ENDO-PERIO RELATIONSHIP
 It has long been recognized that an intimate relationship
exists between the pulp of a tooth and the surrounding
periodo...
 The simultaneous existence of endodontic and
inflammatory periodontal lesions can complicate
•

Diagnosis

•

Treatment ...
Pulpal and periodontal inter-relationship
The pulp and periodontium have
•

Embryonic

•

Anatomic

•

Functional inter- r...
Ectomesenchyme

Dental follicle

Periodontal Ligament

Dental papilla

Pulp
Dental follicle
 The

embryonic

development

gives

rise

to

anatomical

connections which remain throughout the life of the tooth.
 T...
 Tubular communication between the pulp and periodontium
may occur when dentinal tubules become exposed to the
periodonti...
Pathways for the communication of the Dental Pulp
with the Periodontium
PATHWAYS OF DEVELOPMENTAL ORIGIN [ANATOMIC]
 APIC...
PATHWAYS OF PATHOLOGICAL ORIGIN
 ROOT FRACTURES FOLLOWING TRAUMA
 EMPTY SPACES ON ROOT CREATED BY DESTROYED SHARPEY’S
FI...
PATHWAYS OF IATROGENIC ORIGIN
 EXPOSURE OF DENTINAL TUBULES FOLLOWING ROOT PLANING.
 ACCIDENTAL PERFORATIONS OF THE ROOT...
Effects of Pulpal Disease and Endodontic Procedures on
the Periodontium

PULPAL DISEASE

 Pulp inflammation or necrosis m...
 The resulting inflammatory lesion can be
•

a

minimal

inflammatory

process

confined

to

the

periodontal ligament
•...
 A lesion related to pulpal necrosis may also result in a
draining sinus tract that drains through



alveolar mucosa

...
ENDODONTIC PROCEDURES
1. Technical procedures involved in root canal treatment, irrigants,
medicaments, dressings, sealers...
 Procedural errors during root canal treatment

▬► major

destructive inflammatory processes in the periodontium.



Bre...
Effects of Periodontal Disease and Procedures on the Pulp
PERIODONTAL DISEASE
1. Periodontal disease must extend all the w...
PERIODONTAL PROCEDURES


All treatment modalities for periodontal disease have the
potential to adversely affect the pulp...


This

hypersensitivity

is

caused

by

the

complete

removal of cementum and the subsequent exposure of
dentinal tubu...
 Periodontal surgery affects the pulp to the extent that it is
exposed

to

endotoxin

or

bacteria

via

lateral

canals...
ENDO- PERIO LESIONS

PRIMARY ENDODONTIC
DISEASE

COMBINED DISEASES

PRIMARY PERIODONTAL DISEASE

PRIMARY ENDODONTIC DISEAS...
Primary endodontic lesions

• An acute exacerbation of a chronic apical lesion on a tooth
with a necrotic pulp may drain c...
Diagnosis :
•

Insert a gutta-percha cone into the sinus tract and take one
or more radiographs to determine the origin of...
Radiographic changes:

No noticeable changes in the early stages

As the disease continues → widening of PDL → periapical
...
Primary periodontal lesions
•

These

lesions

are

caused

primarily

by

periodontal

pathogens.

•

In most cases, pulp...
Radiographs :
•

Show angular bone loss extending from the cervical
regions of the tooth.

•

The prognosis depends upon t...
Primary

endodontic

lesions

with

secondary

periodontal

involvement

•

If after a period of time a suppurating primar...
•

When plaque or calculus is detected, the treatment and
prognosis of the tooth are different than those of teeth
involve...
•

Primary

endodontic

lesions

with

secondary

periodontal

involvement may also occur as a result of root perforation
...
•

A more chronic response may sometimes occur without
pain, and involves the appearance of
bleeding on probing or exudati...
Primary periodontal lesions with secondary endodontic
involvement
•

The apical progression of a periodontal pocket may co...
•

In molar teeth the prognosis may be better. Since not all the
roots may suffer the same loss of supporting tissues, roo...
•

The treatment of

periodontal disease can also lead to

secondary endodontic involvement.

•

Lateral canals and dentin...
Pulp tests may show an abnormal response or complete
absence of any response.
Treatment : Endodontic therapy + periodontal...
True combined lesions
•

A true combined lesion is said to be present when an endodontic
lesion extends and communicates w...
•

The degree of attachment loss in this type of lesion is
invariably

large

and

the

prognosis

guarded.

This

is

par...
• Treatment :
• Endodontic therapy [ apical surgery if indicated]
• Periodontal therapy
• Root resections / hemisections /...
Diagnosis:


Diagnosis of

combined periodontal-endodontic lesions can

prove difficult.



