brief focus on endo- perio lesions

1. ENDODONTIC
PERIODONTAL
LESIONS
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2. Introduction
Pathogenesis
Classification of Endo- Perio lesions
Differential diagnosis
Rationale for therapy
Conclusion
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content

3. •ENDODONTIC LESION
Inflammatory process in the Periodontal tissues
resulting from noxious agents present in the root canal.
•PERIODONTIC LESION
Inflammatory process in the Periodontal tissues
resulting from accumulation of dental plaque on external
tooth surface
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4. Periodontium & Pulp anatomically
inter-related via :
- Apical foramen
- Lateral canals
- Dentinal tubules
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5. PATHWAYS OF
COMMUNICATION BETWEEN
THE PULP & PERIODONTIUM
Developmental
Apical foramen
Lateral/
Accessory canal.
Dentinal
tubules.
Developmental/
Lingual grooves.
Root anomalies.

6. DIAGNOSTIC PARAMETERS
• There are several signs and symptoms that provide proper
diagnosis of pupal- periodontal lesions.
• These include: Pain, Swelling, Probing, Mobility,
Tenderness, Pulp test, and Radiography.

7. PAIN
Endodontic Periodontic
Pain Acute & severe
Spontaneous
Spreads to PDL
Analgesics ineffective
Endo therapy must
Involves fascial planes.
Dull & chronic
Responds to
analgesics
Flare up: abscess
No fascial planes
involved

8. Endodontic
•Occurs in muccobuccal fold
•Spreads to fascial planes
Periodontal
•Found in attached gingiva
•Rarely spreads to fascial plane
Swelling

9. PROBING
Endodontic Periodontic
Probing Orthodontic wire or
GP used. Ends at apex.
Abscess develops
escape route by sinus
tracts.
Traced sinus goes toward
midroot or lateral canal.
Periodontal probing leads
to apex falsely indicating
endodontic involvement.

10. Endodontic Periodontic
Mobility
Percussion &
Tenderness
Seen around usually just the
involved tooth.
Patient has definite pain on
percussion
Generalized mobility usually
indicate periodontal or
occlusal involvement .
There is no pain on
percussion except for
presence of periodontal
abscess.

11. COLD TEST
• Normal pulp: Immediate pain that disappears on stimulus
removal.
• Necrotic or irreversible pulp: Pain persist.
• One time test as pulp needs time to recover
• 1, 1, 1, 2- tetrafloroethane best material.
• Used on ceramics as well on metal crowns.

12. ELECTRIC TEST
• Gives yes or no response.
• Does not give pulp test.
• Not reliable
• Bare hand should be used to complete the circuit.

13. HEAT TEST
• Healthy pulp shows an increase in pain intensity till
stimulus is removed.
• Once heat removed pain disappears immediately.
• If pain persist irreversible pulp damage suspected.
• Hot G.P, dry rubber cup, ball burnisher etc are used.

