Mobility Stage 2: Up to 3 mm of movement of the tooth Mobility Stage 3: 3 mm or greater and/or the tooth can be depressed into the alveolus Stage-based treatment planning for periodontal disease. Radiographs should be obtained for staging of the lesions. Stage 1: Gingivitis with no attachment loss. Evaluation of the patient s anatomy to determine the risk of periodontal disease in the future. Potential dietary changes that promote a healthier oral environment such as grazing grass or soft grass hay that promotes a longer mastication cycle and more soft tissue cleansing of the teeth. Proper occlusal adjustment and odontoplasty to promote normal mastication and cleansing of the periodontium within the oral soft tissues and tongue during chewing. Stage 2: Gingivitis and up to 25% attachment loss. All of the same treatments performed in Stage 1 lesions apply to Stage 2. Determine the type of diastema if present. Debridement of the pocket with instrumentation. Possible treatment with perioceutic medications and protection of the pocket from further food impaction. Stage 3: Gingivitis and up to 50% attachment loss. Similar treatment for Stage 2 lesions. In advanced Stage 3 lesions 32

6 with nearly 50% attachment loss, extraction may be discussed with the owner. Stage 4: Teeth that have over 50% attachment loss should be recommended for extraction. Endodontic Disease Endodontic disease is the disease process that affects the internal structures of the tooth. This includes the vital pulp, and disease processes that affect the infundibula. Tooth fractures are also considered part of the endodontic disease complex. Fracture classification is explained in the component based oral exam abstract. 6 The diagnostic process concerning endodontic disease is aimed at deciding whether the affected tooth can be restored and/or monitored, or whether the tooth needs to be extracted. Restoration procedures that are employed in the equine patient include root canal treatment and restoration of the infundibulum with composite materials. These treatments are still considered in the experimental phase in horses compared to other species. Single rooted teeth in the horse can have root canal treatment performed similar to other species and can be expected to have comparable success rates. The multi-rooted teeth in the horse have a common pulp chamber located near the apex of the tooth, which is opposite of brachydont teeth which have the chamber located in the crown. This increases the difficulty in the debridement, disinfection, and obturation of the pulp horns, common pulp chamber and root canal system of the tooth. Treatments that have been reported are surgical root canal treatment with removal of the apex of the tooth and retrograde obturation. Experimental treatments include normograde treatment of the root canal system in stages, and extraction of the affected tooth with retrograde treatment and re-implantation of the tooth, the success rates are reported that range from 45-80%. 7,8 Ultimately if the tooth is non vital and there is another complicating disease process, extraction should be considered. Complicating disease processes would include periodontal disease, resorption of the tooth structure, draining tracts and severe secondary sinusitis. diagnosis. The diagnostic process should determine the vitality of the tooth, stage of the lesion, and whether the tooth should be extracted or not. Without performing this diagnostic process, a proper treatment plan cannot be formulated and implemented. REFERENCES 1. Easley J. Dental and oral examination, in Equine Dentistry 3rd ed. Elsevier: New York, 2011; Niemiec BA. Fundamentals of endodontics. Vet Clin North Am Small Anim Pract, 2005;35(4): Klugh DO. Equine periodontal disease. Clin Tech in Equine Pract, 2005;4(2): Arzi B, Verstraete FJ. Diagnosis of periodontal disease in dogs. J Small Anim Pract, 2009;50(2): Dixon PM, et al. A long-term study on the clinical effects of mechanical widening of cheek teeth diastemata for treatment of periodontitis in 202 horses ( ). Equine Vet J, 2014;46(1): AVDC. Dental Fracture Classification. Available from: - toothfracture. 7. Simhofer HC, Stoian, Zetner K. A long-term study of apicoectomy and endodontic treatment of apically infected cheek teeth in 12 horses. Vet J, 2008;178(3): Stoll M. Personal communication, Lundstrom, Teeth with periodontal endodontic lesions are definitely candidates for extraction. These are seen in 3 forms: 1. The tooth has endodontic disease with a large periapical abscess that drains through the periodontal structures causing significant periodontal disease; 2. severe periodontal lesions that have progressed to the point that the periodontal disease has involved the apex of the tooth causing death of the pulp tissue and 3. the instigating casuse of the disease process can not be determined or both disease processes are present separately. In all of these situations, the tooth is affected by two disease processes making treatment difficult and carrying a poor prognosis for tooth longevity. Extraction of the tooth is one treatment that cures both disease processes. V. CONCLUSION Understanding the diagnostic findings of both periodontal disease and endodontic disease is crucial in making a correct 33