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INDIAN DENTAL ACADEMY
Leader in continuing dental education
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CONTENTS
INTRODUCTION
DEFINITION
CLASSIFICATION
ETIOLOGY
CONTROVERSIES REGARDING THE COMBINED LESION
PATHWAYS OF SPREAD
CO...
DEFINITION

An isolated, usually narrow, deep probing depth of pulpal or
periodontal origin.
Lesion with sub marginal or i...
COHEN
•
•
•
•
•
•
•

Primary endodontic lesion
Primary endodontic lesion with secondary periodontal
involvement
Primary pe...
WEINE

Type I - Tooth in which symptoms clinically and radiographically
simulate periodontal disease but are due to pulpal...
LESIONS REQUIRING ENDODONTIC TREATMENT ONLY
GROUP I
 necrotic pulp and apical granulomatous tissue replacing periodontium...
LESIONS REQUIRING PERIODONTAL TREATMENT ONLY

GROUP II
 Occlusal trauma causing reversible pulpitis
 Occlusal trauma plu...
LESIONS REQUIRING COMBINED ENDO – PERIO TREATMENT

GROUP III
 Any lesion in Group I That results in irreversible reaction...
ATYPICAL ANATOMIC FACTORS
Malaligned tooth
Multirooted teeth / additional root
Additional canal
Cervical enamel projection...
MISCELLANEOUS
Iatrogenic
systemic

SINUS TRACT

INFRABONY POCKET

•From canal

•From gingival crevice

•Narrow

•wide

www...
Causes : ( Stock )

Root fractures –
crown / root ( vital / non vital )

Root canal infection

Root resorption

Anatomical...
Multiple endo perio lesion

•Isolated lesion upon gen. periodontitis

•Chronic periodontitis

•Aggressive periodontitis

w...
CONTROVERSIAL ASPECT CONCERNING THE COMBINED
LESION
 PULPAL
 PERIODONTAL
Chacker
Massler
Czarnecki & Schilder

PERIODONT...
Physiologic :
• Apical foramen
• Lateral canals
• Dentinal tubules
• Periodontal ligament
• Alveolar bone
• Neural pathway...
COMPARISION
MARGINAL
PERIODONTITIS

APICAL
PERIODONTITIS

Cervical

Apex

Plaque

Pulpal inflammation

Horizontal / Vertic...
Attachment loss asso. with
 Anatomic defect on root
 Nature of pathogenic flora
 Necrotic & infected pulp
 Host defens...
DIFFERENTIAL DIAGNOSIS
PULPAL

PERIODONTAL

CLINICAL
Cause

pulp infection

periodontal

Vitality

non vital

vital

Resto...
RADIOGRAPHIC
Pattern
Bone loss
Periapical
Vertical bone loss

localized
wider apically
radiolucent
no

generalized
wider c...
Problems in
diagnosis :
Vertical root fracture:
varied radiographic picture
Different angulations
Surgical exposure
latera...
EFFECT OF PULP AND ITS TREATMENT ON PERIODONTIUM
Periodontal inflammation & bone loss
Sub marginal bone loss
Horizontal bo...
EFFECT OF PERIODONTAL DISEASE & ITS TREATMENT ON PULP
Periodontal disease & pulp
•Limited
•Channels closed + dystrophic ca...
PRIMARY ENDODONTIC LESION
Caries / trauma / restorative procedure
Pulp

Inflammation

Apical / lateral / Furcation / Attac...
PRIMARY ENDODONTIC WITH SECONDARY PERIODONTAL
Unchecked endo lesion
Periapical alveolar bone destruction
Interradicular ar...
PRIMARY PERIODONTAL LESION
Sulcus

Plaque / Calculus
Inflammation

Apex
Alv. Bone / Pdl
Clinical attachment loss
acute
Abs...
PRIMARY PERIODONTAL & SECONDARY ENDODONTIC
Periodontium

Pulp

Dentinal tubules
Lateral canals
Diagnosis : Deep pocket
H/O...
DIAGNOSIS OF ENDO PERIO LESIONS
History of dentinal / pulpal pain
History of periodontal symptoms (bleeding, recur. Infe...
Clinical signs of pocket formation :
Bluish red marginal gingiva /
vertical zone extending from
marginal to attached ging...
Symptoms of pocket formation
Usually painless
Localized or radiating pain or sensation of pressure after
eating which gr...
BIOLOGIC DEPTH
PROBING DEPTH
FORCE : 0.75N
POCKET DEPTH
LEVEL OF ATTACHMENT
GINGIVAL RECESSION
6 POINT CHARTING

DISTOPALA...
CONTINUOUS PROBING PROFILE

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LONG NARROW POCKETS: ENDODONTIC ORIGIN

LATERAL ENDODONTIC ABSCESS
WIDE AND DEEP POCKET
“BLOW OUT” LESION

www.indiandenta...
RADIOGRAPHIC PATTERN OF BONE LOSS
•Apical extent of bone loss
•Definite Pdl space absent
•Shape of bone defect ( angularit...
Causes:
o Endo
o Perio
o Fracture
o Resorption
o Anatomy

Endo perio lesion
usually isolated, narrow localized pocket

Che...
Feasible re-treatment?
No

Yes

Try OHI + debridement
OHI
Resolution?

