Taking root
Whether it is an idea or a plant, when something takes root, it hopefully grows and develops. If all goes well, a healthy future can lie ahead, but if damage occurs, the outcome may be disappointing or worse. Because roots are often invisible, problems can lie hidden and cause difficulties.
When it comes to teeth, endodontics involves the treatment of root canal problems, while periodontics deals with the “prevention, diagnosis and treatment of diseases of the supporting and surrounding tissues of teeth”.[i]
Although periodontal disease attacks the gingiva, it has additional, sinister potential. The relationship between periodontitis and endodontitis has been described as a continuum i.e. “a continuous sequence in which adjacent elements are not perceptibly different from each other, but the extremes are quite distinct”[ii] and this aspect was considered in a review of 2008.[iii] This inter-relationship has “aroused much speculation, confusion and controversy” and the review looked at various aspects, including the cause and development of perio-endo lesions. In respect of periodontal lesions on pulp, the review notes that while factors relating to the evolution of these lesions can vary “it is widely accepted that microbial agents are the main cause”. In relation to the transmission of disease between pulpal and periodontal tissue, it also observes that there are studies that showed “microbiological similarities between infected root canals and advanced periodontitis”.
Where there has been root canal surgery, periodontal disease may go ‘underground’ in the form of apical periodontitis. In a French study of 1035 root-canal treated teeth, apical periodontitis was found in 33% of the treated teeth, with only 19% of the teeth found as receiving ‘adequate endodontic treatment’.[iv] The relationship between the quality of root canal treatment and the prevalence of apical periodontitis was also considered in a Palestinian study where 15.1% of teeth examined “had radiographic signs of apical periodontitis”.[v]
With regard to treatment when apical periodontitis has occurred, the Quality Guidelines of the European Society of Endodontology[vi] note that “treatment is aimed at restoring the periradicular tissues to health: this is usually carried out by root canal treatment”.
The treatment of periodontal disease is very important, particularly bearing in mind the observations of the 2008 review.[vii] Treatment depends upon the disease type and “no single treatment approach can provide the only means of any one or all periodontal diseases”,[viii] with different treatments being appropriate for different sites including good oral hygiene, antibiotics, and/or root planing and scaling. However, given that microbial agents can play a part in the evolution of perio-endodontic lesions, combating these agents is important, and scaling and planing may not necessarily be adequate.
An adjunctive treatment may also be needed, with the use of antibiotics as one possibility. However, given the clear links found between widespread use of antibiotics and the selection of resistant organisms, a better adjunctive treatment for periodontal pockets of 5mm or more may be a PerioChip®. Once inserted into the pocket, the wafer thin gelatin chip immediately releases a high local concentration of chlorhexidine diglucontate, continuing as it biodegrades over approximately a seven-day period and suppressing bacterial flora for up to 11 weeks.[ix] The process should be repeated at three monthly intervals if the pocket remains larger than 5mm as part of an ongoing periodontal treatment programme.
As the British Endodontic Society observe, “Endodontic treatment saves teeth that would otherwise need to be extracted”.[x] Ensuring good periodontal health can help to play a part in this and other treatments.
For more information or to contact the team behind PerioChip®, email This email address is being protected from spambots. You need JavaScript enabled to view it. or call 0800 013 2333
DPD/14/0021
[i] Guideline for Periodontal Therapy. American Academy of Periodontology. Endorsed/Reaffirmed by the American Academy of Pediatric Dentistry, 1992, 1993, 2000, 2001, 2003. J Periodontol 2001; 72:1624-8. Available at: www.aapd.org/media/Policies_Guidelines/E_PerioTherapy.pdf?
[ii] http://www.oxforddictionaries.com/definition/english/continuum
[iii] Raja V S, Emmadi P, Namasivayam A, Thyegarajan R, Rajaraman V. The periodontal - endodontic continuum: A review. J Conserv Dent [serial online] 2008 [cited 2014 Apr 15];11:54-62. Available from: http://www.jcd.org.in/text.asp?2008/11/2/54/44046
[iv] Prevalence of apical periodontitis in root canal-treated teeth from an urban French populatio: influence of the quality of root canal fillings and coronal resorations. Tavares, P.B., Bonte, E., Boukpessi, T., Siqueira, J.F Jr., Lasfarquess, J.J. J Endod. 2009. June; 35 (6): 810-3.
[v] Prevalence of apical periodontitis and quality of root canal treatment in an adult palestinian sub-population. Mukhaimar, R., Hussein, E., Ibtesam, O. The Saudi Dental Journal; vol. 24, issue 3, pp 149-155, July 2012.
[vi] Quality guidelines for endodontic treatment: consensus report of the European Society of Endodontology. European Society of Endodontology. International Endodontic Journal, 39, 921–930, 2006
[vii] Raja V S, Emmadi P, Namasivayam A, Thyegarajan R, Rajaraman V. The periodontal - endodontic continuum: A review. J Conserv Dent [serial online] 2008 [cited 2014 Apr 15];11:54-62. Available from: http://www.jcd.org.in/text.asp?2008/11/2/54/44046
[viii] Guideline for Periodontal Therapy. American Academy of Periodontology. Endorsed/Reaffirmed by the American Academy of Pediatric Dentistry, 1992, 1993, 2000, 2001, 2003. J Periodontol 2001; 72:1624-8. Available at:
[ix] Jeffcoat M K et al. Adjunctive use of a subgingival controlled-release chlorhexidine chip… J Periodontal 1998; 69 (9): 989 – 997.
[x] http://www.britishendodonticsociety.org.uk/patients/index.php?action=show&id=10
Abbreviated Prescribing Information
PerioChip® 2.5mg Dental Insert (Chlorhexidine digluconate)
For full prescribing information, including side effects, precautions and contraindications, see Summary of Product Characteristics (SmPC).
Presentation: Dental insert: bullet shaped orange brown containing Chlorhexidine digluconate 2.5mg.
Indications: PerioChip® is an adjunctive antimicrobial treatment for moderate to severe chronic periodontal disease in adults with pocketing, combined with Root Surface Debridement (RSD). Not indicated in children and adolescents.
Dosage and Administration: One PerioChip® is inserted into a periodontal pocket with a probing pocket depth of ?5mm. Retreatment with PerioChip® following mechanical plaque removal at 3 month intervals may provide additional benefit if pocket depth remains ?5mm. For details see SmPC. Removal is unnecessary as PerioChip® biodegrades.
Contraindications: Hypersensitivity to Chlorhexidine digluconate or excipients.
Precautions: Allergic reactions have occurred but are rare.
Interactions: Avoid nystatin: antagonistic of Chlorhexidine. Chlorhexidine is incompatible with anionic agents present in some toothpastes and with dietary sucrose, but there is no significant impact on the efficacy of PerioChip®.
Undesirable effects: During the first few days after insertion, transient pain or discomfort of gums or teeth; redness and/or swelling of the gums.
Overdose: Not reported
Pregnancy/ Lactation: Controlled studies in pregnant women have not been conducted, so weigh expected benefits against possible foetal risks: caution in nursing mothers (see SmPC).
NHS list price: £207.20
Legal category: P, Product Licence Number: PL 14017/0035
MA holder: Full prescribing information is available on request from Dexcel Pharma Ltd, 7 Sopwith Way, Drayton Fields Industrial Estate, Daventry, Northants, NN11 8PB.
Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard.
Adverse events should also be reported to:
Dexcel Pharma Ltd on 01748 828784
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