endo perio lesions

1. ENDO PERIO
LESIONS
V NAGARAJAN
POSTGRADUATE STUDENT
DEPT OF CONSERVATIVE DENTISTRY

2. PERIODONTIUMPULP

3. CONTENTS
INTRODUCTION
PATHWAYS OF COMMUNICATION OF PULP AND PERIODONTIUM
CONTRIBUTING AND ETIOLOGICAL FACTORS
INFLUENCE OF PULPAL DISEASE ON PERIODONTIUM
INFLUENCE OF PERIODONTAL DISEASE ON PULP
CLASSIFICATIONS OF ENDO PERIO LESIONS
CLINICAL SIGNS
DIAGNOSIS
MANAGEMENT OF ENDO PERIO LESIONS(PROGNOSIS AND TREATMENT)
CONCLUSION
REFERENCES

4. The tooth , pulp tissue within it and its supporting structures
should be viewed as one biological unit
Pulp and the periodontium have embryonic, functional and
anatomical relationship.
 Embryonic- both develops from ectomesenchyme
 Functional - common blood supply
 Anatomic - patent pathways - apical foramen, lateral canals
INTRODUCTION

5. • These inter-relationship of these structures influences each
other during heath function and disease process.
• Since then the term perio endo lesion has been used to
describe lesions due to inflammatory products found in
varying degrees in both periodontium and pulp
The relationship between the periodontium and pulp was first
discovered by SIMRING and GOLDBERG in 1964
The term pulpodontic periodontal syndrome was first described
by BENDER AND SELTZER in 1972

6. Rubach and Mitchell suggested that the periodontal disease
may affect the pulp heath when the accessory canal exposure
occurs
Lindhe also reported that bacterial infiltrates of the
inflammatory process may reach the pulp when there is
accessory canal exposure ,through apical foramens and canals in
furcation areas
Adrians et al demonstrated that bacteria coming from the
periodontal pockets have the capacity of reaching the root
canals ,suggesting that the dentinal tubules may serve as the
reservior for these microorganisms

7. PATHWAYS OF
IATROGENIC
ORIGIN
PATHWAYS OF
PATHOLOGIC ORIGIN
PATHWAYS OF
DEVELOPMENTAL
ORIGIN
PATHWAYS OF COMMUNICATIONS BETWEEN PULP AND
PERIODONTIUM

8. APICAL
FORAMEN
LATERAL AND
ACCESSORY
CANALS
DENTINAL
TUBULES
DEVELOPMENTAL
GROOVES
PATHWAYS OF DEVELOPMENTAL ORIGIN
(ANATOMIC PATHWAYS)

9. EMPTY SPACES ON ROOT CREATED BY
SHARPEY’S FIBERS
ROOT FRACTURE FOLLOWING TRAUMA
IDIOPATHIC INTERNAL AND EXTERNAL ROOT
RESORPTION
LOSS OF CEMENTUM DUE TO EXTERNAL
IRRITANTS
PATHWAYS OF PATHOLOGICAL ORIGIN

10. PATHWAYS OF IATROGENIC ORIGIN
ROOT
PERFORATIONS
DURING
RCT
ROOT
FRACTURES
DURING
RCT
EXPOSURE
OF DENTINAL
TUBULES
DURING ROOT
PLANING
EXTENSIVE
ACTION OF
ROOT
CONDITIONING
AGENTS

11. POOR ENDODONTIC TREATMENT
POOR RESTORATIONS
TRAUMA
IDIOPATHIC RESORPTIONS
DEVELOPMENTAL MALFORMATIONS
IATROGENIC PERFORATIONS
AND FRACTURES
SYSTEMIC DISEASES
CONTRIBUTING
FACTORS

12. ETIOLOGICAL FACTORS

13. INFLUENCE OF PULPAL DISEASE ON
PERIODONTIUM
• Pulpal disease
• Procedural
errors in RCT
• Perforations
• Vertical root
fractures
• Peri-radicular
inflammation
Bone loss +
CAL +/- Pus
discharge
RETROGRADE
PERIODONTITIS

14. INFLUENCE OF PERIODONTAL DISEASE ON
PULP
Pathogenic
Bacteria and
inflammatory
products of
periodontal
disease
Accessory canal /
Lateral canals /
apical foramen
Pulpal
infection/necrosis
RETROGRADE
PULPITIS

15.  Severe breakdown of the pulp apparently does not occur
until periodontitis has reached a terminal state- that is,
when bacterial plaque has involved the main apical
foramina.
 Effect depend on cemental and remaining dentin thickness
 The pulp has a good capacity for defense as long as the
blood supply via the apical foramina is intact. Therefore
retrograde pulpitis, if it occurs, is exceedingly rare.