14. EFFECT OF PERIODONTAL TISSUES ON
PULP
Exposure / irritation through auxiliary canals
Furcation canals
Effect of Periodontal therapy on pulp
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15. INFLUENCE OF PERIODONTAL
DISEASE ON PULP
• Formation of plaque on detached root surfaces – potential
to induce pathologic changes in the pulp
• Access to pulp by bacterial products is gained via:
- Exposed lateral canals
- Apical foramina
- Dentinal tubules
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16. INFLUENCE OF PERIODONTAL
TREATMENT ON PULP
During Scaling & root planing – Cementum & superficial parts of
Dentin may be removed
↓
Exposure of Dentinal tubules
↓
Bacterial invasion
↓
Inflammation of Pulp
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17. EFFECT OF PULPAL DISEASE ON
PERIODONTIUM
• Vital pulp
• Necrosed pulp
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18. DISEASED VITAL PULP
Caries, restorative procedures & traumatic injuries
↓
Pulp hyperemia
↓
↑ Intra pulpal pressure
↓
Pulp death
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19. NECROSED PULP
Necrosis of pulp
↓
Extension of inflammation
↓
Periapical tissues
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20. IMPACT OF ENDODONTIC TREATMENT
ON PERIODONTIUM
• Periodontal breakdown associated with root canal filled teeth –
Endodontic etiology
• Infectious products from unfilled spaces – into Periodontal
tissues - ↑ Probing depth
• Mechanical & Chemical irritation (RCT) – Periodontal
inflammatory lesion
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21. MANIFESTATIONS OF ACUTE
ENDODONTIC LESIONS IN THE
MARGINAL PERIODONTIUM
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22. ROOT PERFORATIONS
Undetected / Unsuccessfully treated root perforation –
inflammation of marginal periodontium
Manifested as - ↑ PD, Suppuration ,↑ mobility
The closer the perforation to sulcus – greater likelihood
for proliferation of sulcular epithelium
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23. VERTICAL ROOT FRACTURE
• Bacterial ingrowths in the fracture space – adjacent Periodontal
tissues – seat of inflammatory lesion
• Suspicion of root fracture:
- Pocket in aberrant position.
- Sudden appearance of symptoms in a root
filled teeth ,asymptomatic so far.
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24. EXTERNAL ROOT RESORPTION
• In advanced stages – may interfere with the
gingival sulcus
• May cause development of Periodontal abscess
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25. • In teeth with moderate breakdown – Pulp
functions normal
• When plaque bacteria reach main apical
foramen - breakdown of pulp
(Langeland et al , 1974)
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26. CLASSIFICATION
(SIMON & GLICK,1972)
Primarily Endodontic Lesions
Primarily Endodontic Lesions with Secondary
Periodontal involvement
Primarily Periodontal Lesion
Primarily Periodontal Lesion with
Secondary Endodontic involvement
True combined lesion
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27. PRIMARILY ENDODONTIC LESION
• Fistulous tract may exist from apex along
Mesial /Distal root
• Buccal Swelling
• In multi-rooted teeth, fistulation from
apex to bifurcation area
• D/D – When crestal bone levels normal &
only Furcation area is radiolucent
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28. PRIMARILY ENDODONTIC LESION
WITH SECONDARY PERIODONTAL
INVOLVEMENT
• When primarily endodontic lesion left
untreated
• Requires both Endodontic & Periodontal
treatment
• Prognosis depends upon periodontal
therapy if Endodontic treatment is done
properly
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29. PRIMARILY PERIODONTAL LESION
• Periodontitis progresses to reach
apical foramen
• Probing reveals calculus along the
root surface
• Pulp responds vitally
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30. PRIMARILY PERIODONTAL LESION
WITH SECONDARY ENDODONTIC
INVOLVEMENT
• As Periodontal lesion
progresses towards apex
• Necrosis of pulp
• Tooth non – vital
• Radio graphically not distinct from primarily endodontic
lesion
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31. TRUE COMBINED LESION
• When Endodontically induced lesion
exists on a Periodontally involved tooth
• Clinical & Radiographic features
indistinguishable from two lesions that
are secondarily involved
• Periodontal tissues – may / may not
respond to therapy depending on
severity
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32. TYPES OF ENDO – PERIO PROBLEMS
(FRANKLIN S WEINE)
• Class I
• Class II
• Class III
• Class IV
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33. CLASS I
• Tooth in which Symptoms
clinically & radio graphically
simulate Periodontal
disease
• But are in fact Due to
Pulpal inflammation /
necrosis
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34. CLASS II
• Both Pulpal &
Periodontal conditions
exist
- 2 separate lesions
- Single lesion
- Initially 2 separate
lesions, later single lesion
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35. CLASS III
• No Pulpal problem
• Requirement of Endodontic therapy & root
amputation
• Facilitate Periodontal healing
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36. CLASS IV
• Clinically & radio
graphically simulates Pulpal
or Periodontal disease
• Origin is Periodontal
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37. DIFFERENTIAL
DIAGNOSIS
•History
•Pain
•Vitality
•Percussion
•Suppuration
•Pockets
•Radiographs
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38. DIAGNOSTIC AIDS
• Radiographs – very important
 Tracing radiographs
 RVG
• Other aids:
 Visual & digital examination
 Thermal pulp testing
 Electric pulp testing
 Test cavity
 Selective anesthesia
 Tran illumination
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39. 39
PROBING WITH
SILVER CONE
THERMAL TESTING
AIDS

40. TRACING RADIOGRAPHS
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41. 41
VISUAL
Swelling/
Redness
No swelling/
redness
ASSESS PERIODONTAL
STATUS
No PD PD with no
Attachment loss
PD with
Attachment loss

42. 42
SWELLING + NO PD
PULPAL STATUS
No RL
No POP
Pain on lateral
Percussion
Vital
CRACKED TOOTH
SYNDROME
RL Defect apically
POP
No Pain on lateral
Percussion
NonVital
Evaluate for
Extraction
Endodontic
therapy

43. 43
SWELLING + PD with no AL
Pain
Swelling
Purulent exudate
Foreign body impaction
GINGIVAL ABSCESS

44. 44
SWELLING + PD with AL
PULPAL STATUS
No RL
No POP
Vital
RL Defect apically
POP
NonVital
Evaluate for
-Extraction
-Endodontic
-Periodontal
treatment
Periodontal therapy

45. RATIONALE FOR
THERAPY
• Both Pulpal & Periodontal lesions – affect the attachment
apparatus
• Therapy – removal of the etiologic factor
• Treatment of choice – Simplest procedure that will obtain
most ideal therapeutic results
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46. • Maintenance of arch integrity – most important step in
preventing development of Periodontal lesions.
• Prevention of tooth loss – Endodontic therapy wherever
possible
• Integrity of supporting structures & not vitality of pulp
that is important for tooth maintenance
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47. MANAGEMENT
• Primarily endodontic
lesions
- Endodontic therapy
• Primarily endodontic
lesion with secondary
periodontal involvement
- Endodontic therapy
done first
- Periodontal therapy
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48. • Primarily Periodontal lesion
-Periodontal therapy alone
• Primarily Periodontal lesion with secondary Endodontic
involvement
- Depends upon extent of pulpal
involvement
- Early diagnosis - reversible pulpal
hypersensitivity
- If progressive – involves accessory canals
–
irreversible pulpitis – Combined treatment
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49. True Combined lesion
- Poor Prognosis
- Root amputation
- Hemisection
Root Perforation
- Complete seal for each canal
- Seal of perforation
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50. COMBINED LESION
- If larger extent of the lesion is due
to Endodontic involvement – more
favorable prognosis
- Endodontic therapy → Observe
- Evaluate → Periodontal therapy
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51. CONCLUSION
• Periodontal disease – loss of support around tooth
• May be the cause of breakdown of Pulpal tissues
• Successful treatment – depends upon treatment of all
contributing factors
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