ENDO-PERIO LESION: DIAGNOSIS, PROGNOSIS AND DECISION-MAKING. Antonio Bonaccorso ENDOD (Lond Eng)2014;8(2):105-127 DR ANUBHUTI

ENDO-PERIO LESION: DIAGNOSIS,
PROGNOSIS AND DECISION-MAKING
Antonio Bonaccorso
ENDOD (Lond Eng)2014;8(2):105-127
ENDOD 2014;8(2):105-127 1
GUIDED BY:
DR.RAHUL MARIA
PRESENTED BY:
DR.ANUBHUTI

Presence of tooth with simultaneous lesions of endodontic and
periodontal origin is a challenge to clinician as far as
ENDOD 2014;8(2):105-127 3

Such infections are typically polimicrobial
and therefore, interactions, both
antagonistic and synergistic, between
different strains and species would be
expected
ENDOD 2014;8(2):105-127 4

Treatment and prognosis of endodontic–
periodontal diseases vary and depend on
the cause and the correct diagnosis of
each specific condition.
ENDOD 2014;8(2):105-127 5

In particular its critically important to determine whether
the lesion is primarily periodontal or primary endodontic
in origin, because accuracy of diagnosis will determine
whether or not the appropriate treatment plan is insight
ENDOD 2014;8(2):105-127 6

In 1919 Turner and Drew first
described the effect of periodontal
disease on the pulp.
The relationship between periodontal
and pulpal disease was first described
by Simring and Goldberg in 1964
Dr. Syed Wali Peeran INTERNATIONAL JOURNAL OF SCIENTIFIC & TECHNOLOGY RESEARCH VOLUME 2, ISSUE 5, MAY 20137

Tissues of dental
pulp and
periodontium are
inter-linked from
the embryonic
stage.
ENDOD 2014;8(2):105-127
ILAN ROTSTEIN & JAMES H. SIMON Endodontic Topics 2006, 13, 34–56
SHAH.N DEPT OF DENTAL SURGERY AIIMS
COHEN’S PATHWAYS OF PULP 8TH EDITION
INGLES’6TH EDITION 8

DENTAL
PAPILLA PULP
ENDOD 2014;8(2):105-127 9

Dental
follicle
Periodontal
ligament
ENDOD 2014;8(2):105-127
INGLES’6TH EDITION
10

Therefore, its natural to expect that any part of
periodontium can get affected by pulpal inflammation
and vice versa
At the late bell stage ,epithelial root sheath separates
the dental papilla and dental follicle respectively except
at the apical foramen
ENDOD 2014;8(2):105-127
SHAH.N DEPT OF DENTAL SURGERY AIIMS 11

When a pulpal lesion presents itself to the
periodontium via the apical foramina, lateral canals or
in furcation areas, progresses coronally and eventually
joins with an infected marginal pockets which
progresses apically, it is defines as an ‘endo-perio
lesion’(EP) or ‘true combined endo-perio disease’
ENDOD 2014;8(2):105-127
ILAN ROTSTEIN & JAMES H. SIMON Endodontic Topics 2006, 13, 34–56 12

ENDOD 2014;8(2):105-127 13
Harrington and steiner defined EP as a
non-vital tooth that shows destruction of
periodontal attachment reaching the whole
way to the root apex or a lateral canal, for
which both root canal treatment and
periodontal therapy are required
ENDOD 2014;8(2):105-127

ENDOD 2014;8(2):105-127
14
Increased
periodont
al probing
depth
Localised
gingival
inflammation
or swelling
Bleeding
on probing
Suppuration Fistula
formation
Infections of periodontal or endodontic origin may result in :
ENDOD 2014;8(2):105-127

ENDOD 2014;8(2):105-127 15
Tender on
percussion
Increased
tooth
mobility
Angular
bone loss
Pain
ENDOD 2014;8(2):105-127

EP are difficult to classify because they may
remain symptom-free for long periods and they
are rarely diagnosed until the disease starts
manifesting itself in the form of acute symptoms
of inflammation and /or increased pain.
ENDOD 2014;8(2):105-127 16