Resolution?
No

Yes

No

Yes

oDo first stage endo
...
Vitality tests

Negative

Positive

Root canal treatment

Perio treatment

Resolution?

Resolution?
Yes

No

No

Yes

Chec...
TREATMENT ALTERNATIVES
ROOT RESECTION

REGENERATIVE TECHNIQUES
ROOT RESECTION :
“ Sectioning & removal of one or two roots...
RADISECTION :
“Newer terminology for removal of roots of maxillary molars .”
BISECTION / BICUSPIDIZATION :
“Separation of ...
ROOT RESECTION
Furcation involvement.

( Maxillary / Mandibular - 3 point / Nabers probe )

Classification of degree of Fu...
INDICATIONS FOR RESECTIONS

Periodontal indications
Severe vertical bone loss involving only
one root of a multi rooted t...
Restorative and endodontic indications:
Prosthetic failure of abutments within
a splint
Endodontic failure: perforations...
Contraidications
Root fusion making separation impossible
Angulation or position of tooth in the arch
Root morphology
...
 Poor prognosis
 Retained roots

SURGICAL CONSIDERATIONS
 Buccal + Palatal flaps
 Releiving incision
 Intracrevicular...
Envelop Type Flaps
Little Or No Attached Gingiva
Flap Edges - Sutured
Full Flap - Periodontal Disease - Scaling, Curet...
REGENERATIVE TECHNIQUES
GTR – Differential tissue development
Barrier

Resorbable

Collagen
Synthetic

Non resorbable

Ena...
ANTIBIOTICS FOR ENDO PERIO LESION

 Tetracycline

250 mg (qid)

 Doxycycline

100 mg ( bd / od )

 Metronidazole

250 m...
REFERENCES

 The use of guided tissue regeneration principles in endodontic surgery for
induced chronic periodontic-endod...
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Endo perio interrelation /certified fixed orthodontic courses by Indian dental academy

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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.

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Endo perio interrelation /certified fixed orthodontic courses by Indian dental academy

