- Endo perio relations

1. Dr. Khalid Alrashedi
Restorative dental sciences
Endo-Perio relationship
PERIODONTIUM
PULP

2. The pulp tissue and the periodontium should be viewed as one
biological unit. They have embryonic, functional and
anatomical relationship.
 Embryonic- both develops from ectomesenchyme
 Functional - common blood supply
 Anatomic - patent pathways - apical foramen, lateral canals
INTRODUCTION
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

3. Pathways of
Iatrogenic origin
Pathways of pathologic origin
Pathways of developmental origin
Pathways of communications between pulp and
periodontium

4. APICAL
FORAMEN
LATERAL AND
ACCESSORY
CANALS
DENTINAL
TUBULES
DEVELOPMENTAL
GROOVES
Pathways of Developmental Origin (Anatomic Pathways)

5. Root fracture or cracks following trauma
Idiopathic internal and external root resorption
Loss of cementum due to external irritants
Pathways of Pathological Origin

6. PATHWAYS OF IATROGENIC ORIGIN
ROOT
PERFORATION
S
DURING
RCT
ROOT
FRACTURES
DURING
RCT
EXPOSURE
OF DENTINAL
TUBULES
DURING ROOT
PLANING

7. 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

8. 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

9.  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.
 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.

10. CLASSIFICATION
1. Primary Endodontic Disease
2. Primary Periodontal disease
3. Primary Periodontal Secondary Endodontic
4. Primary Endodontic Secondary Periodontal
5. True Combined Lesion
Simon, Glick and Frank in 1972

11. Workshop for Classification Of Periodontal Disease -2017

12. Primary endodontic
Etiology
Dental caries, restorative procedures, traumatic injuries
Clinical features
Pain, tenderness to palpation and percussion
Sinus opening.
No response to sensibility tests.

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

14. Examination Primary endodontic lesion Primary periodontal lesions
VISUAL Presence of caries, large restorations,
fractured restorations or teeth attrition,
abrasion, erosion, cracks.
Presence of plaque and calculus ,inflamed gingiva, gingival
recession, presence of swelling and pus discharge through
gingival crevice in case of periodontal abscess
PAIN Sharp Usually dull ache
PALPATION It does not indicate whether the
Inflammation is pulpal or periodontal origin.
Presence of pain on palpation
PERCUSSION No in early stage. present
MOBILITY No mobility unless if it recently traumatized Localized to generalized mobility of teeth
PULP VITALITY Lingering response – irreversible pulpitis.
No response – non vital teeth.
Pulp is vital and responsive to testing
POCKET PROBING No pocket. Multiple wide deep pockets. Multiple teeth.
SINUS TRACING GP points to apex or furcation areas. Sinus tract mainly at lateral aspect of the root
RADIOGRAPH Deep carious lesions, extensive restorations,
periapical radiolucency,
Poor rct, mishaps like root fractures,
perforations, root resorptions.
Intact tooth.
Horizontal or vertical bone loss, bone loss wider
coronally.
CRACKED TEETH
TESTING
May present Null.

15. Primary Endo Secondary Periodontal:
Etiology
Progression of chronic primary
endodontic lesion coronally.
Plaque and calculus

16. Primary Periodontal Secondary
Endodontic
Etiology
Progression of periodontal disease apically
Clinical features
Pocket formation ,bone loss, attachment loss
Acute pulpal pain

17. Examination PRIMARY ENDO SECONDARY PERIO PRIMARY PERIO SECONDARY ENDO
VISUAL Plaque formed at the gingival margin of the
sinus tract
Plaque calculus, gingival swelling around the multiple
teeth, gingival recession, presence of pus exudate,
PAIN Usually sharp shooting pain. Dull ache in
chronic cases
Usually dull ache ,sharp pain in case of acute
periodontal abscess
PALPATION Pain on palpation Pain on palpation
PERCUSSION Tenderness on percussion Tenderness on percussion
MOBILITY Single tooth mobility Multiple teeth mobility
PULPVITALITY negative Positive in cases of multi rooted teeth
POCKET PROBING Localized solitary wide pocket. Presence of multiple wide deep periodontal pockets
SINUS TRACING Sinus tract mainly at apex or furcation areas Sinus tract mainly at the lateral surface of the root
RADIOGRAPH Presence of deep carious lesions, extensive
restorations, previous poor root canal
treatment, root fractures, root resorptions
Angular bone loss in multiple teeth wide base coronally
and narrow at the apex of the root.
Intact tooth.
CRACKED TEETH
TESTING
May present. Null.

18. True Combined Periodontal &
Endodontic
Distinct etiological factors which do not influence
each other

19. Features of Pulpal and Periodontal Lesions
Clinical Signs Pulpal Periodontal
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

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

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

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

23. o Pulp Testing (EPT + Cold
test):
LESION RESPONSE
Primary Periodontal +
Primary Periodontal Secondary Endodontic +/-
Primary Endodontic +/-
Primary Endodontic Secondary Periodontal -
Combined pulpal -
Primary Periodontal Secondary Endodontic:
Multi-rooted teeth may give False positive response.

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

25. Radiographic evaluation:
Root fractures
Perforations
Resorption
Restoration margins
Extension of bone loss
Adequacy of obturation

26. Management of Endo Perio
Lesions
•Prognosis
•Treatment of endo perio cases

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

28. TREATMENT
• RCT
Primary Endodontic
• Periodontal Therapy + Follow up
Primary Periodontal
• RCT + Periodontal therapy after 3 months, if
not healed
Primary Endodontic
Secondary Periodontal
• Periodontal therapy + RCT  Follow up &
observe pocketing  Surgical periodontal
therapy
Primary Periodontal
Secondary Endodontic
• Periodontal therapy + RCT  Follow up &
observe pocketing  Surgical periodontal
therapy
True Combined
lesion

29. 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
Bicuspidization: Separation of mesial and distal roots of mandibular molar along
with its crown portion, where both segments are then retained individually

30. Indications for Resections and hemisection
Periodontal indications
1- Severe vertical bone loss involving only one root of a multi rooted tooth
2- Through and through furcation destruction
3- Unfavorable proximity of roots of adjacent teeth, preventing adequate hygiene
maintenance in proximal areas
4- Severe root exposure due to dehiscence
Restorative and endodontic indications
1- Endodontic failure: perforations, over extension , obstructed canals, separated
instrument , root resorption
2-Vertical fracture of one root
3- Restorative reasons: sub gingival caries, erosion of large part of crown and root,
traumatic injury
4- Combination of these

31. 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 into
destructive forces and cause failure of hemisection

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

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

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

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

36. REFERENCES :
• Cohen Pathways of the pulp, 9th Edition