endo perio lesin

1. Endodontic periodontal
interrelationships
BY- DR. SONAL
BANSAL

2. • Both endodontic and periodontal diseases are
caused by a mixed anaerobic infection.
• In both cases, the periodontal tissues become
chronically inflamed as a result of an anaerobic
and Gram-negative dominated microbiota

3. • Turner and Drew(1919) 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.
history

4. • A process involving interaction of diseases of
the pulp and periodontium.
- Glossary of endodontic terms
“Lesion with submarginal or intra-bony
periradicular bone loss of pulpal and/or
periodontal origin that communicates with the
oral cavity via a periodontal probing defect”
K Gulabivala, UR Darbar, Y-L Ng. Multidisciplinary aspects of endodontic management
The perio–endo interface.

5. Pulpal
pathology
Periodontal
pathology
Inter relation

6. ETIOLOGICAL FACTORS
• Pulp degenerates necrotic debris, bacterial
byproducts, toxins
inflammatory response and destruction in
periodontium
PULPAL DISEASE- major causes of inflammation are
1. Dental caries
2. Incorrect Restorative procedures
3. Dental trauma

7. Periodontal lesions are initiated by deposits of
plaque and calculus.
toxins produced by bacteria
chronic inflammation
destroy supporting tissues.

8. • Apical foramina
• Lateral canals
• Dentinal tubules
• Palatogingival grooves
Potential paths for
inflammatory
reciprocity

9. Non-physiological
• Iatrogenic root canal perforations
• Vertical root fractures

10. Difference Between Endodontic
and Periodontal Lesions
Diagnosis Endodontic Periodontal
Etiology Necrosis of the pulp Infection
and inflammation of the periodontium
Pain Acute, excruciating, and
spontaneous in nature Dull and chronic in
nature
Swelling Occurs in cases with periapical abscess
and is diffuse in nature Localized
Percussion Positive and vertical in direction Mild

11. Probing Probing depth of sulcus< 3 mm
Probing depth of sulcus> 3 mm
Sinus tracing Gutta-percha point leads to the apex of
the involved tooth
Gutta-percha point would lead to the
sulcus of the involved tooth
Mobility Rare and localized in nature
More common and generalized in nature
Junctional epithelium Normal Apical migration
Gingiva Normal Gingival inflammation and recession
Therapy Root canal therapy Periodontal therapy

12. Classification
Etiology Pathology
Rx &
prognosis

13. According to Simon ,1972
BASED ON ETIOLOGY
• Class I - Primary endodontic lesion
• Class II - Primary periodontial lesion
• Class III - Primary endodontic disease with
secondary periodontal involvement
• Class IV - primary periodontal disease with
secondary endodontic involvement
• Class V - True combined lesion

14. Oliet and Pollock, 1968
BASED ON TREATMENT PLAN
• Class I Primary endodontic involvement with
secondary peridontal factors, requiring only
endodontic treatment.
• Class II Primary periodontal involvement with
secondary endodntic factors, requiring
periodontal treatment alone.
• Class III endodontic-periodontal involvement
requiring correlated and combined therapy.

15. Primary Endodontic Lesions
• Most common causes: Caries, restorative
procedures, and traumatic injuries.
• Typically, endodontic lesions resorb bone
apically and laterally and destroy the
attachment apparatus adjacent to a nonvital
tooth.

16. Clinical features
• Pain
• Tenderness to pressure and percussion,
• Increased tooth mobility, and swelling of the
marginal gingiva, simulating a periodontal
abscess.
• The suppurative process may cause a sinus
tract that can be easily traced down to the
tooth apex

17. • The pocket that forms is narrow and has little
or no local factors.
• Vitality test: degenerating pulp.
Complete resolution
following Nonsurgical
endodontic therapy without
any periodontal treatment.

18. Primary Periodontal Lesions
• Periodontal disease has a progressive nature.
• It begins in the sulcus and migrates to the
apex as deposits of plaque and calculus
produce inflammation.
• This leads to a loss of clinical attachment and
formation of a periodontal abscess during the
acute phase of destruction.

19. • Osseous lesions of periodontal origin are usually
associated with tooth mobility.
• The affected teeth respond positively to pulp
testing.
• Careful periodontal examination will usually
reveal broad-based pocket formation and an
accumulation of plaque and calculus.
• The bony lesion is usually more widespread and
generalized.

20. • Probing in a typical
periodontal lesion
demonstrates the
conical characteristics
of the lesion.