  1. 1. www.indiandentalacademy.com
  2. 2. INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  3. 3. CONTENTS INTRODUCTION DEFINITION CLASSIFICATION ETIOLOGY CONTROVERSIES REGARDING THE COMBINED LESION PATHWAYS OF SPREAD COMPARISION OF CLINICAL PRESENTATION B/W APICAL & MARGINAL PERIODONTITIS DIFFERENTIAL DIAGNOSIS EFFECT OF PULP & ITS TREATMENT ON PERIODONTIUM EFFECT OF PERIO. DISEASE & TREATMENT ON PULP LESIONS DIAGNOSIS TREATMENT REFERENCES CONCLUSION www.indiandentalacademy.com
  4. 4. DEFINITION An isolated, usually narrow, deep probing depth of pulpal or periodontal origin. Lesion with sub marginal or intrabony periradicular bone loss of pulpal and/or periodontal origin that communicates with the oral cavity via probing defect. A localized periodontal probing depth of pulpal or periodontal origin. www.indiandentalacademy.com STOCK
  5. 5. COHEN • • • • • • • Primary endodontic lesion Primary endodontic lesion with secondary periodontal involvement Primary periodontal lesion Primary periodontal lesion with secondary endodontic involvement True combined lesion Concomitant pulpal & periodontal lesion www.indiandentalacademy.com
  6. 6. WEINE Type I - Tooth in which symptoms clinically and radiographically simulate periodontal disease but are due to pulpal inflammation Type II - Tooth that has both pulpal and periodontal disease concomitantly Type III - Tooth has no pulpal problem but require endodontic therapy plus root amputation to gain periodontal healing Type IV - Tooth that clinically and radiographically simulate pulpal or periapical disease but infact have periodontal disease www.indiandentalacademy.com
  7. 7. LESIONS REQUIRING ENDODONTIC TREATMENT ONLY GROUP I  necrotic pulp and apical granulomatous tissue replacing periodontium with or without sinus tract  Chronic periapical abscess with sinus tract  Longitudinal and horizontal root fractures  Pathologic and iatrogenic root perforations  Teeth with incomplete apical root development  Endodontic implants / replants / transplants  Teeth that require hemisection  Root submergence GROSSMAN www.indiandentalacademy.com
  8. 8. LESIONS REQUIRING PERIODONTAL TREATMENT ONLY GROUP II  Occlusal trauma causing reversible pulpitis  Occlusal trauma plus gingival inflammation resulting in pocket formation and reversible pulpitis  Suprabony or infrabony pocket formation treated with overzealous root planning and curettage leading to pulpal sensitivity  Extensive infrabony pocket formation extending beyond the root apex and sometimes coupled with lateral or apical resorption yet with pulp that responds with in normal limits to clinical testing www.indiandentalacademy.com
  9. 9. LESIONS REQUIRING COMBINED ENDO – PERIO TREATMENT GROUP III  Any lesion in Group I That results in irreversible reactions in the attachment apparatus and requires periodontal treatment  Any lesion in Group II that results in irreversible reactions to the pulp tissue and also requires endodontic treatment www.indiandentalacademy.com
  10. 10. ATYPICAL ANATOMIC FACTORS Malaligned tooth Multirooted teeth / additional root Additional canal Cervical enamel projection Large lateral / accessory canal TRAUMA With gingival inflammation Tooth fracture Pulp / perio involvement + sinus tract Cellular changes - resorption www.indiandentalacademy.com
  11. 11. MISCELLANEOUS Iatrogenic systemic SINUS TRACT INFRABONY POCKET •From canal •From gingival crevice •Narrow •wide www.indiandentalacademy.com
  12. 12. Causes : ( Stock ) Root fractures – crown / root ( vital / non vital ) Root canal infection Root resorption Anatomical anomalies ( palatogingival groove,enamel pearls , root division , fused teeth , invagination ) Root perforation Orthodontic treatment Localized periodontal disease Transplantation & replantation www.indiandentalacademy.com Poorly designed restorations
  13. 13. Multiple endo perio lesion •Isolated lesion upon gen. periodontitis •Chronic periodontitis •Aggressive periodontitis www.indiandentalacademy.com
  14. 14. CONTROVERSIAL ASPECT CONCERNING THE COMBINED LESION  PULPAL  PERIODONTAL Chacker Massler Czarnecki & Schilder PERIODONTAL PULPAL ? Venous blood flow outward Drawback Lateral / accesory canal - flow bothways Seltzer & bender Stahl www.indiandentalacademy.com
  15. 15. Physiologic : • Apical foramen • Lateral canals • Dentinal tubules • Periodontal ligament • Alveolar bone • Neural pathways • Vasculolymphatic pathway • Palatogingival grooves • Cementum defect Iatrogenic : • • Vertical root fractures Perforations www.indiandentalacademy.com
  16. 16. COMPARISION MARGINAL PERIODONTITIS APICAL PERIODONTITIS Cervical Apex Plaque Pulpal inflammation Horizontal / Vertical bone loss - Seldom bone loss – localized generalized & deep Open Contained www.indiandentalacademy.com
  17. 17. Attachment loss asso. with  Anatomic defect on root  Nature of pathogenic flora  Necrotic & infected pulp  Host defense mechanism defect. Aggresiveness asso with  Lateral & apical foramen  Nature of flora  Apical host defense Periodontal probing & radiographic examination Radiographic examination www.indiandentalacademy.com
