This presentation gives a thorough insight into the concept of endo perio lesions, their clinical features, diagnosis and treatment plan.

1. ENDO-PERIO LESIONS
Dr Shazeena Qaiser

2. C O N T E N T S
 Introduction
 Terminologies
 Pulp-periodontal
relationship
 Embryological Basis
 History
 Pathways of
Communication
 Physiological
 Pathological
 Iatrogenic
 Etiological Factors
 Etiopathogenesis
 Effect of Pulp on
Periodontium
 Effect of Periodontium
on Pulp
 Differential Diagnosis
 Classification
 Diagnosis
 Treatment
 Prognosis
 Case Reports
 Conclusion
 References
2

3. INTRODUCTION

4. TERMINOLOGIES
▪ ENDODONTICS
(Within the tooth)
▪ PERIODONTAL
(Surrounding the tooth)
4

5. 5
PULP-PERIODONTAL INTERRELATIONSHIP

6. EMBRYOLOGICAL BASIS
6

7. CONCEPT
7

8. HISTORY

9. 1919
• Turner and
Drew:
First described
effect of
periodontal
disease on pulp.
1964
• Simring and
Goldberg:
Relationship
between
periodontium and
pulp first
discovered
1972
• Simon:
Classification
based on etiology,
diagnosis,
treatment and
prognosis
1982
• Weine:
Based on clinical
presentation
strategies for each

10. 1988
• Stock:
modified Simon’s
classification lesions
was not necessary.
1991
• Grossman:
Classified based on
treatment plan
1999
• World Workshop for
Classification
Periodontal
Diseases

11. 2001
• von Arx T,
• Cochran DL.
2011
• Preetinder Singh
Similar; added the
term iatrogenic
lesions
2014
• Al-Fouzan:
New classification,
based on primary
disease and its
secondary effect

12. Pathways of
Communication

13. 13
• Apical foramen, accessory canals/lateral canals
• Congenital absence of cementum exposing dentinal tubules
• Developmental grooves
Pathways of developmental origin (anatomical pathways):
• Empty spaces on root created by Sharpey's fibers
• Root fracture following trauma
• Idiopathic root resorption - internal and external
• Loss of cementum due to external irritants.
Pathways of pathological origin:
• Exposure of dentinal tubules following root planning
• Accidental lateral root perforation during endodontic procedures
• Root fractures during endodontic procedures.
Pathways of iatrogenic origin
Shenoy N, Shenoy A. Endo-perio lesions: Diagnosis and clinical considerations. Indian J Dent Res 2010;21:579-85.

14. Anatomical Pathways

15. 1. Accessory Canals and Lateral Canals
15

16. 16

17. 17
Accessory Canals and Lateral Canals

18. 18

19. 2. Apical Foramen
19

20. 20

21. 3. DENTINAL TUBULES
21

22. 22
DENTINAL TUBULES

23. 23
DENTINAL TUBULES

24. 4. Palatogingival groove
24

25. Pathological/ Iatrogenic
Pathways

26. 5. Root Perforation
26

27. 27
Root Perforation

28. 6. VERTICAL ROOT FRACTURE
28

29. 29
VERTICAL ROOT FRACTURE

30. 30
Shenoy N, Shenoy A. Endo-perio lesions: Diagnosis and clinical considerations. Indian J Dent Res 2010;21:579-85.

31. ETOLOGICAL FACTORS

32. 32Parolia A, Gait TC, Porto IC, Mala K. Endo-perio lesion: A dilemma from 19th until 21st century. J Interdiscip Dentistry 2013;3: 2-11

33. 33Parolia A, Gait TC, Porto IC, Mala K. Endo-perio lesion: A dilemma from 19th until 21st century. J Interdiscip Dentistry 2013;3: 2-11

34. 34Parolia A, Gait TC, Porto IC, Mala K. Endo-perio lesion: A dilemma from 19th until 21st century. J Interdiscip Dentistry 2013;3: 2-11

35. 35Parolia A, Gait TC, Porto IC, Mala K. Endo-perio lesion: A dilemma from 19th until 21st century. J Interdiscip Dentistry 2013;3: 2-11

36. Etiopathogenesis of
Perio-Endo Lesions

37. EFFECT OF PULPAL DISEASE
ON PERIODONTIUM

38. 38

39. 39

40. ENDODONTIC PROCEDURES
AFFECTING PERIODONTIUM

41. 41
Technical
Procedures
Over-
instrumentation
Materials
Used
Irrigant
solutions
Medicaments
Dressings
Sealers
Filling
materials
Procedural
errors
Access
perforations
Strip
perforations
Vertical root #
Blomlof L, Lengheden A, Lindskog S. Endodontic infection andcalcium hydroxide treatment. Effects on periodontal healing in mature and immature replanted
monkey teeth. J Clin Period ontol 1992;19:652-8.
Jansson L, Ehnevid H, Blomlof L, Weintraub A, Lindskog S,. Endodontic pathogens in periodontal disease augmentation. J Clin Periodontol 1995;22:598-602.

42. EFFECT OF PERIODONTIUM
ON PULP

43. 43

44. 44

45. EFFECT OF PERIODONTAL
PROCEDURES ON PULP

46. 46
Technical Procedures
Scaling and Root Planing
Acid Etching
Gold S, Hasselgren G. Peripheral inflammatory root resorption: A review of literature with case reports. J Clin Periodontol 1992;19:523-34.
Adriaens PA, De Boever JA, Loesche WJ. Bacterial invasion of root cementum and radicular dentin of periodontally diseased teeth in humans: A reservoir of periodontopathic bacteria. J Periodontol
1988;59:222-30.
Cotton WR, Siegel RL. Human pulpal response to citric acid cavity cleanser. J Am Dent Assoc 1978;96:639-44.