21. Treatment
• Appropriate instruction in oral hygiene
• Root surface debridement
• and monitoring of the pulp vitality during and
after periodontal therapy

22. Acute Or "Blow-out" Lesions
• C/F: localized swelling that involves the
gingival sulcus.
• The swelling is usually on the labial or buccal
side of the tooth but may be on the lingual
side.
• Vitality of tooth: negative

23. • At the edge of the
swelling the probe
drops precipitously to a
level near the apex of
the tooth

24. • At the opposite edge of the
swelling, probing is once
again within normal limits.
• The width of the detached
gingiva can be as broad as
the entire buccal or lingual
surface of the tooth.
• This swelling can be
characterized as having
"blown out" the entire
attachment on that side.

25. • Endodontic treatment only is indicated.
• As the result of endodontic management of
the swelling, complete periodontal
reattachment occurs within 1 week in most
cases.

26. Primary Endodontic Lesions
With Secondary Periodontal
Involvement
• Primary endodontic
lesion with a draining
abscess through the
periodontium if left
untreated over a period
of time may lead to local
factors accumulating in
the sinus tract and a
creation of secondary
periodontal problem

27. • Such a lesion may result in a localized or
diffuse swelling that may occasionally involve
the gingival attachment.

28. Features
• Pulpal inflammation or
necrotic root canal
• Periodontal pocket will
form in this area with
evidence of further
angular bone loss and
sinus tract formation

29. Treatment
• Root canal therapy is carried out and certain
time is allowed for periodontal tissues to heal.
• After evaluation period of 2-3 months
periodontal therapy is carried out if required.
• Prognosis depends on the amount of
attachment loss and severity of periodontal
disease.

30. Primary Periodontal Lesions
With Secondary Endodontic
Involvement
• On radiographs, these
lesions may be
indistinguishable from
primary endodontic
lesions with
secondary periodontal
involvement.

31. This situation exists when
“THE APICAL PROGRESSION OF PERIODONTAL
DISEASE”
is sufficient to open and expose the pulp to the oral
environment by way of lateral canals or dentinal
tubules.
• Unless periodontal disease has progressed to
involve the tooth apex, the effect of periodontal
disease on the pulp appears to be negligible.
• Generally have severe periodontitis with necrotic
pulp

32. • Both periodontal and endodontic therapies
are required.
• Prognosis depends on the severity of the
periodontal disease and periodontal response
to treatment.

33. True Combined Lesions
• True combined perio-endo lesions occur when
independent periodontal and periapical or
lateral lesions are present and do
communicate.
• C/F: Radiographic evidence of bone loss,
which appears to extend some distance down
the lateral root surface from crestal bone.

34. • typical conical
periodontal type of
probing
• at the base of the
periodontal lesion the
probe will abruptly drop
farther down the lateral
root surface and may
even extend to the apex
of the tooth

35. • Adequate root canal treatment will resolve
the periapical lesion either with or without
periodontal therapy.

36. Concomitant Pulpal and
Periodontal Lesions
• This additional group of lesions was proposed
by Belk and Guntmann
• lesions that may commonly be seen clinically
and reflect the presence of two separate and
distinct entities

37. • Both disease states exist but with different
causative factors and with no clinical evidence
that either disease state has influenced the
other.

38. • Both disease processes must be treated
concomitantly, with the prognosis dependent
on the removal of the individual etiologic
factors.

39. Abott ( in a detailed analysis on treatment
considerations) recommends the following
protocol.
• Initial management
• Remove existing restorations and caries
• Chemomechanically prepare canals
• Medicate canals (depends on symptoms)
• Follow-up management
• Change intracanal dressing after 3–4 weeks
• Provide initial periodontal treatment
• Review healing after 3 months
• Reassess need for further periodontal treatment

40. • If more periodontal treatment (e.g.,
surgery) is required
• Change intracanal medication again
• If healing response is favourable,
• Complete root canal filling

41. Oliet and Pollock’s Classification
Based on treatment protocol.
A. Lesions that require endodontic treatment
procedures only
• 1.Any tooth with a necrotic pulp and periradicular
pathosis, with or without a sinus tract (chronic
periapical abscess)
• 2. Chronic periapical abscess with a sinus tract
draining through the gingival crevice, thus passing
through a section of the attachment apparatus in
its entire length alongside the root

42. • 3. Root fractures, longitudinal and horizontal
• 4. Root perforations, pathologic and iatrogenic
• 5. Teeth with incomplete apical root development
and inflamed or necrotic pulps, with and without
periradicular pathoses
• 6. Replants, intentional or traumatic
• 7. Transplants, autotransplants or allotransplants 8.
Teeth requiring hemisection or radisectomy
• 9. Intentional endodontic therapy for prosthodontic
consideration