  18. 18. DIFFERENTIAL DIAGNOSIS PULPAL PERIODONTAL CLINICAL Cause pulp infection periodontal Vitality non vital vital Restorative deep or extensive not related Plaque /calculus not related primary cause Inflammation acute chronic Pockets single and narrow multiple and wide pH value acidic alkaline Trauma primary or secondary contributing factor Microbial few coronally www.indiandentalacademy.com complex
  19. 19. RADIOGRAPHIC Pattern Bone loss Periapical Vertical bone loss localized wider apically radiolucent no generalized wider coronally not related yes HISTOPATHOLOGY Junctional epithelium Granulation tissues Gingival no apical migration apical (minimal) normal present coronal (larger) recession TREATMENT Therapy RCT www.indiandentalacademy.com Periodontal therapy
  20. 20. Problems in diagnosis : Vertical root fracture: varied radiographic picture Different angulations Surgical exposure lateral condensation excessive Post placement Cause Extensive restorations Older patients Gingival sulcus & pocket area Single rooted teeth multirooted teeth Developmental grooves In doubt ? – Biopsy / Histological analysis Systemic diseases mimic lesion on radiograph : Scleroderma Metastatic carcinoma Osteosarcoma www.indiandentalacademy.com
  21. 21. EFFECT OF PULP AND ITS TREATMENT ON PERIODONTIUM Periodontal inflammation & bone loss Sub marginal bone loss Horizontal bone loss Vertical intrabony pockets Furcation involvement Periodontal wound healing Traumatized necrotic pulp RC infection – compromised healing Gingival tissue thickness Alveolar bone level Surgical trauma to flap Effective flap repositioning Root canal treatment Doubtful pulpal status Iatrogenic problems www.indiandentalacademy.com
  22. 22. EFFECT OF PERIODONTAL DISEASE & ITS TREATMENT ON PULP Periodontal disease & pulp •Limited •Channels closed + dystrophic calcification- chronic •Sufficient viurlence – pulpal disease •Poor prognosis •Extraction / Root resection Periodontal treatment & pulp •Scaling & root planing – excessive cementum removal •Compromised pulp www.indiandentalacademy.com
  23. 23. PRIMARY ENDODONTIC LESION Caries / trauma / restorative procedure Pulp Inflammation Apical / lateral / Furcation / Attachment apparatus Pain , swelling , tenderness , marginal gingiva swelling Suppurative process – Sinus tract Pdl / Patent channels Multirooted Teeth Gr. III thru & Thru Furcation defect Diagnosis : Necrotic / Vitality test Treatment : RCT www.indiandentalacademy.com Ging. Sulcus ( GP / Probe to apex)
  24. 24. PRIMARY ENDODONTIC WITH SECONDARY PERIODONTAL Unchecked endo lesion Periapical alveolar bone destruction Interradicular area Drainage Hard / soft tissue Plaque / Calculus Apical attachment migration ( perio disease) Diagnosis : Necrosis / Calculus accumulation Treatment : Both www.indiandentalacademy.com
  25. 25. PRIMARY PERIODONTAL LESION Sulcus Plaque / Calculus Inflammation Apex Alv. Bone / Pdl Clinical attachment loss acute Abscess Lateral root / Furcation / TFO ( isolated lesion ) Diagnosis : Tooth mobility positive pulp test Broad based pocket / Plaque & calculus Generalized Treatment : Periodontal therapy www.indiandentalacademy.com osseous defects
  26. 26. PRIMARY PERIODONTAL & SECONDARY ENDODONTIC Periodontium Pulp Dentinal tubules Lateral canals Diagnosis : Deep pocket H/O extensive periodontal disease Past treatment Treatment : Both TRUE COMBINED LESIONS CONCOMITANT LESIONS www.indiandentalacademy.com Oral cavity
  27. 27. DIAGNOSIS OF ENDO PERIO LESIONS History of dentinal / pulpal pain History of periodontal symptoms (bleeding, recur. Infection , mobility) - nature / duration - risk factors Signs and symptoms of pulpal / periapical disease (vitality) Periodontal charting (probing profile) - Recession - Mobility - Furcation involvement - Attachment loss www.indiandentalacademy.com
  28. 28. Clinical signs of pocket formation : Bluish red marginal gingiva / vertical zone extending from marginal to attached gingiva. “Rolled” edge separating gingival margin form tooth surface. Enlarged edematous gingiva. Bleeding, suppuration, loose extruded teeth. www.indiandentalacademy.com
  29. 29. Symptoms of pocket formation Usually painless Localized or radiating pain or sensation of pressure after eating which gradually diminishes. Foul taste in localized areas. Sensitivity hot and cold Tooth ache in absence of caries are present www.indiandentalacademy.com
  30. 30. BIOLOGIC DEPTH PROBING DEPTH FORCE : 0.75N POCKET DEPTH LEVEL OF ATTACHMENT GINGIVAL RECESSION 6 POINT CHARTING DISTOPALATAL MID PALATAL www.indiandentalacademy.com MESIOPALATAL
  31. 31. CONTINUOUS PROBING PROFILE www.indiandentalacademy.com
  32. 32. LONG NARROW POCKETS: ENDODONTIC ORIGIN LATERAL ENDODONTIC ABSCESS WIDE AND DEEP POCKET “BLOW OUT” LESION www.indiandentalacademy.com
