This document provides an overview of endodontic-periodontal interactions. It discusses the pathways connecting endodontic and periodontal tissues, the etiology of endo-perio lesions, classifications of endo-perio lesions, diagnostic procedures, differences between periodontal and periapical abscesses, the endo-perio controversy, and management of pulpal and periodontal diseases. The key relationships covered are the anatomical and pathological connections between the pulp and periodontium, the bacteria commonly found in both tissues, and the debate around whether periodontal or endodontic disease can cause the other.

1. ENDODONTIC-PERIODONTAL
INTERACTIONS
GUIDED BY: PRESENTED BY:
DR. AMIT GOEL DR. VIRSHALI GUPTA
PG 2ND YEAR

2. CONTENTS
 Introduction
 Pathways connecting endodontic and periodontal tissues
 Etiology of endo-period lesions
 Classification of endo-perio lesions
 Clinical diagnostic procedures
 Differences b/w periodontal and periapical abscess
 Endo-perio controversy
 Therapeutic management of pulpal and periodontal diseases
 Conclusion
 References
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3. INTRODUCTION
Endodontic-periodontal problems are responsible for more than 50% of tooth mortality today.
In 1919 Turner and Drew first described the effect of periodontal disease on the pulp. The
relationship between the periodontium and the pulp was first discovered by Simring and
Goldberg in 1964.
Since then, the term ‘endo- perio lesion’ has been used to describe lesions due to inflammatory
products found in varying degrees in both periodontium and pulpal tissues.
The pulp and periodontium have embryonic, anatomic and functional interrelationship.
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4. PATHWAYS CONNECTING ENDODONTIC &
PERIODONTAL TISSUES
 Anatomical pathways:
 Apical foramen, accessory canals /lateral canals
 Congenital absence of cementum exposing
dentinal tubules
 Developmental grooves
 Non-physiological pathways:
 iatrogenic root canal perforations
 vertical root fractures caused by trauma,
pathway created due to resorption etc.
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5. ETIOLOGICAL AND CONTRIBUTING FACTORS
IN ENDO-PERIO LESIONS4/27

6. BACTERIA ASSOCIATED WITH PULPITIS
Eubacterium sp. 59 Gram-positive nonmotile
Peptostreptococcus sp. 54 Gram-positive nonmotile
Fusobacterium sp. 50 Gram-negative nonmotile
Porphyromonas sp. 32 Gram-negative nonmotile
Prevotella sp. 45 Gram-negative nonmotile
Streptococcus sp. 28 Gram-positive nonmotile
Lactobacillus sp. 24 Gram-positive nonmotile
Wolinella sp. 18 Gram-negative motile
Actinomyces sp. 14 Gram-positive nonmotile rods
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7. Most of the species that have
been found in infected root
canals can also be present in
the periodontal pocket.
(Moore 1987, Sundqvist
1994).
Rupf et al (2000) studied the profiles
periodontal pathogens in pulpal and
periodontal diseases associated with the
same tooth and concluded that
periodontal pathogens often
accompany endodontic infections
Didilescu AC et al (2012) - F.
nucleatum, P. micra and C.
sputigena may play a role in
the pathogenesis of endo-
periodontal lesions.
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8. CLASSIFICATION OF ENDO- PERIO LESIONS
I. Based on etiology, diagnosis, treatment and prognosis
(by Simon, 1972)
Primary endodontic lesions
Primary endodontic lesions with secondary
periodontal involvement
Primary periodontal lesions
Primary periodontal lesions with secondary
endodontic involvement
True combined lesions
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9. II. Based on clinical presentation strategies for each (by Weine, 1982)
Class 1 -tooth that clinically and radiographically stimulate
periodontal involvement but is truly due to pulpal inflammation or
necrosis.
Class II – tooth with both pulpal and periodontal disease
concomitantly
Class III – tooth that has no pulpal problem but requires endodontic
therapy with root amputation to receive periodontal healing
Class IV- tooth that clinically and radiographically stimulate pulpal or
periapical disease but in fact has periodontal disease.
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10. IV. Stock (1988) modified Simon’s classification
Omitted Class V of the classification.
He argued that both Class II and Class IV lesions in advanced
stages can become combined lesions and therefore a
class to describe these lesions was not necessary.
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11. III. Based on treatment plan (Grossman classification,1991)
Type 1 – Requiring endodontic treatment only.