16. CLASSIFICATION:
Primary Endodontic
Disease
Primary Periodontal
disease
Combined Disease
Primary Periodontal
Secondary Endodontic
Primary Endodontic
Secondary Periodontal
True Combined Lesion
Simon, Glick and Frank in 1972

18. • Class I : Tooth in which symptoms clinically and
radiographically simulate periodontal disease but are infact
due to pulpal inflammation and/or necrosis.
• Class II : Tooth that has both pulpal or periapical disease and
periodontal disease concomitantly.
• Class III : Tooth that has no pulpal problem but requires
endodontic therapy plus root amputation to gain periodontal
healing.
• Class IV : Tooth that clinically and radiographically simulates
pulpal or periapical disease but infact has periodontal
disease.
According to Weine

19. TORABINEJAD AND TROPE CLASSIFICATION -1996
1.ENDODONTIC ORIGIN
2.PERIODONTAL ORIGIN
3.COMBINED ENDO-PERIO LESION
4.SEPARATE ENDODONTIC PERIODONTAL LESION
5.LESION WITH COMMUNICATION
6. LESION WITHOUT COMMUNICATION
International journal of dentistry volume 2014

20. • ENDODONTIC PERIODONTAL LESION
• PERIODONTIC ENDODONTIC LESION
• COMBINED LESION
WORKSHOP FOR CLASSIFICATION OF PERIODONTAL
DISEASE -1999
International journal of dentistry volume 2014

21. • Lesions that require endodontic treatment
procedures only.
• Lesions that require periodontal treatment
procedures only.
• Lesions that require combined endodontic –
periodontic treatment procedures.
According to Oliet and Pallock – Based on
treatment procedures :

22. Lesions that require endodontic procedures only
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
Teeth that require hemisection or radisectomy

23. II. Lesions that require periodontal procedures only
Occlusal trauma causing reversible pulpitis
Occlusal trauma plus gingival inflammation resulting in pocket
formation
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

24. III. lesions that require combined endodontic and periodontic
treatment
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

25. PRIMARY ENDODONTIC:
Etiology
Dental caries,restorative procedures,
Chemical irritants, traumatic injuries
Clinical features
Pain ,tenderness to palpation and percussion
Sinus opening
Abnornal response to vitality test

26. Examination Primary endodontic lesion
VISUAL Presence of caries,large restorations,fractured restorations or teeth
attrition,abrasion,erosion,cracks, discoloration
PAIN sharp
PALPATION It does not indicate whether the
Inflammation is pulpal or periodontal origin
PERCUSSION Present
MOBILITY Fractured roots ,recently traumatized teeth shows mobility
PULP VITALITY Lingering response – irreversible pulpitis
No response – non vital teeth
POCKET PROBING Deep narrow solitary pockets
SINUS TRACING Gp points to apex or furcation areas
RADIOGRAPH Deep carious lesions,extensive restorations,periapical radiolucency,
Poor rct, mishaps like root fractures, perforations, root resorptions
CRACKED TEETH TESTING Painful response during chewing especially when releasing the
biting pressure

27. PRIMARY PERIODONTAL:
Etiology
Plaque and calculus are the primary etiological factors
Clinical features
Pocket formation
Attachment loss
Bone loss

28. Examination Primary periodontal lesions
VISUAL Presence of plaque and calculus ,inflammed gingiva, gingival
recession, presence of swelling and pus discharge through gingival
crevice in case of periodontal abscess
PAIN Usually dull ache
PALPATION Presence of pain on palpation
PERCUSSION present
MOBILITY Localized to generalized mobility of teeth
PULP VITALITY Pulp is vital and responsive to testing
POCKET PROBING Multiple wide deep pockets
SINUS TRACING Sinus tract mainly at lateral aspect of the root
RADIOGRAPH Horizontal or vertical bone loss, bone loss wider coronally
CRACKED TEETH TESTING No symptoms