Often

characterized

attach...
Endoperio relationship
Endoperio relationship
Endoperio relationship
Endoperio relationship
Endoperio relationship
Endoperio relationship
Endoperio relationship
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Clinical Endodontics
Fifth Year

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Transcript of "Endoperio relationship"

  1. 1. ENDO-PERIO RELATIONSHIP
  2. 2.  It has long been recognized that an intimate relationship exists between the pulp of a tooth and the surrounding periodontium  The periodontium communicates with pulp tissues through many channels or pathways. Pulpal infections ↔ Periodontium  Thus, lesions of the periodontal ligament and adjacent alveolar bone may originate from infections periodontium or tissues of the dental pulp. of the
  3. 3.  The simultaneous existence of endodontic and inflammatory periodontal lesions can complicate • Diagnosis • Treatment planning • Sequence of treatment
  4. 4. Pulpal and periodontal inter-relationship The pulp and periodontium have • Embryonic • Anatomic • Functional inter- relationships They are ectomesenchymal in origin
  5. 5. Ectomesenchyme Dental follicle Periodontal Ligament Dental papilla Pulp
  6. 6. Dental follicle
  7. 7.  The embryonic development gives rise to anatomical connections which remain throughout the life of the tooth.  The apical foramen decreases in size as the proliferation of the Sheath of Hertwig continues. It remains patent and serves as the communication on which the pulpal tissues rely for nutrition and nervous innervation  As the root develops, ectomesenchymal channels get incorporated, either due to dentine formation around existing blood vessels or breaks in the continuity of the Sheath of Hertwig, to become accessory or lateral canals
  8. 8.  Tubular communication between the pulp and periodontium may occur when dentinal tubules become exposed to the periodontium by the absence of overlying cementum  These are the pathways that may provide a means by which pathological agents pass between the pulp and periodontium, thereby creating the perio-endo lesion
  9. 9. Pathways for the communication of the Dental Pulp with the Periodontium PATHWAYS OF DEVELOPMENTAL ORIGIN [ANATOMIC]  APICAL FORAMEN.  ACCESORY CANALS/ LATERAL CANALS  CONGENITAL ABSENCE OF CEMENTUM EXPOSING DENTINAL TUBULES.  PERMEABILITY OF CEMENTUM.  DEVELOPMENTAL GROOVES.  DEVELOPMENTAL ANOMALIES SUCH AS ENAMEL PROJECTIONS AND ENAMEL PEARL.
  10. 10. PATHWAYS OF PATHOLOGICAL ORIGIN  ROOT FRACTURES FOLLOWING TRAUMA  EMPTY SPACES ON ROOT CREATED BY DESTROYED SHARPEY’S FIBRES [ ESPECIALLY AFTER REIMPLANTATION OF AVULSED TEETH]  IDIOPATHIC RESORPTION – INTERNAL AND EXTERNAL.  LOSS OF CEMENTUM DUE TO EXTERNAL IRRITANTS [PLAQUE OR CALCULUS ACCUMULATION]
  11. 11. PATHWAYS OF IATROGENIC ORIGIN  EXPOSURE OF DENTINAL TUBULES FOLLOWING ROOT PLANING.  ACCIDENTAL PERFORATIONS OF THE ROOT DURING ENDODONTIC PROCEDURES.  ROOT FRACTURES CAUSED DUE TO ENDODONTIC / PROSTHODONTIC PROCEDURES.  FRACTURED/ DEFECTIVE RESTORATIONS OF ENDODONTICALLY TREATED TEETH CORONAL LEAKAGE
  12. 12. Effects of Pulpal Disease and Endodontic Procedures on the Periodontium PULPAL DISEASE  Pulp inflammation or necrosis may lead to an inflammatory response in the periodontal ligament at the apical foramina or at the site of a lateral or accessory canal.
  13. 13.  The resulting inflammatory lesion can be • a minimal inflammatory process confined to the periodontal ligament • extensive destruction of the periodontal ligament, tooth socket, and surrounding bone
  14. 14.  A lesion related to pulpal necrosis may also result in a draining sinus tract that drains through  alveolar mucosa  attached gingiva,  the gingival sulcus of the involved tooth or  through the gingival sulcus of an adjacent tooth
  15. 15. ENDODONTIC PROCEDURES 1. Technical procedures involved in root canal treatment, irrigants, medicaments, dressings, sealers, and filling materials have the potential to cause an inflammatory response in the periodontium. 2. An inflammatory response resulting from commonly used root canal treatment methods and materials, however, is usually transient in nature and resolves quickly if filling materials are confined within the canal space
  16. 16.  Procedural errors during root canal treatment ▬► major destructive inflammatory processes in the periodontium.  Breakdown of the attachment resulting in a periodontal defect may occur after procedural errors such as • access perforations in the floor of a pulp chamber • perforations on the root surface apical to the gingival attachment, • strip perforations or root perforations related to cleaning and shaping procedures, and • vertical root fractures
  17. 17. Effects of Periodontal Disease and Procedures on the Pulp PERIODONTAL DISEASE 1. Periodontal disease must extend all the way to the apical foramen or an opening of the lateral/ accessory canals to cause significant pulp involvement. 2. Bacterial & inflammatory products of periodontitis could gain access to the pulp via accessory canals, apical foramina or dentinal tubules. 3. This process , the reverse of effects of necrotic pulp on the periodontal ligament , has been referred to as Retrograde Pulpitis
  18. 18. PERIODONTAL PROCEDURES  All treatment modalities for periodontal disease have the potential to adversely affect the pulp.  Increased hypersensitivity is one of the common sequelae of nonsurgical and surgical periodontal therapy.
  19. 19.  This hypersensitivity is caused by the complete removal of cementum and the subsequent exposure of dentinal tubules to the oral environment.