Once the symptoms occur, they tend to
be severe, and the periodontal aspect
can seem to be so dominant that dentist
tend to settle for strictly symptomatic
periodontal therapy whilst overlooking
the endodontic aspect
ENDOD 2014;8(2):105-127 17

it is difficult to distinguish by hindsight which parts
of the lesion are endodontic ( primary endodontic
disease) and which are periodontal in origin
(primary periodontal disease)
ENDOD 2014;8(2):105-127
18

Primary endodontic lesions are inflammatory
processes located in periodontal tissues and
caused by intra canal microorganisms.
ENDOD 2014;8(2):105-127 19

The term root canal
infection implicates
infection of the main
root canal, lateral canals,
apical delta and radicular
dentine infection.
ENDOD 2014;8(2):105-127 20

Primary periodontal lesions
are inflammatory processes
located in periodontal tissues
caused by bacteria that start
on the external surface of the
root. These lesions are caused
primarily by periodontal
pathogens
ENDOD 2014;8(2):105-127
21

During the
progression in
apical direction of
the destructive
process, all
periodontal tissues
are involved:
cementum;
periodontal
ligament; and
alveolar bone
ENDOD 2014;8(2):105-127 22

ENDOD 2014;8(2):105-127 23
 The characterizing damage of the periodontal
disease is the destruction of periodontal ligament
and alveolar bone.
 In this process, chronic marginal periodontitis
progresses apically along the root surface

ENDOD 2014;8(2):105-127
24
In most cases, pulp sensibility tests are positive.
There is frequently an accumulation of plaque
and calculus, and the pockets are wider
ENDOD 2014;8(2):105-127

EP are characterized by the simultaneous presence of:
Radiographic signs of bone destruction associated with
clinical symptoms of periodontal inflammation
Necrotic pulp tissue associated with radiographic signs
of periradicular lesion or a negative answer to cold test;
or even a previously failed root canal therapy.
ENDOD 2014;8(2):105-127 25

ENDOD 2014;8(2):105-127 26
Pathways of communication

ENDOD 2014;8(2):105-127 27
Apical
foramen
Lateral and
accessary
root canals
Furcation
area with
furcational
canals
Apical
delta
Dentinal
tubules
Anatomical consideration

ENDOD 2014;8(2):105-127 28
Empty spaces
created by
destroyed
Sharpey's fibers
Idiopathic
resorption-
internal & external
Hypophosphatasia
(very thin dentin
near CEJ and
enlarged pulp
chamber)
Pathological consideration

ENDOD 2014;8(2):105-127 29
Accidental
lateral
perforation
during
endodontic
treatment
Exposure of
dentinal
tubules after
root
planning
Vertical root
fracture
Root canal
perforation
Iatrogenic ways of communication

Aetiopathogenetic processes
Bacteria Fungi
(yeasts)
Viruses biofilms
ENDOD 2014;8(2):105-127
30

The apical foramen and accessory
canals are necessary for vascular,
lymphatic, neural and connective
tissue communications between pulp
and periodontal tissues.
ENDOD 2014;8(2):105-127
31

Presence of multiple foramina,
additional canals, fins, apical
delta, intercanal connections,
loops, C-shaped canals and
accessory canals are an integral
part of the pulpal anatomy and
may be difficult to diagnose
ENDOD 2014;8(2):105-127
COHEN’S PATHWAYS OF PULP 9TH EDITION 32

The complex and rich system of anatomical
connections among endodontic structure and
periodontal tissues allows the passage of
pathogenic microorganisms and toxic products
in two directions.
33
Dr. Syed Wali Peeran INTERNATIONAL JOURNAL OF
SCIENTIFIC & TECHNOLOGY RESEARCH VOLUME 2, ISSUE
5, MAY 2013
ENDOD 2014;8(2):105-127
ILAN ROTSTEIN & JAMES H. SIMON Endodontic Topics
2006, 13, 34–56