29. PRIMARY ENDO SECONDARY
PERIODONTAL:
Etiology
Progression of chronic primary endodontic lesion
Plaque and calculus

30. Examination PRIMARY ENDO SECONDARY PERIO
VISUAL Plaque formed at the gingival margin of the sinus tract
PAIN Usually sharp shooting pain. dullache in chronic cases
PALPATION Pain on palpation
PERCUSSION Tenderness on percussion
MOBILITY Localized mobility
PULP VITALITY negative
POCKET PROBING Localized solitary wide pocket.
SINUS TRACING Sinus tract mainly at apex or furcation areas
RADIOGRAPH Presence of deep carious lesions,extensive restorations,previous
poor root canal treatment, root fractures, root resorptions
CRACKED TEETH TESTING Painful response during chewing especially when releasing the

31. PRIMARY PERIODONTAL
SECONDARY ENDODONTIC:
Etiology
Progression of periodontal disease apically
Clinical features
Pocket formation ,bone loss,attachment loss
Acute pulpal pain

32. Examination PRIMARY PERIO SECONDARY ENDO
VISUAL Paque calculus,gingival swelling around the multiple teeth, gingival
recession,presence of pus exudate,
PAIN Usually dull ache ,sharp pain in case of acute periodontal abscess
PALPATION Pain on palpation
PERCUSSION Tenderness on percussion
MOBILITY Generalized mobility
PULP VITALITY Positive in cases of multi rooted teeth
POCKET PROBING Presence of multiple wide deep periodontal pockets
SINUS TRACING Sinus tract mainly at the lateral surface of the root
RADIOGRAPH Angular bone loss in multiple teeth wide base coronally and narrow
at the apex of the root
CRACKED TEETH TESTING No symptoms

33. TRUE COMBINED
PERIODONTAL & ENDODONTIC:
Distinct etiological factors which donot influence each other

34. Pus
discharge
Pocket
formation
Sinus
tract
Tender to
percussion
Mobility
CLINICAL SIGNS
GINGIVAL SWELLING

35. FEATURES OF PULPAL AND PERIODONTAL LESIONS :
Pulpal Periodontal
Clinical
Cause Pulp infection Periodontal infection
Vitality Nonvital Vital
Restorative Deep or extensive Not related
Plaque / calculus Not related Primary cause
Inflammation Acute Chronic
Pockets Single, narrow Multiple,wide coronally
pH value Often acid Usually alkaline

36. Radiographic
Pattern Localized Generalized
Bone loss Wider apically Wider coronally
Periapical Radiolucent Not often related
Vertical bone loss No Yes
Histopathology
Junctional epithelium No apical migration Apical migration
Granulation tissues Apical (minimal) Coronal (Larger)
Gingival Normal Some recession
Therapy
Treatment Root canal therapy Periodontal treatment
Pulpal Periodontal

37. DIAGNOSIS:
History taking
Examination
Pulp testing
Periodontal evaluation
Radiographic evaluation
Fistula tracking

38. o Visual Examination
• Soft Tissue
 Inflammation
 Ulceration
 Sinus tracts
• Teeth
 Caries
 Defective restorations
 Cracks
 Fractures
 Discolorations
o Palpation - Peri-radicular abnormality
o Percussion – Peri-radicularinflammation

39. o Pulp Testing (EPT + Coldtest):
LESION RESPONSE
Primary Periodontal +
Primary Periodontal Secondary Endodontic +/-
Primary Endodontic +/-
Primary Endodontic Secondary Periodontal -
Combined pulpal -
 False Positive response may be interpreted in combined lesion in
multi rooted teeth as either intact vital pulp or partially necrotic
pulp.