  33. 33. RADIOGRAPHIC PATTERN OF BONE LOSS •Apical extent of bone loss •Definite Pdl space absent •Shape of bone defect ( angularity / marginal bone ) Bone defect contributed by pulp infection : - Periodontal intrabony defect – 2/3 root length - Horizontal bone loss - 2/3 root length - periodontal bone loss involving root end Acute pain generally absent in endo perio – open nature 30 – 60 % spirochaetes 0 – 10 % spirochaetes - perio origin - endo origin www.indiandentalacademy.com
  34. 34. Causes: o Endo o Perio o Fracture o Resorption o Anatomy Endo perio lesion usually isolated, narrow localized pocket Check endodontic status Root treated Not root treated Evaluate adequacy Vitality tests Preparation: Obturation: oUnder prepared oOver prepared oPerforation oZipping oledges oUnder filled oOverfilled oPoor adaptation Is root canal re-treatment feasible? www.indiandentalacademy.com MANAGEMENT
  35. 35. Feasible re-treatment? No Yes Try OHI + debridement OHI Resolution? Resolution? No Yes No Yes oDo first stage endo oClean and shape canals oDress with calcium hydroxide Extract Resolution? Yes www.indiandentalacademy.com Extract No
  36. 36. Vitality tests Negative Positive Root canal treatment Perio treatment Resolution? Resolution? Yes No No Yes Check OHI and perio Check vitality again: If in doubt- do RCT Still no resolution: look for other causes Extract, resect , hemisect www.indiandentalacademy.com
  37. 37. TREATMENT ALTERNATIVES ROOT RESECTION REGENERATIVE TECHNIQUES ROOT RESECTION : “ Sectioning & removal of one or two roots of a multirooted teeth with accompanying odontoplasty.” ROOT AMPUTATION : “Removal of one or more roots of a multi rooted tooth while the others are retained.” HEMISECTION : “Removal or separation of root with its accompanying crown portion of mandibular molars.” www.indiandentalacademy.com
  38. 38. RADISECTION : “Newer terminology for removal of roots of maxillary molars .” BISECTION / BICUSPIDIZATION : “Separation of mesial and distal roots of mandibular molar along with its crown portion, where both segments are then retained individually.” www.indiandentalacademy.com
  39. 39. ROOT RESECTION Furcation involvement. ( Maxillary / Mandibular - 3 point / Nabers probe ) Classification of degree of Furcation involvement Class I - Horizontal loss of periodontal support< one third of tooth width Class II - Horizontal loss of periodontal support> one third but not encompassing the total width of the tooth Class III - Horizontal through and through destruction of the periodontal tissue in the furcal area www.indiandentalacademy.com
  40. 40. INDICATIONS FOR RESECTIONS Periodontal indications Severe vertical bone loss involving only one root of a multi rooted tooth Through and through furcation destruction Unfavorable proximity of roots of adjacent teeth Severe root exposure due to dehiscence www.indiandentalacademy.com
  41. 41. Restorative and endodontic indications: Prosthetic failure of abutments within a splint Endodontic failure: perforations, over extension , obstructed canals, separated instrument , root resorption Vertical fracture of one root Restorative reasons: sub gingival caries, erosion of large part of crown and root, traumatic injury Combination of these www.indiandentalacademy.com
  42. 42. Contraidications Root fusion making separation impossible Angulation or position of tooth in the arch Root morphology Improperly shaped occlusal contact www.indiandentalacademy.com
  43. 43.  Poor prognosis  Retained roots SURGICAL CONSIDERATIONS  Buccal + Palatal flaps  Releiving incision  Intracrevicular incision  Full thickness flap  Undersurface of crown - bevelled . www.indiandentalacademy.com
  44. 44. Envelop Type Flaps Little Or No Attached Gingiva Flap Edges - Sutured Full Flap - Periodontal Disease - Scaling, Curettage Or Osseous Contouring Procedures www.indiandentalacademy.com
  45. 45. REGENERATIVE TECHNIQUES GTR – Differential tissue development Barrier Resorbable Collagen Synthetic Non resorbable Enamel matrix derived protein Barrier – principle - stiff www.indiandentalacademy.com
  46. 46. ANTIBIOTICS FOR ENDO PERIO LESION  Tetracycline 250 mg (qid)  Doxycycline 100 mg ( bd / od )  Metronidazole 250 mg ( tid for 7 days)  Chlorhexidine www.indiandentalacademy.com
  47. 47. REFERENCES  The use of guided tissue regeneration principles in endodontic surgery for induced chronic periodontic-endodontic lesions: a clinical, radiographic, and histologic evaluation J Periodontol. 2005 Mar;76(3):450-60.  Pathologic interactions in pulpal and periodontal tissues. J Clin Periodontol. 2002 Aug;29(8):663-71.  The influence of endodontic treatment upon periodontal wound healing. J Clin Periodontol. 1997 Jul;24(7):449-56. www.indiandentalacademy.com
  48. 48. www.indiandentalacademy.com
  49. 49. www.indiandentalacademy.com Leader in continuing dental education www.indiandentalacademy.com

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