Exposed cervical dentine, where the cementum and
enamel do not meet at the cemento enamel
junction, can also provide tubular communication
through patent dentinal tubules
34
ENDOD 2014;8(2):105-127

Apical foramen
The apical foramen is the principal route
and in some cases the amplest and more
direct way of communication between
the pulp and the periodontium
35
Dr. Syed Wali Peeran
INTERNATIONAL JOURNAL OF SCIENTIFIC & TECHNOLOGY RESEARCH VOLUME 2, ISSUE 5, MAY 2013
ENDOD 2014;8(2):105-127

 The blood supply is derived from the inferior
and superior alveolar arteries and reaches
the periodontal ligament (PDL) from three
sources:
ENDOD 2014;8(2):105-127 36

These vessels run closer
to the bone than to the
cementum and the blood
supply increases from the
incisors to the molars
ln all single-rooted teeth, the
blood supply of the individual
PDL is greatest in the gingival
third and least in the middle
third.
ENDOD 2014;8(2):105-127 37

ENDOD 2014;8(2):105-127 38
• Langeland reported that the total histological
disintegration of pulp occurs only when all main apical
foramina are infected by bacteria plaque.
• The apex is also a portal of entry of inflammatory
elements from deep periodontal pockets to the pulp
ENDOD 2014;8(2):105-127

Lateral and accessory canals
Lateral and accessory canals
can be present anywhere along
the root, but are mainly seen in
the apical third of the root
39
ENDOD 2014;8(2):105-127

Lateral canals and apical
ramifications might be revealed by a
variety of filling techniques and are
probably more frequently indicated
in necrotic cases than in vital pulps
ENDOD 2014;8(2):105-127 40

ENDOD 2014;8(2):105-127 41
After root canal filling, lateral canals can also be
visualized on radiographs when a consistent
amount of filling material is forced into the
ramifications by compaction (usually sealer but
also gutta-percha in thermoplasticized techniques)

Lateral lesion
with no
apical lesion
Separate
lateral and
apical lesion
Coalesence of
lateral and
apical lesions
ENDOD 2014;8(2):105-127
42
Wein reported on three types of lateral lesions that can be radiographically
observed

Molar furcation
These accessory canals contain connective
tissue and blood vessels that connect the
circulatory system of the pulp with that of the
periodontium.
Not all these canals extend the full length
from the floor of the pulp
ENDOD 2014;8(2):105-127 43

Apical delta or apical ramification
Apical ramifications of the main root canal
are formed after a localized fragmentation
of the epithelial root sheath develops,
leaving a small gap, or when blood vessels
running from the dental sac through the
dental papilla persist.
ENDOD 2014;8(2):105-127 44

Although ramifications contain connective tissue and blood vessels, this is not
usually regarded as collateral blood supply and consequently provides little
contribution, if any, to pulp function, except possibly for the ramifications located
in the apical to 2 mm of the canal
Dentinogenesis does not occur in this specific area, giving rise to
a canal containing small blood vessels and sometimes nerves
ENDOD 2014;8(2):105-127 45

Large and patent lateral foramina might allow larger
amounts of microbial products to reach and contact a
larger area of the lateral periodontal ligament to cause
disease.
The amount of bacteria irritants in small ramifications,
with small volume and small exiting foramina area,
might be sufficient to induce significant disease to be
discernible radiographically
ENDOD 2014;8(2):105-127 46

Dentinal tubules
ENDOD 2014;8(2):105-127 47
Dentinal tubules are formed or
better left out during tooth
development by odontoblasts
which trail their proccess as they
grow centripetally while
secreting the dentin matrix.
Odontoblastic process does not
reach further than 0.5 mm into
the dentin

Dentinal tubules are filled with a
fluid similar in composition to
extracellular fluid.
ln a mature tooth, each individual
dentinal tubule can be regarded as
an inverted cone, with the smallest
dimension at the periphery and the
largest dimension at the pulp
ENDOD 2014;8(2):105-127
48

ENDOD 2014;8(2):105-127 49
The diameter ranges
from 1 mm in the
periphery to 3 mm
near the pulp