43. Lesions that require periodontal
treatment procedures only
Occlusal trauma causing reversible pulpitis
Occlusal trauma plus gingival inflammation,
resulting in pocket formation
(a) Reversible but increased pulpal sensitivity
caused by trauma or, possibly, by exposed
dentinal tubules
(b) Reversible but increased pulpal sensitivity
caused by uncovering lateral or accessory
canals exiting into the periodontium

44. 3. Suprabony or infrabony pocket formation
treated with overzealous root planing and
curettage, leading to pulpal sensitivity
4. Extensive infrabony pocket formation,
extending beyond the root apex and
sometimes coupled with lateral or apical
resorption, yet with pulp that responds within
normal limits to clinical vitality testing

45. Lesions that require combined endodontic–
periodontic treatment procedures
1. Any lesion in group I that results in
irreversible reactions in the attachment
apparatus and requires periodontal
treatment
2. Any lesion in group II that results in
irreversible reactions in pulp tissue and also
requires endodontic treatment

46. Predisposing Factors
• Grossman has given the possible predisposing
factors leading to combined endodontic–
periodontic treatment procedures:
• 1. Atypical anatomical factors
(a) Malalignment of a tooth, a predisposing
factor to trauma; examples are food impaction
and occlusal trauma
(b) Presence of a multirooted tooth in a position
usually occupied by a singlerooted tooth, or
additional roots, separate or fused, in
multirooted teeth

47. (c) Presence of additional canals, with resultant
changes in root morphology in single and
multirooted teeth
(d) Large lateral (accessory) canals in coronal and
middle sections of roots
• 2. Trauma
(a) Combined with gingival inflammation, trauma
can lead to deep periodontal pockets or, in
multirooted teeth, furca exposure. If large lateral
canals exit in the pocket area, the pulp will
usually be exposed to the oral environment, and
in addition to the periodontal problem,
irreversible pulpitis may also occur

48. • (b) Possible cause of crown fracture, root fracture,
or root displacement, resulting in irreversible
pulpitis, necrosis, or periapical disease
• (c) Possible involvement of the pulp and
disturbance of the periodontal membrane, with
the resultant sinus tract draining through the
periradicular tissue and exiting through the
gingival crevice; a newly found “pathway of least
resistance” that differs from the usual sinus tract,
which drains through the labial or buccal mucosa

49. (d) Possible cellular changes in the pulp or
periodontium leading to internal or external
resorption associated with root perforation.
Trauma to a tooth can originate from an
accidental blow, cavity preparation, and other
restorative procedures, tooth separation,
orthodontic treatment, malocclusion, and
detrimental habits. Trauma appears to be a
major etiological factor in the formation of an
endodontic–periodontic lesion

50. 3. Miscellaneous factors
• (a) Iatrogenic errors, such as perforation into the
furcation of multirooted teeth during root canal
therapy, root perforation during postpreparation, or
perforation in the apical part of a curved root
during instrumentation
• (b) Possibly, systemic factors, such as systemic
disease as a cause of the combined lesion

51. SEQUENCE OF TREATMENT
• Some clinicians suggest that initial treatment be
either endodontic or periodontic, depending on the
origin of the initiating disease.
• Others recommend that partial endodontic
treatment be performed through canal preparation
and disinfection, followed by periodontal therapy,
before finally finishing the endodontic procedures
once a successful periodontal result has been
achieved.
• However, it is recommended that endodontic
treatment should precede periodontal therapy,
regardless of the cause of disease.

52. Differentiation of a Sinus Tract
from an Infrabony Pocket
• It is clinically important to differentiate
between a sinus tract draining into the
gingival crevice and an infrabony pocket
extending to the root apex of a tooth. A sinus
tract originates from the root canal and
progresses occlusally from the apical foramina
or from a lateral canal, whereas an infrabony
pocket originates in the gingival crevice and
progresses apically.

53. • Specifically, a sinus tract closes when routine
endodontic procedures have been performed.
Attacking the focus of infection within the root
canal by instrumentation, by intracanal
disinfection, or even by establishing drainage
through an occlusal access opening usually
results in tract closure in several days.

54. • An infrabony pocket requires periodontal
therapy, with or without endodontic
treatment, to facilitate healing. Fortunately,
the clinical differentiation is simple because a
sinus tract is narrow and can be traversed only
with a gutta-percha cone, whereas an
infrabony pocket, the result of extensive tissue
destruction, can be probed with wider and
larger instruments.

55. Indications for root resection
• root fracture
• Perforation
• root caries
• dehiscence, fenestration,
• external root resorption involving one root,
• severe periodontitis affecting only one root,
• severe Grade II or III furcation involvement.