  20. 20.  Periodontal surgery affects the pulp to the extent that it is exposed to endotoxin or bacteria via lateral canals, dentinal tubules, or in extreme cases the apical foramen
  21. 21. ENDO- PERIO LESIONS PRIMARY ENDODONTIC DISEASE COMBINED DISEASES PRIMARY PERIODONTAL DISEASE PRIMARY ENDODONTIC DISEASE WITH SECONDARY PERIODONTAL INVOLVEMENT PRIMARY PERIODONTAL DISEASE WITH SECONDARY ENDODONTIC INVOLVEMENT TRUE COMBINED DISEASES
  22. 22. Primary endodontic lesions • An acute exacerbation of a chronic apical lesion on a tooth with a necrotic pulp may drain coronally through the periodontal ligament into the gingival sulcus. • This condition may mimic clinically the presence of a periodontal abscess. In reality, it is a sinus tract from pulpal origin that opens through the periodontal ligament area
  23. 23. Diagnosis : • Insert a gutta-percha cone into the sinus tract and take one or more radiographs to determine the origin of the lesion. • When the pocket is probed, it is narrow and lacks width. • A similar situation occurs where drainage from the apex of a molar tooth extends coronally into the furcation area. This may also occur in the presence of lateral canals extending from a necrotic pulp into the furcation area.
  24. 24. Radiographic changes: No noticeable changes in the early stages As the disease continues → widening of PDL → periapical radiolucency → bony lesion Primary endodontic diseases usually heal following root canal treatment
  25. 25. Primary periodontal lesions • These lesions are caused primarily by periodontal pathogens. • In most cases, pulp tests indicate a clinically normal pulpal reaction • There is frequently an accumulation of calculus and the pockets are wider plaque and
  26. 26. Radiographs : • Show angular bone loss extending from the cervical regions of the tooth. • The prognosis depends upon the stage of periodontal disease and the efficacy of periodontal treatment • Treatment : periodontal therapy
  27. 27. Primary endodontic lesions with secondary periodontal involvement • If after a period of time a suppurating primary endodontic disease remains untreated, it may become secondarily involved with periodontal breakdown. • Plaque forms at the gingival margin of the sinus tract and leads to plaque-induced periodontitis in the area.
  28. 28. • When plaque or calculus is detected, the treatment and prognosis of the tooth are different than those of teeth involved with only primary endodontic disease. • Probing may show a solitary but wider pocket • The tooth now requires both endodontic and periodontal treatments
  29. 29. • Primary endodontic lesions with secondary periodontal involvement may also occur as a result of root perforation during root canal treatment, or where pins or posts have been misplaced during coronal restoration. • Symptoms may be acute, with periodontal abscess formation associated with pain, swelling, formation, and tooth mobility. pus or exudate, pocket
  30. 30. • A more chronic response may sometimes occur without pain, and involves the appearance of bleeding on probing or exudation of pus. a pocket with
  31. 31. Primary periodontal lesions with secondary endodontic involvement • The apical progression of a periodontal pocket may continue until the apical tissues are involved. • The pulp may become necrotic as a result of infection entering via lateral canals or the apical foramen. • In single-rooted teeth the prognosis is usually poor.
  32. 32. • In molar teeth the prognosis may be better. Since not all the roots may suffer the same loss of supporting tissues, root resection can be considered as a treatment alternative
  33. 33. • The treatment of periodontal disease can also lead to secondary endodontic involvement. • Lateral canals and dentinal tubules may be opened to the oral environment by scaling and root planing or surgical flap procedures. • It is possible for a blood vessel within a lateral canal to be severed by a curette and for microorganisms to be pushed into the area during treatment, resulting in pulp inflammation and necrosis.
  34. 34. Pulp tests may show an abnormal response or complete absence of any response. Treatment : Endodontic therapy + periodontal therapy [ root resections if indicated]
  35. 35. True combined lesions • A true combined lesion is said to be present when an endodontic lesion extends and communicates with a pre-existing periodontal lesion. • True combined endodontic–periodontal disease occurs less frequently than other endodontic–periodontal problems. It is formed when an endodontic disease progressing coronally joins with an infected periodontal pocket progressing apically
  36. 36. • The degree of attachment loss in this type of lesion is invariably large and the prognosis guarded. This is particularly true in single-rooted teeth. • In molar teeth, root resection can be considered as a treatment alternative if not all roots are severely involved
  37. 37. • Treatment : • Endodontic therapy [ apical surgery if indicated] • Periodontal therapy • Root resections / hemisections /bicuspidisations
  38. 38. Diagnosis:  Diagnosis of combined periodontal-endodontic lesions can prove difficult.  Often characterized attachment and by alveolar extensive bone, loss and of their periodontal successful management depends on careful clinical evaluation, accurate diagnosis, and a structured approach to treatment planning for both the endodontic and periodontic components.

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