• The opening of each of these small tubules
facing the periodontal ligament is sealed with
cementum.
• At a 3.5 mm distance from the pulp, the mean
tubule diameter was found to be 0.8 mm,
compared to 2.5 mm at the pulpal wall
ENDOD 2014;8(2):105-127 50

• The number of dentinal tubules per mm2
decreases from the pulp to the periphery
• The total density of tubules is significantly
lower in the apical root region than in the mid
root and cervical areas
ENDOD 2014;8(2):105-127 51

• The density of dentine tubules varies from
approximately 15000 per mm2 at the CDJ in
the cervical portion of the root to 8000 near
the apex, whereas at the pulpal ends the
number increases to 57000 per square
millimetre
ENDOD 2014;8(2):105-127 52

• When the cementum and enamel do not meet
at the cementoenamel junction (CEJ), these
tubules remain exposed, thus creating
pathways of comunication between the pulp
and the peridontal ligament
ENDOD 2014;8(2):105-127 53

lf enamel or cementum is missing, microbes may invade
the pulp through the exposed tubules.
A tooth with a vital pulp is resistant to microbial invasion.
Normally, movement of bacteria in dentinal tubules is
restricted by viable odontoblastic processes, mineralised
crystals and various macromolecules within the tubules
ENDOD 2014;8(2):105-127 54

Exposed cervical dentine, where the
cementum and enamel do not meet
at the cementoenamel junction (CEJ),
can provide tubular communications
through patent dentinal tubules.
ENDOD 2014;8(2):105-127 55

Cervical dentinal hypersensitivity is an example of this phenomenon.
The pulp chamber can thus communicate with the external root surface in case
of denuded cementum through these dentinal tubules.
Periodontal disease, scaling, root planning, surgical procedures, developmental
grooves, gap joint at the cemento enamel junction may lead to exposed dentine.
ENDOD 2014;8(2):105-127
56

Palatogingival groove
ENDOD 2014;8(2):105-127 57
It is a development groove, a common
anomaly in maxillary lateral incisors. It
begins in the central fossa or across the
cingulum, extends varying distances apically.
It is located in the mid-palatal or mesial or
distal regions of the tooth palatally or even
bucally

It provide funnel like areas
for plaque retention.
Periodontal probing is
advised for patients with
palatogingival grooves.
Palatogingival grooves are
associated with deep
isolated tubular-shaped
periodontal pockets with
intrabony defects.
58
ENDOD 2014;8(2):105-127

On radiographs they appear as a tear drop
shaped area and dark lines parallel or
imposed on the root canal can be noticed.
These lines are termed as parapulpal lines
59
ENDOD 2014;8(2):105-127

Root canal perforation
Iatrogenic root perforations are serious
complications during root canal treatment.
Treatment ,Prognosis of root perforations depends
on the size, location, time of diagnosis and
treatment, degree of periodontal damage as well as
the sealing ability and biocompatibility of the repair
material
ENDOD 2014;8(2):105-127 60

Vertical root fracture
Artificial pathways between periodontal
and pulpal tissues are the vertical root
fractures.
Vertical root fractures are caused by
trauma and have been reported to occur
in both vital and non-vital teeth
ENDOD 2014;8(2):105-127 61

Root resorption
It may be another important way
of communication between
tooth and periodontal tissue.
In this pathology there is loss of
dentin, cementum and in some
cases bone
This process may be infective or
non-infective
ENDOD 2014;8(2):105-127 62

Authors (year) Classification Therapy
Oilet and pollock
(1968)
Class l: Primary endodontic
involvement with secondaiy
periodontal factors
Requiring only root canal
treatment .
O
Class ll: Primary periodontal
involvement with secondary
endodontic factors
Requiring only periodontal
treatment
Class lll: Endodontic-periodontal
involvement
Requiring correlated and
combined therapy
ENDOD 2014;8(2):105-127 64