47. CLASSIFICATION

48. Based on etiology
Simon, Glick and Frank
1972

49. 49
Type 1 -Primary endodontic lesions
Type 2- Primary periodontal lesions
Type 3- Primary endodontic lesions with
secondary periodontal involvement.
Type 4 -Primary periodontal lesions with
secondary endodontic involvement.
Type 5- True combined lesions

50. PRIMARY ENDODONTIC
LESIONS

51. DISEASE PROCESS
51

52. DIAGNOSIS
52
1
3
2

53. TREATMENT
▪ ENDODONTIC
TREATMENT
53
Rotstein I, Ingle J, Ingle J. Ingle's endodontics 7th Edition 2019.

54. 54

55. PRIMARY ENDODONTIC LESION WITH
SECONDARY PERIODONTAL
INVOLVEMENT

56. DISEASE PROCESS
56

57. DIAGNOSIS
57
3
2
1
4

58. TREATMENT
▪ ENDODONTIC
TREATMENT
58
▪ PERIODONTAL
TREATMENT
Rotstein I, Ingle J, Ingle J. Ingle's endodontics 7th Edition 2019.

59. PRIMARY PERIODONTAL
LESIONS

60. DISEASE PROCESS
60

61. DIAGNOSIS
61
1
3
2
4

62. 62
Rotstein I, Ingle J, Ingle J. Ingle's endodontics 7th Edition 2019.

63. TREATMENT
▪ PERIODONTAL
TREATMENT
63
Rotstein I, Ingle J, Ingle J. Ingle's endodontics 7th Edition 2019.

64. PRIMARY PERIODONTAL LESIONS
WITH SECONDARY ENDODONTIC
INVOLVEMENT

65. DISEASE PROCESS
65

66. DIAGNOSIS
66
1
3
2
4

67. 67

68. TREATMENT
▪ ENDODONTIC
TREATMENT
▪ PERIODONTAL
TREATMENT
68
Rotstein I, Ingle J, Ingle J. Ingle's endodontics 7th Edition 2019.

69. TRUE COMBINED
LESIONS

70. DISEASE PROCESS
70

71. DIAGNOSIS
71
1
3
2
4

72. 72
Rotstein I, Ingle J, Ingle J. Ingle's endodontics 7th Edition 2019.

73. TREATMENT
▪ ???
73

74. 75

75. Hiatt
1977

76. 77
Class 1 Pulpal lesions with secondary periodontal disease of short duration
Class 2 Pulpal lesions with secondary periodontal disease of long duration
Class 3 Periodontal lesions of short duration with secondary pulpal disease
Class 4 Periodontal lesions of long duration with secondary pulpal disease
Class 5 Periodontal lesion treated by hemisection or root amputation
Class 6 Complete and incomplete crown-root fractures
Class 7 Independent pulpal and periodontal lesions which merge into a combined
lesion
Class 8 Pulpal lesions which evolve into periodontal lesions following treatment
Class 9 Periodontal lesions that evolve into pulpal lesions following treatment

77. Based on etiology
Weine
1982

78. 79
Class 1 Tooth in which symptoms clinically and radiographically
simulate periodontal disease but are in fact due to pulpal inflammation
and/or necrosis
Class 2 Tooth that has both pulpal or periapical disease and
periodontal disease concomitantly.
Class 3 Tooth that has no pulpal problem but requires endodontic
therapy plus root amputation to gain periodontal healing.
Class 4 Tooth that clinically and radiographically simulates pulpal
or periapical diseases but in fact has periodontal disease.

79. Guldener
1985

80. 81
• Class la: Accidental perforations or resorptive perforations
• Class lb: Chronic periradicular lesions (granuloma or cyst) or acute periradicular
lesion
Class l: Primary endodontic lesions
• Class lla: Advanced periodontal disease with or without extension to the apical
area (pulp vital)
• Class llb: Secondary endodontic involvement
• Class llc: Secondary endodontic involvement
Class ll: Primary periodontal lesions

81. Based on the origin of the periodontal pocket
Torabinejad and
Trope 1996

82. 83
1. Endodontic origin
2. Periodontal origin
3. Combined endo- perio lesion
4. Separate endodontic and periodontal lesions
5. Lesions with communication
6. Lesions with no communication

83. Periodontitis Associated with Endodontic Disease
AAP CLASSIFICATION
1999

84. 85
1.Endodontic- periodontal lesion
2. Periodontal- endodontic lesion
3. Combined lesion.

85. Abbott and Salgado
2000

86. 87
Concurrent endodontic and periodontal diseases without
communication
Concurrent endodontic and periodontal diseases with communication

87. Ahmed
2012

88. 89
Class l: Synchronous endo-perio lesions
Class II: Pulpal lesions with periodontal involvement
Class Ill: Periodontal lesions with pulpal involvement
Class IV: Independent endo-perio lesions
Class V: iatrogenic endo-perio lesions
Class Vl: Advanced endo-perio lesions
Class Vll: lndetinite endo-perio lesions

89. Al-Fouzan
2014

90. 91
(1) retrograde periodontal disease:
(a) primary endodontic lesion with drainage through the periodontal ligament,
(b) primary endodontic lesion with secondary periodontal involvement;
(2) primary periodontal lesion;
(3) primary periodontal lesion with secondary endodontic involvement;
(4) combined endodontic-periodontal lesion;
(5) iatrogenic periodontal lesions.

91. DIFFERENTIAL DIAGNOSIS

92. 93

93. DIAGNOSIS

94. 95

95. 96

96. TREATMENT

97. 98

98. CONCLUSION

99. THANKYOU