periodontal and endodontic diseases in the same time

1. Dr/Alzahraa
A. Alghriany
PERIO-ENDO LESIONS

2.  Endodontic and periodontal diseases are both polymicrobial
anarebic infections.
 The term ‘‘endo-perio’’ lesion describes diseases due to
inflammatory products found in varying degrees in both the
periodontium and the pulpal tissues.
 When inflammation presents on a tooth which is associated
with both pulpal pathology and the periodontal tissues, it is
classed as a perio-endo lesion.

3.  1. Anatomical Pathways
 1.1. Apical foramen: Apical foramina forms the major
connection between the periodontium and dental pulp.
 1.2. Lateral and accessory canals: Lateral canals are the
lateral branches of the root canal, connecting the
neurovascular system of the dental pulp with that of
periodontal ligament.
 1.3. Dentinal tubules: Dentinal tubules are formed during
odontogenesis with a shape of an inverted cone. The opening
of these tunnels has the smallest dimension at the periphery
while the largest at the pulp.
CHANNELS OF COMMUNICATION BETWEEN THE
PULP AND THE PERIODONTAL TISSUE:

4.  2.Non-Physiological Pathways
 Iatrogenic root canal perforations that result artificial
communication may occur during dental treatments such as
post preparation and endodontic treatment.
 Another artificial communication of periodontium and dental
pulp is vertical root fractures caused by trauma or with lateral
condensation technique.

6. Perio-endo lesions can be classified as five distinct types of
lesions:
 1. Primary Endodontic Lesion – This is where the problem is
purely endodontic in nature, but the lesion happens to be
draining through the gingival tissue. It is not unusual for
drainage to present through the gingival crevice or the area of
furcation. Its origin can be traced back to the source of infection
by taking a periapical with a gutta percha (GP) point inserted
from the drainage site.
 2. Primary Endodontic Lesion with Secondary Periodontal
involvement – This occurs when a primary endodontic infection
persists, destroys the surrounding tissue and infiltrates into the
inter-radicular space. This leads to persistent drainage through
the gingival tissues, creating a site where plaque and calculus
can accumulate leading to periodontal disease.
CLASSIFICATION OF PERIO-ENDO
LESIONS

7.  3. Primary Periodontal Lesion – This is the classic appearance of
periodontal disease where pocket formation occurs due to
plaque or calculus accumulation leading to loss of attachment.
Patients with periodontal disease are likely to have multiple
sites of pocketing, provided a local factor, such as an
overhanging restoration or occlusal trauma.
 4. Primary Periodontal Lesion with Secondary Endodontic
Involvement – This happens when periodontal disease
progresses down the root surface and leads to an area of
communication with the pulp. The most obvious way this may
occur is when periodontal disease progresses to the apical
foramen but may also occur if other channels of communication
with the pulp become exposed. Its features are like a primary
endodontic lesion with secondary periodontal involvement and is
differentiated based on which disease process presents first.

8.  5. True Combined Lesion – This diagnosis can be given when
the two separate processes have started independent of each
other but happen to coalesce. The periodontal lesion exists
and progresses, whilst during the same period the tooth
devitalises, and the apical lesion progresses. These two fronts
spread across the root surface and meet to form the
combined lesion.
 6. The Concomitant Pulpal-Periodontal Lesion – Although not
part of the original classification by Smith et al. (1972), this
term has been suggested to describe the presentation of both
pulpal and periodontal conditions on the same tooth which
appear to exist independent of each other.

11. History
 A good patient history remains invaluable to the clinician
when forming a diagnosis.
 The patient’s description of their symptoms can help to
narrow the area of investigation and in some cases, they may
even know what is wrong due to a previous experience or an
existing diagnosis.
 The common features which patients will complain of is pain,
swelling, ‘wobbly’ teeth and maybe even a bad taste. Pain in
the case of the combined lesion is usually well localized and
in the acute stages, quite severe. The patient and/or dentist
may already be aware of active periodontal disease or an
endodontic lesion from previous visits, investigations or
existing radiographs.
DIAGNOSIS

15.  The chosen management method and prognostic of EPL are
based upon correct diagnosis.
 Primary endodontic lesions usually heal after a correct
endodontic treatment. The prognosis is generally a good one
especially if during cleaning and shaping of the root canals,
the irrigation protocol was thoroughly performed. The sinus
tract will retract in the early stages of the root canal
treatment, after the infected pulp is removed.
 Primary periodontal lesions only require periodontal therapy.
Treatment options include etiologic therapy by eliminating all
factors which can induce or promote epithelial downgrowth
followed by surgical periodontics
TREATMENT

16.  Primary endodontic disease with secondary periodontal
involvement should first be treated with endodontic therapy.
Treatment results should be evaluated in 2-3 months and only
then should periodontal treatment be considered. This
sequence of treatment allows sufficient time for initial tissue
healing and better assessment of the periodontal condition. It
also reduces the potential risk of introducing bacteria and
their by-products during the initial healing phase.

17.  Early stage periodontal lesions with secondary endodontic
involvement where involvement may be limited to reversible
pulpal hypersensitivity may be treated purely by periodontal
therapy. Periodontal treatment removes the noxious stimuli
and secondary mineralization of dentinal tubules allows the
resolution of pulpal hypersensitivity. If pulpal inflammation is
irreversible root/re-root treatment is carried out followed by
periodontal treatment.

18.  True-combined lesions are treated initially as for primary endodontic
lesion with secondary periodontal involvement. Periodontal surgical
procedures are almost always called for. The prognosis of a true-
combined perio-endo lesion is often poor or even hopeless, especially
when periodontal lesions are chronic with extensive loss of attachment.
Root amputation, hemisection or separation may allow the root
configuration to be changed sufficiently for part of the root structure to
be saved. Prior to surgery, palliative periodontal therapy should be
completed and root canal treatment carried out on the roots to be
saved.
 The prognosis of an affected tooth can also be improved by increasingly
bone support which can be achieved by bone grafting and guided tissue
regeneration. This is due to the most critical determinant of prognosis
being a loss of periodontal support.
 The ideal therapeutic sequence for the true combined lesion is:
1. Root canal therapy;
2. Review after 2 to 3 months;
3. If lesion is not showing signs of resolving (clinically and
radiographically) perform appropriate periodontal therapy;
4. Review 2 to 3 months after periodontal therapy and re-evaluate
radiographically.

19.  In general, when primary disease of one tissue, i.e. pulp or
periodontium, is present and secondary disease is just
starting, treat the primary disease.
 When secondary disease is established and chronic, both
primary and secondary diseases must be treated.
 By and large, endodontic therapy precedes periodontal
therapy.
 Periodontal therapy may or may not be required, depending
on disease status. The complete healing of destroyed
periodontal support can be expected following the treatment
of pulpal pathology.

20.  It is important to realize that it is clinically not possible to
determine the extent to which one or the other of the two
disorders (endodontic or periodontal) has affected the supporting
tissues.
 Therefore, the treatment strategy must be first to focus on the
pulpal infection and to perform debridement and disinfection of
the root canal system. The second phase includes a period of
observation, whereby the extent of periodontal healing resulting
from the endodontic treatment is followed.
 Reduced probing depth can usually be expected within a couple
of weeks while bone regeneration may require several months
before it can be radiographically detected. Thus, periodontal
therapy, including deep scaling with and without periodontal
surgery, should be postponed until the result of the endodontic
treatment can be properly evaluated.