Simon et al
(1972)
Class l: Primary endodontic lesion Root canal treatment
Class ll: Primary periodontal lesion Periodontal treatment
Class lll: Primary endodontic disease
with secondary periodontal
involvement
Root canal treatment
Class IV: Primary periodontal disease
with secondary endodontic
involvement
Both treeatments
Class V: True combined lesion Both treeatments
ENDOD 2014;8(2):105-127 65

Hiatt
(1977)
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
Both treatments
Class 4:Periodontal lesions of long duration with secondary pulpal
disease
Both treatments
Class 5:Periodontal lesion treated by hemisection or root
amputation
Both treatments
Class 6:Complete and incomplete crown-root fractures Both treatments
Class 7:Independent pulpal and periodontal lesions which merge
into a combined lesion
Extraction
Class 8:Pulpal lesions which evolve into periodontal lesions following
treatment
Both treatments
Class 9:Periodontal lesions that evolve into pulpal lesions following
treatment
Both treatments
66

Guldener
(!985)
Class l: Primary endodontic lesions Root canal treatment
Class la: Accidental perforations or resorptive
perforations
Class lb: Chronic periradicular lesions (granuloma or
cyst) or acute periradicular lesion
Class ll: Primary periodontal lesions Periodontal treatment
Class lla: Advanced periodontal disease with or
without extension to the apical area (pulp vital)
Both treatments
Class lla: Secondary endodontic involvement Both treatments
Class lla: Secondary endodontic involvement Both treatments
ENDOD 2014;8(2):105-127 67

Geurtsen et al
(1985)
1. Combined lesions requiring only a
single root canal treatment
Favourable prognosis
2. Combined lesions requiring both
root canal and periodontal therapy
3 Less favourable prognosis
3. Combined lesions with little hope
of successful treatment
Poor prognosis
ENDOD 2014;8(2):105-127 68

Torabinejad
and
Lemon (1996)
Periodontal detect of endodontic origin Root canal treatment
Periodontal defect ot periodontal origin Periodontal treatment
Combined endodontic--periodontal lesion Both treatments
independent endodontic and periodontal
lesion without communication
Endodontic and periodontal lesionswith
communication
ENDOD 2014;8(2):105-127 69

Rotstein and
simon
(2000)
Class l: Primary endodontic disease Root canal treatment
Class ll: Primary periodontal disease Periodontal treatment
Class ill: Combined diseases, which
include:
Primary endodontic disease with
secondary periodontal involvement
Primary periodontal disease with
secondary endodontic involvement
True combined disease
Both treatments
ENDOD 2014;8(2):105-127 70

Weine
(1984)
Class l: Tooth which simulates periodontal
disease but is in tact due to pulpal inflammation
and/or necrosis
Class ll: Tooth that has both pulpal or periapical
disease and periodontal disease
concomitantly
Both treatment
Class Ill: Tooth has no pulpal problem but
requires endodontic therapy plus root _
amputation to gain periodontal healing
Both treatment
Class IV: Tooth which simulates pulpal disease
but is in fact due to periodontal disease
Periodontal
treatment
ENDOD 2014;8(2):105-127 71

Abbott and
Salgado (2OO9)
Concurrent endodontic and
periodontal diseases without
communication
Both treatments
Concurrent endodontic and
periodontal diseases with
communication
Both treatments
ENDOD 2014;8(2):105-127 72

Foce (2O11) Class 1: Crown-down plaque-induced
periodontal lesions
Periodontal treatment
Class 2: Down-crown periodontal
lesion of endodontic origin
Class 3; Combined endo-perio lesions Root canal treatment
Class 4: Pseudo endo-perio lesions,
for situations in which the initial clinic
and radiologic
examinations points to both
endodontic and periodontal sources.
Both treatments
ENDOD 2014;8(2):105-127 73

Ahmed (2O12) Class l: Synchronous endo-perio lesions Both treatments
Class I: Pulpal lesions with periodontal involvement Root canal treatment
Class Ill: Periodontal lesions with pulpal
involvement
Both treatments
Class IV: Independent endo-perio lesions Both treatments
Class V: iatrogenic endo-perio lesions Root canal treatment
Class Vl: Advanced endo-perio lesions Both treatments
Class Vll: lndetinite endo-perio lesions
ENDOD 2014;8(2):105-127 74