Type II – Requiring periodontal treatment only.
Type III – Requiring combined endo-perio treatment
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12. V. Classification as recommended by the World Workshop for Classification
Periodontal Diseases (1999)
Endodontic-periodontal lesion
Periodontal-endodontic lesion
Combined lesion
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13. DIAGNOSTIC PROCEDURES USED TO IDENTIFY
THE ENDO-PERIO LESION
Examination/
tests
1º endodontic
lesion
1º periodontal
lesion
1º endodontic
2º periodontal
1º periodontal
2º endodontic
True combined
lesion
Visual  Soft tissue -
sinus opening
 Tooth -
decay/ large
restoration/
fractured
restoration or
tooth/
erosions/abrasio
ns/cracks/
discolorations/
poor RCT
 Inflamed
gingiva/
recession
(multiple
teeth)
 Plaque &
subgingival
calculus
(multiple
teeth)
 swelling
indicating
periodontal
abscess
 Plaque forms
at the
gingival margin
of the sinus tract
leads to
inflammation
of marginal
gingiva
 exudate
 Root
perforation/
fracture
 plaque,
subgingival
calculus &
swelling
(multiple
teeth)
 pus, exudate
 localized/
generalised
recession &
exposure of
root
 Plaque,
calculus &
periodontitis will
be present in
varying degrees
 Swelling
around single
or multiple
teeth
 pus, exudate
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14. Examination/
tests
1º endodontic
lesion
1º periodontal
lesion
1º endodontic
2º periodontal
1º periodontal
2º endodontic
True combined
lesion
Pain Sharp  Usually dull
ache
 Sharp only in
acute
condition
 Usually sharp
shooting
 Dull ache in
chronic
conditions
 Usually dull
ache
 Sharp only in
acute
periodontal
abscess
 Dull ache
usually
 Only in acute
conditions it
is severe
Palpation does not indicate
whether
the inflammatory
process is
of endodontic or
periodontal
origin
Pain on Pain on Pain on Pain on
Percussion Normally tender
percussion
sensitivity of the
proprioceptive
fibers in an
inflamed pdl will
help identify
the location of
the pain
Tender on
percussion
Tender on
percussion
Tender on
percussion
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15. Examination/
tests
1º endodontic
lesion
1º periodontal
lesion
1º endodontic
2º periodontal
1º periodontal
2º endodontic
True combined
lesion
Mobility Fractured roots and
recently
traumatized teeth
often present high
mobility
Localized to
generalized
mobility of teeth
Localized
mobility
Generalized
mobility
Generalized
mobility with
higher grade of
mobility related
to the involved
tooth
Pulp vitality
test,
 A lingering
response-
rreversible pulpitis
 No response -
Necrotic pulp
(non-vital)
pulp is vital and
responsive to
testing
Pulp vitality tests
negative
Pulp vitality may
be positive in
multirooted teeth
Usually negative
because
of non-vital pulp.
Pocket probing A deep narrow
solitary pocket*
Multiple wide
deep
pockets
Presence of
solitary wide
pocket
Presence of
multiple
wide and deep
periodontal
pockets
Probing reveals
typical conical
periodontal type
of probing
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16. Examination/
tests
1º endodontic
lesion
1º periodontal
lesion
1º endodontic
2º periodontal
1º periodontal
2º endodontic
True combined
lesion
Sinus tracing A radiograph with
GP points to apex
or furcation area in
molars
Sinus tract mainly
at the
lateral aspect of
the root
Sinus tract mainly
at the apex/
furcation
area
Sinus tract mainly
at the lateral
aspect of the root
Difficult to trace
out the origin of
the lesion *
Radiographs
Cracked tooth
testing
Painful response on
chewing
No symptoms Painful response
on chewing
No symptoms Painful response
on chewing
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17. DIFFERENCES BETWEEN PERIODONTAL AND
PERIAPICAL ABSCESS
PERIODONTAL ABSCESS PERIAPICAL ABSCESS
Periodontal pocket is present caries/ fracture is present
May occur after periodontal treatment May occur after endodontic or restorative
Tooth is vital Tooth is non - vital
Pain is usually dull and localized Pain is severe and difficult to localize
Swelling is present on the lateral surface of root
usually without fistulous track as abscess usually
drains from pocket opening.
Swelling is present at the apical portion of tooth
which drains by formation of a fistulous track.
