Carranza's Clinical Periodontology Chapter 43 Diagnosis and Management of Endodontic-Periodontic Lesions

1. Carranza's Clinical
Periodontology
Chapter 43
Diagnosis and Management
of Endodontic-Periodontic
Lesions
Textbook Reading
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2. Retrograde
periodontitis
• Advanced pulpitis - > pulp
necrosis -> bone resorption at
root apex or apical abscess
• Periodontal tissue breakdown
from apical to cervical

3. Orthograde
periodontitis
• Results from a sulcular infection.

4. Classification of endodontic-
periodontic lesions.
A, Primary pulpal infection can lead to chronic periradicular periodontitis
B, Primary periodontal infection can lead to extensive breakdown of alveolar crest bone
that migrates from the cervical area to the apex.
C, Both primary pulpal and primary periodontal infection occur simultaneously
D, Primary pulpal and primary periodontal infections can occur extensively in this
“combined” endodontic-periodontic lesion.

5. Summary
• Retrograde periodontitis
• Orthograde periodontitis

6. Accessory canals
• 59.5% of maxillary second premolars possess lateral canals
• 78.2% of maxillary second premolars located in the apical
regions of the root canals.
• Located in midroot and cervical regions, frequencies at
16.2% and 4.0%, respectively.
• 28.4% of permanent molars posses accessory canals in
furcation regions

7. Accessory canals
• Kirkham 100 permanent human teeth extracted as result
of severe periodontal disease
• 2 teeth possessed accessory canals within periodontal
pockets

8. Lateral
canal-led
periodontal
defect
A, Bone loss is present in the furcation
with sinus tract present on the buccal
mucosa. Tooth #30 tested nonvital.
B, During condensation, a large amount of
sealer was expressed through a large
lateral canal in the distal root.

9. Dentinal tubules
• Tapered structure along the length from pulpodentinal
complex (PDC) to the dentinoenamel junction (DEJ)
• Diameter of 2.5 µm at PDC and 0.9 µm at the DEJ.
• Permeability changes at different locations along the root
surface
• Bacterial colonization in tubules from infected root canals
and periodontal pocket both demonstrated
• Root planing shown to decrease dentin permeability

10. Iatrogenic defects
• iatrogenic defects such as vertical root fractures and tooth
p forations.

11. Summary
• Retrograde Periodontitis
• Orthograde Periodontitis
• Accessory canals
• Dentinal tubules
• Iatrogenic defects

12. Factors Initiating
Pulpal Diseases
• Microorganisms
• Trauma
• Excessive heat
• Restorative procedures
• Restorative agents
• Malocclusion.

13. Classification of Pulpal and Apical
Diseases
American Association of Endodontists revised terminology published
in 2009 in volume 35 of the Journal of Endodontics (page 1634)

14. Biologic Effects of Pulpal
Infection on Periodontal Tissues
• Biofilm is composed of 15% cellular and 85% matrix
• Proteolytic bacteria predominate in early root canal infections
• Viruses play in the pathogenesis of both periodontal and endodontic
disease
• Gingival herpes viruses associated with the increased growth of
pathogenic periodontal bacteria 22,45
• Epithelial rests, cholesterol crystals, Russell bodies, Rushton hyaline
bodies, and Charcot-Leyden crystals.125
• Responsible for the lack of healing of apical lesions in teeth that have
received appropriate endodontic treatment.125
22. Contreras A, Slots J: Typing of herpes simplex virus from human periodontium. Oral Microbiol Immunol 16:63–64, 2001.
45. Glick M, Trope M, Pliskin ME: Detection of HIV in the dental pulp of a patient with AIDS. J Am Dent Assoc 119:649–650, 1989.
125. Rothstein I, Simon JH: The endo-perio lesion: a critical appraisal of the disease condition. Endod Topics 13:34–56, 2006.

15. Cellulitis
• Dissect PDL space and result in the formation of a deep
but narrow periodontal pocket.
• Whether the probing defect is the result of an endodontic
or periodontal problem.

16. continued tooth mobility, and
occlusal trauma
splinting is sometimes necessary to help stabilize the
tooth and allow for potential repair of the apical tissues

17. Summary
• Factors Initiating Pulpal Diseases
• Classification of Endodontic Disease
• Biologic Effects of Pulpal Infection - > Periodontal Tissues