40. o Mobility
• Loss of periodontal support
• Peri-radicular abscess
• Fractured roots
o Probing
• Deep solitary pocket – Endo
cause
• Broad and deep pockets -
Perio
o Fistula Tracking
• #25 GP/Probe - radiopaque
• Until Resistance is felt

41. Radiographic evaluation
Root fractures
Perforations
Resorptions
Restoration margins
Extension of bone loss
Adequacy of obturation

42. Management Of Endo Perio Lesions
• Estimation of prognosis
• Treatment of endo perio cases

43. PROGNOSIS:
o Depends on
• Patients oral hygiene
• The amount of attachment loss
• Endodontic status
• Effectiveness of the periodontal treatment accomplished
o Primary endo -- Good to excellent prognosis
o Primary perio -- Depends on periodontal therapy
o Combined lesion -- Poor prognosis
Periodontology 2000, Vol. 34, 2004, 165–203

44. Treatment :
• RCTPrimary Endodontic
• Periodontal therapyPrimary Periodontal
• RCT + Periodontal therapy immediately/later
Primary Endodontic
Secondary Periodontal
• Scaling + Immediately followed by cleaning and
shaping  Follow up & observe pocketing 
Obturation
Primary Periodontal and
Secondary Endodontic
• RCT + periodontal therapyTrue Combined lesion

45. Removal of underlying cause
Check endodontic
status
If Root canal treated
Evaluate adequacy
Preparation:
oUnder prepared
oOver prepared
oPerforation
oZipping
oledges
Obturation:
oUnder filled
oOverfilled
oPoor adaptation
Is root canal re-treatment feasible?

46. If Yes
oDo first stage endo
Clean and shape canals
Dress with calcium hydroxide
Resolution?
Yes No Extract

47. Elimination of palatogingival groove

48. Management of cervicoenamel
projection
Should be eliminated down to the crestal bone
level by saucerization
osteoplasty or regenerative procedures may required
to treat the osseous defect

49. Management of internal resorption
Extirpation of pulp
Routine endodontic treatment
and Obturation with
Thermoplasticized guttapercha
If the root is perforated
MTA is used to repair the defect

50. Management of external resorption
If due to pulpal disease
-root canal therapy
If it is due to orthodontic appliances
-Reducing the forces
In case of external cervical root resorption
-surgical exposure of the defect and restoration
with suitable material

51. Management of trauma from occlusion
• Occlusal adjustments
• Orthodontic tooth movement
• Management of parafunctional habits
`

52. ALTERNATIVE TREATMENT MODALITIES :
When traditional endodontic and periodontal treatments
prove insufficient to stabilize affected teeth, the clinician must
consider other treatment alternatives like:
 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
 Radisection : Newer terminology for removal of roots of
maxillary molars
 Bicuspidization : Separation of mesial and distal roots of
mandibular molar along with its crown portion, where both
segments are then retained individually

53. Indications for Resections and
hemisection
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,
preventing adequate hygiene maintenance in proximal
areas
Severe root exposure due to dehiscence

54. Restorative and endodontic indications:
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

55. Contraindications
Root fusion making separation impossible
Angulation or position of tooth in the arch: if the tooth is
buccally or lingually, mesially or distally cannot be resected
When the loss of bone involves more than one root
Improperly shaped occlusal contact may convert occlusal
forces in to destructive forces and cause failure of
hemisection

56. Surgical exposure
of Furcation prior
to sectioning of
disto buccal root Initial cut with a
diamond
instrument
Widened cut to allow
instrumentation
ROOT RESECTION

57. Elevation of disto buccal
root
Surgical
closure
Appearance of
tooth following the
removal of disto
buccal root

58. HEMISECTION Refers to sectioning of molar teeth with removal of one half
crown and its supporting root structure

59. BICUSPIDIZATION
Bicuspidization is a surgical procedure carried out exclusively on the mandibular molars
Where the mesial and distal roots are seperated with their respective crowns and retention of
both halves
This seperation eliminates the existance
Of furcation and makes it easy for the
patients to maintain hygiene

60. CONCLUSION :
• The endodontic periodontal problems are responsible for more
than 50% mortality today.
• They present challenges to the clinicians as far as the diagnosis
and prognosis of the involved teeth.
• The treatment rendered and the subsequent success or failure of
that treatment, is directly dependent on making an accurate
diagnosis of the lesion.

61. REFERENCES :
– Seltzer – Biologic considerations in endodontic practice, 4th edition
– Grossman Endodontic Practice, 13th Edition
– Cohen Pathways of the pulp, 9th Edition
– Franklin S.Weine endodontictherapy ,4th edition
– Nisha garg ,text book of endodontics ,3rd edition
– Carranza text book of periodontics ,11 th edition