Difference between endodontic and
periodontal lesions
ENDOD 2014;8(2):105-127 75

Diagnosis Endodontic Periodontal
Etiology Necrosis of the pulp Infection and inflammation of
the periodontium
Pain Acute,excaberating and spontaneous in
nature
Dull and chronic in nature
Swelling Occurs in cases with periapical abcess and
diffuse in nature
Localized
Percussion Positive and vertical in direction mild and lateral in direction
Probing Probing depth of sulcus<3mm Probing depth of sulcus>3mm
Sinus
tracing
Gutta percha leads to the apex of the
involved tooth
Gutta percha point would
lead to the sulcus of involved
tooth
76

Diagnosis Endodontic Periodontal
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
77

Endo perio lesion
usually isolated, narrow localized pocket
Causes:
o Endo
o Perio
o Fracture
o Resorption
o Anatomy
Check endodontic status
Root treated
Not root treated
Evaluate adequacy
Preparation:
oUnder prepared
oOver prepared
oPerforation
oZipping
oledges
Obturation:
oUnder filled
oOverfilled
oPoor adaptation
Is root canal re-treatment feasible?
Vitality tests
MANAGEMENT

Feasible re-treatment?
Yes
No
oDo first stage endo
oClean and shape canals
oDress with calcium hydroxide
Resolution?
Yes No
OHI
Try OHI + debridement
Resolution?
Yes No
Extract
Resolution?
Yes No Extract

Vitality tests
Positive Negative
Perio treatment
Resolution? Resolution?
Yes No Yes No
Check vitality again:
If in doubt- do RCT
Check
OHI and perio
Still no resolution: look for other causes
Extract, resect , hemisect

TREATMENT ALTERNATIVES
ROOT RESECTION
REGENERATIVE TECHNIQUES
ROOT RESECTION : “ Sectioning & removal of one or two roots of
amultirooted teeth with accompanying odontoplasty.”
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.”

RADISECTION : “Newer terminology for removal of roots
of maxillary molars .”
BISECTION / BICUSPIDIZATION : “Separation of mesial
and distal roots of mandibular molar along with its
crown portion, where both segments are then retained
individually.”

ROOT RESECTION
Furcation involvement.
Classification of degree of Furcation involvement
( Maxillary / Mandibular - 3 point / Nabers probe )

INDICATIONS FOR RESECTIONS
Periodontal indications
Severe vertical bone loss involving only one root of a multi
rooted tooth
Through and through furcation destruction
Unfavorable proximity of roots of adjacent teeth
Severe root exposure due to dehiscence

Prosthetic failure of abutments within a splint
Endodontic failure: perforations, over extension ,
obstructed canals, separated instrument , root resorption
Vertical fracture of one root
Restorative reasons: sub gingival caries, erosion of large
part of crown and root, traumatic injury
Combination of these
Restorative and endodontic indications:

Root fusion making separation impossible
Angulation or position of tooth in the arch
Root morphology
Improperly shaped occlusal contact
Contraindications

REGENERATIVE TECHNIQUES
GTR – Differential tissue development
Barrier Resorbable Collagen
Synthetic
Non resorbable
Enamel matrix derived protein
Barrier – principle - stiff

Tetracycline 250 mg (qid)
Doxycycline 100 mg ( bd / od )
Metronidazole 250 mg( tid for 7 days)
Chlorhexidine
ANTIBIOTICS FOR ENDO PERIO LESION

THANK YOU
ENDOD 2014;8(2):105-127 94

ENDO-PERIO LESION: DIAGNOSIS, PROGNOSIS AND DECISION-MAKING. Antonio Bonaccorso ENDOD (Lond Eng)2014;8(2):105-127 DR ANUBHUTI

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ENDO-PERIO LESION: DIAGNOSIS, PROGNOSIS AND DECISION-MAKING. Antonio Bonaccorso ENDOD (Lond Eng)2014;8(2):105-127 DR ANUBHUTI