Tender on lateral percussion Tender on vertical percussion
Usually not visible on radiographs Appears as a periapical radiolucency
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18. ENDODONTIC PERIODONTAL-CONTROVERSY
• Two basic questions have been raised and continue to
be a matter of dispute :
1) Is periodontal disease a cause of pulp necrosis?
2) Can a pulpless tooth be the cause of periodontal
disease?
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19. EFFECT OF PULPAL DISEASE ON THE
PERIODONTIUM
Bacteria and toxic irritants in pulp increase intrapulpal pressure. Inc pressure may cause toxic
to be expressed through patent channels which results in retrograde periodontitis.
Unresolved endodontic lesion causes bone loss, pocket formation and impair wound healing.
Potential effect of tooth with a necrotic pulp has been described as a risk factor (Jansson,
Ehnevid and Blomlof 1998) in the initiation and progression of periodontal disease, and the
initiation of periodontal pockets.
Diem et al (2002) reported that all tissues of the periodontium had a potential for regeneration
regardless of the status of the pulp.
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20. INFLUENCE OF ENDODONTIC PROCEDURES
ON PERIODONTIUM
 Endodontic therapy adversely affects periodontal healing.
 Mechanical preparation, sealers, surgical trauma hinder new bone, cementum and
connective tissue repair.
 Precautions to be taken when periodontal therapy to follow endodontic treatment.
 Induce less mechanical trauma
 Use more biocompatible sealers
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21. CONTRADICTING STUDY
 Sanders et al. (1983) reported that after the use of freeze dried bone allograft, 65% of
the teeth that did not have root canal treatment showed complete or greater than 50%
bone-fill in periodontal osseous defects; while only 33% of the teeth which had root
canal treatment prior to the periodontal surgical procedure had complete or greater
than 50% bone-fill.
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22. EFFECT OF PERIODONTITIS ON THE PULP
Result in atrophic and other degenerative changes like
 reduction in the number of pulp cells,
 dystrophic mineralization,
 fibrosis,
 reparative dentin formation,
 inflammation and
 resorption.
CAUSE:
Disruption of blood flow through the lateral canals localized areas of coagulation
necrosis in the pulp.
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23. Seltzer et al (1978) found
inflammatory alterations
and localized pulp
necrosis adjacent to
lateral canals in roots
exposed by periodontal
disease.
Mazur and Massler (1979)
found that only
periodontitis involving
apical foramen can lead
to pulp necrosis.
Cohen, 2002 have suggested that
periodontal disease causes pulpal
necrosis. Periodontal disease is a
direct cause of pulpal atrophy
necrosis.
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24. EFFECT OF PERIODONTAL PROCEDURES ON
PULP
Scaling and root planing: removes the
bacterial plaque and calculus. However,
improper root planing procedures can also
remove cementum and the superficial parts
of dentin, thereby exposing the dentinal
tubules to the oral environment.
Acid etching: citric acid removes the smear
layer, an important pulp protector.
Application of citric acid may have a
detrimental effect on the dental pulp.
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25. CONTRADICTING STUDIES
Kirkham (1975) studied 100
periodontally involved
& found 2% had lateral
canals in the periodontal
pocket.
Tagger & Smukler (1979)
removed roots from
extensively involved with
periodontal disease in
which root amputation was
necessary. Pulps of these
showed no inflammatory
changes.
Mazur and Massler (1979) found
no relationship and disclaimed
relationship of periodontal
disease as a causative factor in
pulpal disease.
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26. TREATMENT
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27. CONCLUSION
 Endo perio lesions present challenges to the clinicians in their proper diagnosis,
treatment and prognosis of the involved teeth.
 They have a varied pathogenesis which ranges from quite simple to relatively
complex.
 Knowledge of these diseases is essential in coming to the correct diagnosis and proper
treatment plan.
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28. REFERENCES
 Carranza, Newman 1Oth edition. Endodontic and Periodontics consortium.
 Jan Lindhe. Endodontics and Periodontics. Clinical Periodontology and Implant Dentistry.
318-351.
 Shalu Bathla, PERIODONTICS REVISITED – 1st edition.
 Parolia A, Gait TC, Porto IC, Mala K. Endo-perio lesion: A dilemma from 19th until 21st
century. J Interdiscip Dentistry 2013;3: 2-11.
 Syed Wali Peeran et al, endo- perio lesions, international journal of scientific & technology
research volume 2, issue 5, may 2013
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